Medicaid Managed Care Panel: Connecticut’s Transition from Managed Care Organizations to Administrative Services Organizations

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Transition to Medical ASO n 

A Snapshot of the Program

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Transition to Medical Administrative Services Organization (ASO) ¨ Rationales ¨ Contrast

with Managed Care Organization (MCO) arrangement ¨ Key strategies McEvoy

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A Snapshot of the Program

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A Snapshot of the Program: Participation n 

Overall, Medicaid currently serves 631,782 beneficiaries (17.6% of the state population) ¨  437,652

HUSKY A adults and children ¨  13,436 HUSKY B children ¨  97,203 HUSKY C older adults, blind individuals, individuals with disabilities and refugees ¨  93,749 HUSKY D low-income adults age 19-64 ¨  3,178 limited benefit individuals (includes behavioral health for children served by DCF, tuberculosis services, and family planning services) McEvoy

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A Snapshot of the Program: Costs in Context Connecticut has: n  the fourth highest level of health care expenditures at $8,654 per capita, behind only the District of Columbia, Massachusetts, and Alaska [2009 data] n  the ninth highest level of Medicare costs at $11,086 per enrollee [2009 data] n  the highest level of Medicaid costs at $7,561 per enrollee [2010 data] [Kaiser State Health Facts] McEvoy

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A Snapshot of the Program: Costs in Context Please note the following per capita break-out of Medicaid costs by recipient group: n  n  n  n 

$16,955 Aged $25,393 Disabled $3,533 Adult $3,339 Children [Kaiser State Health Facts, 2010 data]

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A Snapshot of the Program: Costs in Context (cont.) ¨ per

capita spending for the 32,583 individuals who are age 65 and over and the 24,986 individuals with disabilities under age 65 who are eligible for both Medicare and Medicaid (MMEs) is 55% higher than the national average

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A Snapshot of the Program – health outcomes n 

Key health indicators for Connecticut Medicaid beneficiaries, including hospital readmission rates and outcomes related to chronic disease, are in need of improvement

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Transition to Medical ASO: Rationales

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Context n 

Prior to transition, Medicaid medical services were handled as follows: ¨  Individuals

covered under HUSKY A & B were served by multiple, at-risk, capitated Managed Care Organizations (MCOs) ¨  Individuals covered under HUSKY C (coverage for older adults and individuals with disabilities) were served in an unmanaged fee-for-service arrangement

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Context (cont.) ¨  Individuals

up to 53% of the Federal Poverty Level (FPL) who were historically served by SAGA medical became eligible effective April, 2010 for new HUSKY D (Low Income Adult, LIA) group

¨  Connecticut

was the first state in the country to gain CMS approval for an early expansion group

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Context (cont.) n 

Medicaid behavioral health services had since January 1, 2006 been overseen by the Connecticut Behavioral Health Partnership, and managed by a behavioral health ASO (Value Options)

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Medicaid dental services had since September 1, 2008 been managed by a dental ASO (BeneCare)

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Rationales for Transition Transition to an ASO arrangement would: n 

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build upon a model that had worked successfully for Medicaid behavioral health and dental services improve access to and use of data in support of best use of public resources and transparency centralize and streamline administration, utilization management and member and provider supports

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The Central Hypothesis . . . Centralizing management of medical services for all Medicaid beneficiaries in self-insured, managed fee-for-service arrangement with an Administrative Services Organization, as well as use of predictive modeling tools and data to inform and to target beneficiaries in greatest need of assistance, will yield improved health outcomes and beneficiary experience, and will help to control the rate of increase in Medicaid spending. McEvoy

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Transition to Medical ASO: Contrast with MCO Arrangement

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Contrast with MCO Arrangement MCO

ASO

Structure

Multiple managed care entities

One managed fee-for-service entity

Contract

Administrative

Department withholds 7.5% of each quarterly administrative payment contingent upon ASO’s success in meeting performance targets related to beneficiary health outcomes and experience of care, as well as provider satisfaction

Payment model

Capitated payment

Managed fee-for-service

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Contrast with MCO Arrangement (cont.) MCO

ASO

Care delivery model

Each MCO handled utilization management (e.g. prior authorization) on its own terms

Utilization management has been standardized for all Medicaid beneficiaries, Intensive Care Management (ICM) is available to all Medicaid beneficiaries

Data

Multiple data sets, inconsistent/nonstandard reporting of data to Department

One integrated data set is immediately available to Department, provides much greater level of detail and transparency

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Contrast with MCO Arrangement (cont.) MCO

ASO

Provider enrollment

Providers enrolled Enrollment is handled through an in one or many online process by the Department’s MCOs contractor, HP

Provider rates

Established by each MCO (nonstandard)

Department uses a standard rate schedule and common service definitions for all services

Provider payment

Each MCO was responsible for payment

Payment is made by HP on a twice per month

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Transition to Medical ASO: Key Strategies

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Transition to Medical ASO: Direct Access to and Use of Data to Inform Strategies n 

Under the ASO arrangement, the Department has direct access to a single, integrated data set that includes a wealth of claims and encounter data

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Transition to Medical ASO: Data Analytics n 

The ASO has unprecedented capability in analyzing data for purposes including, but not limited to: ¨  attribution

of members to primary care practices ¨  supporting members through Intensive Care Management ¨  supporting providers in understanding the needs of the members whom they serve

