Medicaid Health Plans’ Strategies to Managing Care for Dual Eligibles Thomas L. Johnson President & CEO October 31, 2012 1
MHPA and Our Mission 111 Member Plans 34 States + DC
Develop and Advance Public Policies that… Control Costs, while Improving Access and Delivery of Quality Health Care 2
36 States and DC Have Medicaid Health Plans
May 2012 Medicaid Health Plan Penetration 3
2006 Medicaid MCO Penetration
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2008 Medicaid MCO Penetration
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Enrollment in Medicaid
Data Sources: 2010 CMS Medicaid Managed Care Enrollment Report
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States Addressing Special Populations Difficult, high‐risk, high‐needs, chronically ill populations are focus for states •Complex, High‐Risk Patients •Aged, Blind and Disabled (ABD) •Long‐Term Services and Supports (LTSS) •Dual Eligibles ‐ Integration
Dual Eligibles
Duals (9 m)
• 60% have multiple chronic conditions; 43% have mental impairments • 15% of Medicaid population; 39% of Medicaid Spending • Cost Medicaid nearly $130 billion in ’08 10
Duals in Risk‐based MCOs
CMS Medicaid Managed Care Enrollment Data, 2010 11
Barriers for States • Medicare Freedom of Choice – The Social Security Act guarantees that Medicare beneficiaries are entitled to insurance benefits for services under any willing provider of their choosing.
• Lack of ability for States to benefit from Medicare savings – Medicare savings are realized by the federal government only.
• Nursing Home Care – States may realize cost savings when Dual Eligibles receive care in a hospital, since Medicare is the payer. 12
Barriers for States Cont’d • Lack of access to Medicare data – States have a difficult time accessing necessary information about Duals since Medicare data is collected at the federal level. • Lack of previous authority to align and integrate administrative requirements for Dual Eligibles, including beneficiary protections – States have lacked authority to align/integrate administrative requirements for Dual Eligibles, including beneficiary protections (enrollment and grievance/appeals).
• Differing marketing policies – Policies for health plan marketing to populations varies in the Medicaid and Medicare programs 13
Care Integration for Duals • April 2011, CMS awarded $1 million to 15 states for designing systems to integrate Dual Eligibles • July 2011, CMS announced a Financial Alignment Initiative for developing state payment/delivery systems for integration of care for Duals • 38 states and DC submitted letters of intent in Oct ’11 • 20 states are currently focusing on the capitated model (with the other option being the managed FFS model) • CMS is currently reviewing states’ proposals and released a Memorandum of Understanding (MOU) for the Massachusetts’ proposal. 14
Challenges for Plans • Uncertainty of rates and cost‐savings • Potentially insufficient risk‐adjustment – Important to plans’ ability to managed costs
• Uncertainty of states’ proposals – Details of proposals could change
• Limited timeframe of the demonstrations – Limited to 3 years and extension/expansion of demos are unclear 15
Health Reform Impact: Medicaid Expansion Implementing Health Reform – Post SCOTUS •Uncertainty regarding the Medicaid expansion ‐ – Governors in Florida, Iowa, Louisiana, South Carolina, Texas and Mississippi have indicated they do not plan to expand their states’ Medicaid programs – Plans must be prepared for the expansion population as well as the Dual Eligible population – The expansion could potentially positively impact Dual Eligibles • Those newly eligible adults who may need LTSS after turning 65 could experience better continuity of care by already being enrolled in a Medicaid health plan
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Opportunities for Medicaid Health Plans • Ability to expand and grow the business of Medicaid managed care • Opportunity to deliver care to an otherwise neglected population –Care coordination –Care management –Cost containment 17
Additional Opportunities • Strengthened networks through Medicare provider experience • Better partnerships with long‐term care providers • Improved continuity of care for beneficiaries • Access to resources to help increase use of home and community‐based services • Widespread quality measures can help patient outcomes as well as states customers • EMRs usage will help with better care coordination 18
