Massachusetts Medicaid Delivery Model Advisory Committee
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Massachusetts Medicaid Delivery Model Advisory Committee Assessment of MassHealth MCO and PCC Programs. November 13, 2012. Agenda. Section 1. Introduction. Introduction. Today’s discussion corresponds to these tasks from Navigant’s scope of work:

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November 13 2012

Massachusetts Medicaid Delivery Model Advisory CommitteeAssessment of MassHealth MCO and PCC Programs

November 13, 2012


Agenda

Agenda


November 13 2012

Section 1

Introduction


Introduction

Introduction

Today’s discussion corresponds to these tasks from Navigant’s scope of work:

  • Conduct research on Medicaid delivery of care models, including lessons learned from innovation in the MCO and PCC plans in Massachusetts and implications for the future.

  • Describe the strengths and weaknesses of the MCO and PCC models to inform the state’s vision for health care payment and delivery moving forward, including the impact on patients and providers and long-term sustainability.

    Today’s discussion addresses these items from the Committee’s vision statement:

  • Identifying lessons learned from the MCO program and the PCC plan over the past years and implications for the future, including the strengths and weaknesses of the MCO and PCC models in addressing the needs of the new payment and delivery system.


Introduction1

Introduction

Completed tasks from Navigant’s scope of work:

  • Identify individuals or organizations with expertise in Medicaid delivery of care models.

  • Coordinate and lead meetings with various stakeholder groups.

  • Analyze the experience of other entities and states in initiating and implementing innovative care delivery models. The additional information related to these experiences will be highlighted for the Advisory Committee (this includes state surveys).

    Ongoing tasks from Navigant’s scope of work:

  • Model the fiscal impact to the Commonwealth for different delivery of care models, taking into consideration cost drivers and trends, utilization, case mix, and potential for adverse selection. This analysis should consider the impact of National Health Care Reform implementation.

  • Draft the Advisory Committee’s report of findings and recommendations, including development of an implementation strategy.

  • Meeting support for the Committee.


November 13 2012

Section 2

Overview of MassHealth

  • Key Elements of MCO and PCC Program Designs

  • MassHealth Demonstrations and Initiatives


Key elements of masshealth mco and pcc program designs

Key Elements of MassHealth MCO and PCC Program Designs


Key elements of masshealth mco and pcc program designs1

Key Elements of MassHealth MCO and PCC Program Designs


Mco program administration and contracting structure

MCO Program Administration and Contracting Structure

* Four of the five MassHealth MCOs subcontract behavioral health; one MCO provides behavioral health services directly.


Pcc program administration and contracting structure

PCC Program Administration and Contracting Structure


Masshealth demonstration and initiatives

MassHealth Demonstration and Initiatives

  • Dual eligibles demonstration

    • An integrated care management model scheduled to begin Summer 2013 for 110,000 dual eligible adults ages 21-64. Eligible enrollees will receive Medicaid and Medicare benefits along with behavioral health diversionary services and community support services through Integrated Care Organizations (ICOs). The Commonwealth will contract with ICOs, which will receive a capitated global payment and be required to meet quality benchmarks that enhance patient-centered care and coordination.

  • Patient centered medical home initiative (PCMHI)

    • A multi-payer (including MassHealth MCO and PCC and commercial health plans), three-year demonstration project authorized through Legislative directive. PCMHI goals are supporting primary care practices in the transition to PCMHs and evaluating the transformation’s impact on quality and health expenditures.

  • Primary care payment reform (PCPR)

    • The goal is to improve access, patient experience, quality and efficiency through care management and coordination, and integration of behavioral health and primary care. PCPR will be implemented in both the MCO and PCC programs with 25 percent of MCO and PCC members enrolled with PCPR providers by July 2013, 50 percent by July 2014 and 80 percent by July 2015.


Masshealth demonstration and initiatives cont

MassHealth Demonstration and Initiatives (cont.)

  • Pediatric asthma bundled payment pilot

    • Multiple services patients receive during an episode of care will be bundled into one payment. MassHealth’s first bundled payment initiative, the Pediatric Asthma Bundled Payment Pilot will cover 100-200 asthmatic children and be implemented only in the PCC program. Currently awaiting CMS approval of the evaluation process for the pilot, which will be implemented in two phases.

  • Delivery system transformation initiatives (DSTI)

    • Allowed for via MassHealth’s 1115 demonstration extension, participating safety net hospitals will be required to demonstrate quality improvements in order to receive incentive payments. DSTI promotes alternative payment arrangements that reward high-quality, efficient, and integrated systems of care.


Masshealth payment and delivery system initiatives

MassHealth Payment and Delivery system Initiatives*

Payment Innovation

True Accountable Care

Global

Payment

Duals

PCPR

PCMHI

“Business as Usual”

Delivery System Transformation

Payment Methodology

DSTI

Current

Market

FFS

Limited Integration

Full Care Integration

Degree of Integration

*MCO initiatives appear in various places throughout this diagram.