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Transition to Medical ASO: Centralization of Member Services n 

Centralization of member services with CHN-CT has enabled streamlined support with: ¨  referral

to primary care physicians ¨  referral to specialists ¨  assistance with prior authorization requirements and coverage questions ¨  building relationships with members throughout their entire enrollment periods, promoting continuity

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Transition to Medical ASO: Centralization of Provider Services n 

Centralization of provider services with CHN-CT has improved support with: ¨  Prior

authorization requirements ¨  Coverage questions ¨  Referrals

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Transition to Medical ASO: Utilization Management n 

CHN-CT has implemented a range of functions relating to utilization management: ¨ prior

authorization ¨ utilization review ¨ specific programs including a pain management initiative

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Transition to Medical ASO: Predictive Modeling n 

Predictive modeling tools and other referral means (e.g. self-report, provider referrals) enable CHN-CT to identify those beneficiaries most in need of care management support

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CareAnalyzer logic utilizes the Johns Hopkins University ACG® Predictive Models in conjunction with HEDIS methodology to identify members who may benefit from early intervention and improved coordination of care.

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Transition to Medical ASO: Intensive Care Management n 

CHN has fully implemented a tailored, personcentered, goal oriented care coordination tool that includes assessment of critical presenting needs (e.g. food and housing security), culturally attuned conversation scripts as well as chronic disease management scripts

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Additionally, CHN-CT now has in place geographically grouped teams of nurse care managers

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Transition to Medical ASO: Intensive Care Management (cont.) n 

An important feature of ICM is coordination with a co-located unit of Value Options (the behavioral health ASO)

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Care managers from CHNCT, DSS and Value Options meet twice weekly to review hospitalizations and planned admissions to identify the appropriate care manager to take responsibility for the member’s care

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For Reference: Related Initiatives

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Improving the Patient Experience Of Care Issues Presented

DSS Strategies

Anticipated Result

Individuals face access barriers to gaining coverage for Medicaid services

•  ConneCT •  MAGI income eligibility •  Integrated eligibility process with Access Health CT

Streamlined eligibility process that optimizes use of public and private sources of payment

Individuals have difficulty in connecting with providers

•  ASO primary care attribution process and member support with provider referrals •  Support for primary care providers (PCMH, EHR, ACA rate increase)

DSS will help to increase capacity of primary care network and to connect Medicaid beneficiaries with medical homes and consistent sources of specialty care

Individuals struggle to integrate and coordinate their health care

•  ASO predictive modeling and Intensive Care Management (ICM) •  Duals demonstration •  Health home initiative

Individuals with complex health profiles and/or cooccurring medical and behavioral health conditions will have needed support

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Improving the Health of Populations Issues Presented

DSS Strategies

Anticipated Result

A significant percentage •  Medicaid expansion of Connecticut residents •  Integrated eligibility does not have health determination with Access insurance Health CT

Increased incidence of individuals covered by either Medicaid or an Exchange policy

Many Connecticut residents do not regularly use preventative primary care

•  PCMH initiative in partnership with State Employee Health Plan PCMH

Increased regular use of primary care; early identification of conditions and improved support for chronic conditions

Many health indicators for Medicaid beneficiaries are in need of improvement, and Medicaid has the opportunity to influence other payers

•  Behavioral health screening for children •  Rewards to Quit incentivebased tobacco cessation initiative •  Obstetrics and behavioral health P4P initiatives

Improvement in key indicators for Medicaid beneficiaries; greater consistency in program design, performance metrics and payment methods among public and private payers

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Reducing the Per Capita Cost of Care Issues Presented

DSS Strategies

Anticipated Result

Connecticut’s historical experience with managed care did not yield the cost savings that were anticipated

•  Conversion to managed feefor-service approach using ASOs •  Administrative fee withhold and performance metrics

DSS and OPM will have immediate access to data with which to assess cost trends and align strategies and performance metrics in support of these

Connecticut Medicaid’s fee-forservice reimbursement structure promotes volume over value

•  PCMH performance incentives •  Duals demonstration performance incentives and shared savings

Evolution toward valuebased reimbursement that relies on performance against established metrics

Connecticut Medicaid’s means of paying for hospital care is outmoded and imprecise

•  Conversion of means of making inpatient payments to DRGs and making outpatient payments to APCs

DSS will be more equipped to assess the adequacy of hospital payments and will be able to move toward consideration of episodebased approaches

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Reducing the Per Capita Cost of Care (cont.) Issues Presented

DSS Strategies

Anticipated Result

Connecticut expends a high percentage of its Medicaid budget on a small percentage of individuals who require long-term services and supports; historically, this has primarily been in institutional settings

•  Strategic Rebalancing Initiative (State Balancing Incentive Payments Program, Money Follows the Person, nursing home diversification funding, workforce analysis, My Place campaign) •  Duals demonstration payments for care coordination

Connecticut will achieve the stated policy goal of making more than half of its expenditures for long-term services and supports at lower cost in home and community-based settings

Consumers strongly prefer to receive these services at home

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In conclusion . . . n 

Transitioning Medicaid medical services from MCOs to a single, streamlined ASO platform has improved member and provider support; has through predictive modeling, ICM and data sharing enabled tailored responses to members’ needs; and created a partnership between DSS and CHN that is mission-driven toward improving the health outcomes and satisfaction of those served by Medicaid.

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Questions or comments?

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