MAHP Medicaid MCOs: Providing Value Through Innovation

1. MAHP Medicaid MCOs:Providing Value Through Innovation Medicaid Advisory Committee November 13, 2012

2. About MAHP MAHP represents 16 member health plans that provide coverage to approx. 2.7 Million Massachusetts residents that operate in the Commercial, Medicaid, Medicare, Commonwealth Care markets. • MAHP member health plans are the nation’s best health plans • The Massachusetts Medicaid MCOs (MMCOs) are the best in the nation as measured by quality and member satisfaction. • The MA Medicaid MCOs are among the top 10 Medicaid health plans in the country. The rankings are based on performance in accreditation, preventive health, chronic disease management and satisfaction. The data are publicly reported and are audited by independent auditors.

3. MAHP MCOs Outperform National Quality Averages Massachusetts MMCOs performed well overall when compared to the performance rates of other Medicaid plans around the country. In 2012 HEDIS reports, Massachusetts Medicaid MCOs outscored the national averages on several key quality indicators governing follow-up treatment and preventive screening measures.

4. MMCOs and Payment Reform • The goals for payment reform are to lower health care costs and improve the quality of care by encouraging efficiency and effective care management and integration. • Through innovative contracting, MMCOs have long assisted providers in moving towards APM through budgeting, population-based analytics, and risk adjustments. • MMCOs provide participating providers with real-time access to patient data, consultative support teams, medical management programs, information sharing, and utilization monitoring. • Current percentage of MMCO members in APM: • HNE: 48% • NHP: 30% • NH: 23% • BMCHP: 20% • FCHP: 85% • As the Commonwealth moves forward with implementation of payment reform, MMCOs are well positioned to utilize their experience and expertise to help the state achieve its goals.

5. MMCOs: Leading Through Innovation • Over the years, MMCOs have developed innovative programs to meet the complex needs of their members. • Such programs have displayed positive results for beneficiaries and help in controlling Medicaid costs and achieving the highest value for their members and for the state.

6. ACO Reimbursement Arrangement with a CHC Model supports PCP-centered medical care Provide high quality of care Manage utilization and cost Supports include: data and consultation Targeted outreach Aggregate performance indicators Financial & Quality Reporting Program effective July 1, 2011 Preliminary 1st year results1: On track to exceed financial target by approximately 10% Strong quality performance 1 Final quality and efficiency results will not be available until early 2013

7. Reducing 30 Day Readmissions & Enhancing Continuity of Care Transition to Home Program (TTH) Target population: Members with medical admissions to inpatient setting MCO Care Manager outreaches to member within 2 business days of discharge Member is followed for 31-45 days post discharge Objectives of TTH program include: Post discharge assessment Review of discharge instructions Medication reconciliation (a pharmacist is included as needed) Ensure timely follow-up appointment with PCP or Specialist Referral to behavioral health care management if appropriate Coordination of care Education and improved self-management of chronic conditions Member is assessed for ongoing care management and referred to Care Management or Disease Management Program (BH or Medical) or continues in an established care management relationship/program Results show a reduction in readmissions during a 9-month period from a baseline readmission rate of 18.5% to an intervention readmission rate of 16.9% and a corresponding annualized savings of $1.1M

8. FCHP MassHealth Innovative Provider Relationships • A large at risk provider group manages 85.7% of FCHP’s MassHealth population • FCHP has maintained a risk relationship with this provider for the FCHP MassHealth population since FCHP has contracted with the state as an MCO. • The provider is globally capitated. • The provider assumes risk share on the majority of medical expenses. • There is no cap on surplus share for any of the risk pools. • There is a downside cap on hospital risk pool losses which protects the provider from significant deficits.  8 Fallon Community Health Plan

9. FCHP MassHealth Innovative Provider Relationships • The provider manages the MassHealth population as they manage their entire risk population. They work to keep I/P admissions and lengths of stay down; most referrals within provider’s own medical group; and use the lowest cost providers without compromising quality • When care can’t be provided within the providers group, the provider clinicians work aggressively with FCHP Care Services team to find treatment alternatives. • The provider also makes extensive use of FCHP’s disease and care management programs. • The provider, in certain geographies, provides transportation services (via shuttle) to its MassHealth members for specialty/ancillary services. • FCHP’s high quality scores are bolstered by these risk relationships. • High HEDIS and other quality measures • #1 Medicaid Plan in the country according to NCQA 9 Fallon Community Health Plan

10. FCHP MASSHEALTH Disease Management Program • Health Educator Model • Bilingual, Educated in motivational interviewing techniques • Empower members to self-manage their disease • Supports enrollee/practitioner relationship • 99% enrolled in programs would refer the program to a friend • Closely integrated with their BH provider. PHQ2 embedded into all assessments, referral process to BH, frequent co-managing Goals: • Slow disease progression • Prolong periods of health • Improve quality of life by focusing on healthier living Fallon Community Health Plan 10