Dual Eligibles ‐ Care Management Challenges • Elderly and often frail (majority over 65 yrs old) • Very low‐income (86 percent have annual incomes below 150% FPL) • Behavioral health problems are common (over 40% have at least one mental impairment) • Chronic conditions present (as much as 35% have 4 or more chronic conditions) • Cultural and language barriers (disproportionately more likely to be of a minority race/ethnic group and speak a language other than English) • Caretakers often involved (many duals have cognitive impairments and need assistance) • Limited access to phone, internet, and transportation 19
Dual Eligibles – A Diverse Population Age 85+
14%
No Mental Impairments
Age 75-84
21%
Age 65-74
26%
51%
39%
87%
20%
Mental Impairment
49%
Facility
Type of Residence
2 Chronic Conditions
20%
0 or 1 Chronic Conditions
25%
13% Age
35%
3 Chronic Conditions
Community
Under Age 65
4 or more Chronic Conditions
Mental Impairments
Number of Chronic Conditions
NOTE: Mental impairments were defined as Alzheimer’s disease, dementia, depression, bipolar, schizophrenia, or mental retardation. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey, 2008 20 Kaiser Family Foundation Slide Deck: Dual Eligible Beneficiaries Are a Diverse Population. June 7, 2012
Care Management Strategies • Care management to improve outcomes and care transitions • Care coordination ‐ using care management teams to coordinate medical, behavioral and long‐term care services • Person‐centered care planning and member engagement • Self‐direction ‐ allowing members to actually direct care which engages members more actively • Comprehensive benefit design (both physical and non‐physical services and benefits included) and providing enhanced benefits, such as social services and transportation, in addition to common medical services • Pharmacy benefits management 21
Care Management Strategies Cont’d • Increasing access to home and community‐based services and keeping individuals out of nursing homes • Partnering with community‐based organizations and providers that have experience serving dual eligibles • Rewarding medication and health screening compliance • Participating in medical/health homes • Entering shared savings arrangements with providers to encourage better health for the population • Reducing complexity among beneficiaries by combining both Medicare and Medicaid benefit materials • Using data systems to evaluate the effectiveness of care management of the population 22
Care Coordination Works • The June 2012 edition of Health Affairs found that unpublished data on the Massachusetts Seniors Care Options, which allows Medicaid managed care organizations to coordinate care for the elderly, shows that hospitalizations among Dual Eligibles in the Seniors Care program is 45 percent less than those in the FFS system. And, nursing home placement is 66 percent lower. • A March 2012 Avalere Health study found that care coordination among Dual Eligibles resulted in a hospital readmission rate that was 25 percent lower than those in fee‐for‐service and performed 14 percent better at keeping people out of the hospital to begin with. 23
Care Coordination Saves • The Congressional Budget Office estimated that enrolling Dual Eligible beneficiaries into Medicaid managed would save the federal government $12 billion by 2020. • The Lewin Group estimated about $148 billion in federal savings over 10 years can be realized by enrolling Dual Eligibles into capitated Medicaid managed care plans. • UnitedHealth Group estimated that expanded use of coordinated care for Dual Eligibles can save $250 billion in the first 10 years and $1.62 trillion over 25 years. 24
2012 Elections • The 2012 elections could bring a Republican President into office, which could result in ACA repeal or administrative changes that affect ACA implementation. • Even with repeal of the ACA, CMS believes it will continue to have the authority to carry out the duals demonstrations. • That said, both the current administration or possible future administration could change the demonstration projects for various reasons. • Dual eligibles are, however, in great need for better care coordination and financial alignment among payers. • With the demonstrations so close to realization, we expect and hope that our country’s leaders will continue to support this promising effort. 25
Looking Ahead • Medicaid Health Plans: – Face uncertainly regarding states’ budgetary challenges and decisions to expand their Medicaid programs under the ACA. – Continue to pursue the Dual Eligible population. – Remain a positive solution to the budget strain felt by states and the federal government and will continue to serve as an innovative and cost‐effective delivery system. – Will continue meeting quality measures and creating positive patient outcomes to ensure that plans remain of tremendous value to patients and the Medicaid program. 26
Questions?
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