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Medicare/Medicaid Integration: Charting the Future Mark R. Meiners Ph. D. National Program Director Robert Wood Johnson Foundation Medicare/Medicaid Integration Program

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Medicare/Medicaid Integration:

Charting the Future

Mark R. Meiners Ph. D.

National Program Director

Robert Wood Johnson Foundation

Medicare/Medicaid Integration Program

New York State Medicaid Managed Care Conference, Beyond Managed Care: Striving for Excellence, Saratoga Springs, NY, May 30-31, 2006


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Background to MMIP Experiences

Robert Wood Johnson Foundation

15 Participating States: CO, FL, MN, NY, OR, TX, WA, WI, VA, CT, MA, ME, NH, RI, VT

For Background and Technical Assistance Documents go to:

CHPRE.GMU (click: Medicare/Medicaid Integration Program)


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Why the Interest in Dual Eligibles?

Important public financing considerations

Cost shifting in both directions

Unintended consumer consequences

An opportunity to do better with limited resources

Managed care implications

Aging of the population/Chronic Care Imperative


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Key Dimensions of Dual Eligible Integrated Care Program Development

» Scope and flexibility of benefits - more than M&M fee-for-service

» Delivery system - broad, far reaching, options, experience

» Care integration - care teams, central records, care coordination.

» Program administration - enroll, dis-enroll, integrated data & IS

» Quality management and accountability - unified, broad, CQI

» Financing and payment - flexible, aligned incentives


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State Environmental Diversity Development

Major differences in Medicaid programs

Wide variations in state managed care infrastructure

Differences in state goals and target populations

States are in various stages of program development

Divergent definitions of integration/coordination


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Program Development Options Development

Budget Neutral or Cost Saving

Statewide or regional pilot (large vs. limited)

Mandatory or Optional

Duals/Medicaid-only Aged/Disabled Both? Timing?

Well, Community Frail, Nursing Home

National MCOs or Local Safety-Net Providers

Provider Networks – open or closed?

Waivers, Risk Adjustment, Enrollment Strategy

M/M Coordination or Integration

Benefits: Comprehensive/ Carve Outs


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RWJF Medicare/Medicaid Integration Program Development

Medicare Coordination

Managed FFS

Medicare Integration

  • Issues/Features

  • Medicaid and Medicare reimbursed FFS

  • No waivers required

  • Care coordinator link between programs and providers

  • Use of incentives (fees, co-location, reporting)

  • Issues/Features

  • Medicaid LTC capitated

  • Medicare HMO enroll encouraged

  • Various Medicaid waivers/authorities

  • Inability to capture Medicare savings

  • Case management lacks authority over Medicare

  • Issues/Features

  • 222 Medicare payment waiver &

  • Various Medicaid waivers

  • One contract for both payers

  • Flexibility to use savings for non-traditional services

  • Case management has control over both programs


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Models: Development

Buy-In Wraparound

Capitated Wraparound

Three-Party Integrated

Plan-Level Integrated

Key Considerations:

Enrollment

Operations

Benefits

Payments

Appeals

Part D Implementation

CMS Guidance to Integrating Medicare/Medicaid


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Chronic Care Model Development

Community

Health System

Health Care Organization

Resources and Policies

ClinicalInformationSystems

Self-Management Support

DeliverySystem

Design

Decision

Support

Prepared,

Proactive

Practice Team

Informed,

Activated

Patient

Productive

Interactions

Improved Outcomes


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P Development

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Overall Aim: Implement the CCM for a specific Dual Eligible/Chronic Care Population

Community Resources and Policy

Organiz-ation of health care

Clinical

Information

Systems

Self-

Manage-

ment

Support

Delivery

System

Design

Decision Support

Develop Strategies for Each Component of the CCM


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Core Building Blocks Development

Targeting Beneficiaries: Risk vs. Reward

Case Management / Care Coordination

- Integrating Information

Quality Methods and Measures

Primary Care / Chronic Care Management


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Quality/Consumer Focused Care Is the Key: Development

Look at quality from various perspectives (i.e., consumer, provider, payer)

Look at entire picture

Consider structure, process and outcomes


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Key Micro Strategy: Primary Care Teamwork Development

Focus on holistic approach encompassing health and welfare (e.g., psychosocial, economic, environmental, social supports)

Monitor ongoing health status for early detection of problems

Emphasize health education and prevention

Support chronic care self management

Increase opportunities for communication


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Summary Thoughts for Discussion Development

Integrated Care Programs need to be expanded and replicated.

Special Needs Plan represent both opportunity and challenge to IC.

Continuous Quality Improvement Evaluation is necessary going forward.


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