11. HNE Patient Centered Medical Homes (PCMH) • Over 50,000 HNE members in a Level 3 PCMH across all lines of business (Medicaid, Commercial and Medicare) • 28% of HNE Be Healthy (MassHealth) members are in 18 PCMH practices across Western MA • PCMH practices moved from fee-for-service to shared savings or shared risk with infrastructure support • PCMH standards require the practice to: • Have a disease registry • Provide/manage the patients care via pre-visit planning • Engage in proactive and point-of-care reminders of services needed • Assessment of patient progress toward treatment goals • Address patient barriers to treatment goals

12. HNE Patient Centered Medical Homes (PCMH) • HNE is working with the PCMHs around clinical interactions: • Conduct population based care management • Assist with care coordination outside of the immediate care circle • Define the infrastructure necessary to move to a patient centered approach • Understand the cost implications of referring to different providers and interact with unengaged patients by using total health and wellness solutions • HNE is assisting with analytics and reporting by: • Turning raw data into meaningful and action-oriented information • Providing comparative benchmarks • Shedding light on the total cost for services not rendered by the PCMH • Sharing unique ideas arising from interactions with multiple provider organizations and with other health plans across the country

13. Neighborhood Health PlanWorkforce Diversity, Cultural Competence, and Health Equity • NHP’s mission is to promote the health and wellness of their members, and to ensure equitable, affordable health care for diverse communities. • In order to achieve objectives: • NHP has collected race and ethnicity data from membership – Data from 2/3 of members today help to identify and address disparities. • Promotes a diverse workforce to ensure cultural competent interaction with members. • Through this foundation, NHP assesses health promotion, disease prevention and chronic disease management.

14. Comparison of Race/EthnicityEastern Massachusetts Population/ NHP Members/NHP Employees Eastern MA

15. Neighborhood Health PlanWorkforce Diversity, Cultural Competence, and Health Equity Example: Breast cancer screening among Black/ African American women. • Target: women residing in Roxbury, Mattapan, Dorchester, Brockton, and Hyde Park • Community Participation: • Charles Street Church • Dana Farber Mobile Mammography Van • Dimock Community Health Center • YWCA Boston • Hair Salons/Nail Salons in target neighborhoods • Intervention • Public Service ads on MBTA, bus shelters and stations • Educational brochures for community health centers and small neighborhood businesses • Educational inserts for church bulletins • Public service announcements aired on Comcast in targeted communities during relevant programming • Annual YWCA Breast Cancer Awareness phone-a-thon • Results • NHP members are receiving breast cancer screening at the national 90th percentile with no disparities for Black/African American women.

16. Integrated care approach • Seeks to address the fact that high-risk membership (“top 10%”) accounted for 67% of medical cost • Common diagnoses include: • Behavioral health issues – Social disorientation – Homelessness – Chronic health conditions • Fully integrated, in-house approach addresses member needs across the care continuum (medical, physical, socio-economic, etc) • Uses a BCAP paradigm of identification, stratification, targeted outreach, and engagement • Predicts likelihood of member being in the top 10% PMPM total costs in next year • Examines high-cost/high-risk indicators for correlation with probability of benefiting from care management 16

17. Case Study Example • 55-year-old male identified through state referral; monitored by DMH; MassHealth (RCII) • Diagnosis of psychosis • Recent symptoms of depression with suicidal and homicidal ideation • Diagnoses of hypertension, diabetes insipidus, hepatitis-C • HIV positive with diagnosis of HIV-related dementia • History of substance use • Lives in a DMH group home, following discharge from skilled nursing facility 2 years ago • Has a court appointed legal guardian • Recent admission due to disorganization of thought, responding to internal stimuli, unable to manage basic activities of daily living (ADLs) • Residential home requested evaluation due to increased agitation and bizarre behavior 17

18. Action and Current status Actions • Network Health coordinated with member’s guardian for discharge needs • Network Health coordinated with group home to prepare for return home • Network Health participated in team meetings to triage medical and behavioral health to successfully implementation treatment plan; clearly identify mental health issues, and clarify if member has growing HIV-related dementia • Network Health coordinated with medical and BH facility case managers to evaluate status and develop discharge plan Current Status • Has returned to group home without hospitalization since April 2012 • Currently participating in structured day program at group home • Network Health’s ICM is conducting care coordination meetings with DMH case worker, guardian and providers for close monitoring and to incorporate additional community based services when indicated. • Network Health provides open process for visiting nurse as needed for lab drawing, evaluating medication adherence, and evaluating participation in ADLs • Network Health, guardian, group home and DMH working long term plan to assist member in achieving long term goals of living in the community, physical safety, medication adherence and monitoring to prevent psychotic symptoms

19. Summary • Massachusetts MMCOs have instituted unique programs as well as alternative payment contracts that serve MassHealth and Commonwealth Care members and residents throughout the state. • Competition in the health care marketplace has resulted in development of these innovative programs to meet the population’s needs and has improved the quality of care while managing costs. • It is important to maintain this dynamic in order to successfully implement payment reform for the Medicaid population and ensure high quality affordable health care.