Transcript Strategies to Improve Care Management for Beneficiaries

Strategies to Improve Care
Management for Beneficiaries
with Complex Needs
Managing the Care and Costs of High-Cost
Beneficiaries in Medi-Cal Fee-for-Service
June 9, 2009
Alice Lind
Associate Vice President
Center for Health Care Strategies
CHCS Mission
To improve health care quality for low-income children and
adults, people with chronic illnesses and disabilities, frail
elders, and racially and ethnically diverse populations
experiencing disparities in care.
Our Priorities
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 Advancing Health Care Quality and Cost Effectiveness
 Reducing Racial and Ethnic Disparities
 Integrating Care for People with Complex and Special Needs
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Managing Care in Medicaid
Goals:
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Improve or maintain health status
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Create accountable medical homes
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Coordinate care for those with complex
conditions
Control cost
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Purchasing Strategies Used
by States
Interviews with Medicaid officials in 12 states to examine
innovations in care management for the SSI/ABD
population.
Key Themes:
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Growing momentum to move beyond FFS to more coordinated
approaches (e.g., EPCCM, medical home).
Increasing interest in alternative financing methods (e.g.,
shared risk/savings, P4P, etc.).
Emerging efforts to develop and test more appropriate
performance measurement and monitoring strategies.
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Common Elements: Emerging
Models of Care
• Identifying and stratifying target populations
• Targeting tailored interventions
• Integrating/coordinating services (e.g., physical &
mental health)
• Creating better connections between patients and
providers
• Using appropriate measures to promote
accountability
• Structuring financing to support care management
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Key Issues: Emerging Models
of Care
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Predictive Modeling
Health Risk Assessments
Physical-Behavioral Health Integration
Role of Medical Homes
Engagement Strategies (Patients and Providers)
Accountability
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Elements of Medical Home
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A participant is linked with a physician, non-physician medical
practitioner, clinic, or other safety net provider who will serve
as their medical home.
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The medical home acts as a team to:
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Assess the participant’s health care needs
Coordinate and plan the participant’s care
Provide quality primary care services and preventive screenings
Authorize referrals to specialists, and
Provide linkages to other care and equipment providers
The team has a whole person orientation: “Success depends on
their ability to focus on the needs of a patient or family one case at a time.”
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The medical home integrates IT to support quality and safety.
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Typical Medical Home Enhancements
• Beneficiaries are offered:
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Toll-free health advice, 24/7;
In person health education and counseling;
Linkages to community-based services (housing, behavioral
health, etc.);
Integrated care management for those identified as having
complex medical and social needs.
• Providers are offered:
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Practice support as needed;
Training and education on Patient-Centered Medical Home;
Technical assistance on quality improvement, evidence-based
medicine, IT resources.
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Medical Home – current literature
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Evidence indicates that medical homes improves health
outcomes and reduce access disparities. 1
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Physician-based organizations support the medical home
because it provides an on-going relationship with the patient
that improves quality.2
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National Demonstration on Patient-Centered Medical Home3:
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Transformation requires a strategic developmental approach.
Cautious optimism despite the challenges of implementation.
Complex care management in Medicare demos4:
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Programs that reduced hospital costs for Medicare beneficiaries with multiple
chronic conditions who were generally not cognitively impaired included key
features (next slide).
1 Rosenthal
TC. The Medical Home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008; 21(5): 427-440.
Principles of the Patient-Centered Medical Home, March 2007; American Academy of Family Physicians, American Academy of Pediatrics,
American College of Physicians, and the American Osteopathic Association.
3 Nutting et al. “Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home”,
Annals of Family Medicine, 2009.
4 Brown R et al. The Promise of Care Coordination. Located at http://socialworkleadership.org/nsw/Brown_Full_Report.pdf
2 Joint
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Care Coordination in
Enhanced PCCM Programs
• Care coordination in PCCM programs has some of these
characteristics, but not all (upcoming article by Verdier):
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Targeting of patients at substantial but not extremely high risk of hospitalization
(OK, PA, IN)
In person contact with patients (some in OK, PA, NC, and IN, but most is by
telephone)
Close interaction between care coordinators and physicians (best in NC, more
limited in other states)
Access to timely information on hospital and ER admissions (generally lacking
in all states)
Medical education and social services to patients, including education on selfmanagement of care, especially medications (some in all states but AR)
• In considering lessons from Medicare, keep in mind differences
between Medicare and Medicaid beneficiaries
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Medicaid ABD PCCM beneficiaries generally are younger, have lower education
and income levels, fewer family and community supports, more mental health
and substance abuse problems, and more housing problems
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Proposed Medi-Cal Model:
Enhanced Medical Home (EMH)
• Starting with high level concept:
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Target population: 360,000 high cost Medi-Cal Feefor-Service enrollees
CA will contract with one or more entities to
administer Enhanced Medical Home model
Best practices from other states will be integrated
Mandatory statewide: where managed care is
available individuals can select the Medical Home
model or a managed care model.
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Model Option 1: State-operated
• Oklahoma’s Sooner Care Choice:
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Builds on, supports, and strengthens the existing
primary care provider network
Provides supports to beneficiaries and providers
(nurse advice; education)
Provides care coordination to high risk beneficiaries
P4P model rewards providers
Difference for CA: OK pays Medicare rates to
providers; fully capitated managed care was not
viable
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Model Option 2: Single Private
Vendor
• State of Illinois:
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Single contractor provides all operations
Vendor forms and operates provider network
Vendor provides supports for beneficiaries and
providers
Care coordination through subcontracted
arrangement for high risk population
Is relatively quick to implement & can be contracted at
risk
Difference for CA: local involvement not a priority in
IL, except for Disease Management
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Model Option 3: Local
Public/Private Partnership
• Community Care of North Carolina:
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Gradually developed local public/private entities in 14
geographic locations
Local entities responsible for network, provider and
beneficiary supports
Local determination of QI efforts
State funds are split between providers and regional
partnerships
Difference for CA: NC had many years to develop
model before cost neutrality was required
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Model Option 4: Blended Model
• Washington’s King County Care Partners:
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Local entities given preference if willing and able to
contract for enhanced medical home
Statewide contract awarded to cover remaining
geographical regions
Statewide vendor’s role diminished over time, shifting
responsibility to local and state staff as they
developed capacity
Difference for CA: WA grew out of totally unmanaged
care for ABD population; cost neutrality a goal but not
required
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Your Role in the Medi-Cal Project
• You are a key informant!
• Respond by June 10 (tomorrow) with your
availability to interview on June 22, 23, or 24
• CHCS will reply with your time & directions by
June 15
• Optional: Review documents on CHCS or CHCF
website from December 15 meeting
• Email with questions: [email protected]
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Visit CHCS.org to…
• Download practical resources to improve the
quality and efficiency of Medicaid services.
• Subscribe to CHCS eMail Updates to find out
about new CHCS programs and resources.
• Learn about cutting-edge state/health plan
efforts to improve care for Medicaid’s highestrisk, highest-cost members.
www.chcs.org
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