November 13 2012

Section 3

Lessons Learned from MCO and PCC Programs


Lessons learned from mco and pcc programs

Lessons Learned from MCO and PCC Programs

  • PCC and MCO programs take different approaches for the structure, delivery and financing of Medicaid services

  • This section documents strengths and areas for consideration in relation to how the programs can facilitate MassHealth’s strategies for moving forwardwith payment and delivery system reform

  • Navigant conducted interviews with leaders from MassHealth, the Health Connector, and the Division of Health Care Finance and Policy (now the Center for Health Information and Analysis) as well as representatives from MBHP and the MassHealth MCOs, and reviewed previously published studies and other available information. Navigant did not perform a comprehensive operational assessment of MassHealth or its contractors.

    Note: provider interviews are currently being scheduled.


Masshealth reform strategies

MassHealth Reform strategies


Strengths and considerations the masshealth mco program

Strengths and Considerations: The MassHealth MCO program


Strengths and considerations the masshealth mco program1

Strengths and Considerations: The MassHealth MCO program

*Navigant interview with Dr. Julian Harris on 10/11/12.


Strengths and considerations the masshealth mco program2

Strengths and Considerations: The MassHealth MCO program


Strengths and considerations the masshealth mco program3

Strengths and Considerations: The MassHealth MCO program


Strengths and considerations the masshealth pcc program

Strengths and Considerations: The MassHealth PCC program


Strengths and considerations the masshealth pcc program1

Strengths and Considerations: The MassHealth PCC program

  • Community Support Program for People Experiencing Chronic Homelessness (CSPECH) aims to provide housing for homeless individuals with behavioral health issues. MBHP partnered with the Massachusetts Housing and Shelter Alliance and the Department of Transitional Assistance to link MBHP members with housing programs that have available housing vouchers.MBHP is developing a pilot project to encourage the primary behavioral health provider for high-risk members to take a greater level of responsibility for members overall health. MBHP is supplying profiling data to providers, which can later support alternative payment methodologies

  • *The Massachusetts Child Psychiatry Access Program (MCPAP) extends limited child psychiatry resources using a team-based approach (including a child psychiatrist, a social worker, and a care coordinator) to provide psychiatric telephone consultation to primary care providers. The initiative helps support primary care providers in caring for children with less-complex behavioral health needs. The requirements of MCPAP are detailed in the contract.

  • .


Strengths and considerations the masshealth pcc program2

Strengths and Considerations: The MassHealth PCC program


Strengths and considerations the masshealth pcc program3

Strengths and Considerations: The MassHealth PCC program


November 13 2012

Section 4

Resources Needed


Resources needed to support masshealth s strategies

Resources Needed to Support MassHealth’s strategies

  • This section assess how implementing MassHealth’s strategies may impact resources for MassHealth, its contractors and providers in the following areas:

    • Contracting

    • Staffing

    • IT

    • Reporting

    • Quality

    • Finance

  • We used a Low, Moderate and High scale to illustrate the impacts


November 13 2012

Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients


November 13 2012

Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)


November 13 2012

Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)


November 13 2012

Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)


Strategy effectively engage consumers in their care

Strategy: Effectively engage consumers in their care


Strategy effectively engage consumers in their care cont d

Strategy: Effectively engage consumers in their care (cont’d)


Strategy coordinate with community supports long term care and public health programs

Strategy: Coordinate with community supports, long term care, and public health programs


Strategy coordinate with community supports long term care and public health programs cont d

Strategy: Coordinate with community supports, long term care, and public health programs (cont’d)


November 13 2012

Strategy: Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures


November 13 2012

Strategy: Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures


November 13 2012

Strategy: Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures


November 13 2012

Strategy: Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures


November 13 2012

Strategy: Provide care for specific populations, including those with behavioral health needs, disabilities, low English literacy


November 13 2012

Strategy: Provide care for specific populations, including those with behavioral health needs, disabilities, low English literacy (cont’d)


November 13 2012

Strategy: Program evaluation and dissemination of best practices, including strong and standardized quality measurement and reporting


November 13 2012

Strategy: Program evaluation and dissemination of best practices, including strong and standardized quality measurement and reporting (cont’d)


Strategy ensure responsible stewardship of resources including efficient contracting

Strategy: Ensure responsible stewardship of resources including efficient contracting


Strategy ensure responsible stewardship of resources including efficient contracting cont d

Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)


Strategy ensure responsible stewardship of resources including efficient contracting cont d1

Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)


Strategy ensure responsible stewardship of resources including efficient contracting cont d2

Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)


November 13 2012

Section 5

Gap Analysis


Gap analysis of masshealth s current capabilities

GAP Analysis of MAssHealth’s Current Capabilities

  • Based on the findings identified in the previous two sections, this section

    • Summarizes MassHealth’s current capacity to move forward and

    • Indicates where there are gaps.

    • Identifies improvements needed to achieve the strategies identified by MassHealth.

  • This section also articulates the priority with which MassHealth should consider addressing the gap for either the MCO or PCC program.


November 13 2012

Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients

  • Current Program Capacity:

  • Contractors are currently providing profiling reports to providers, although metrics and formats vary; some provide access to reports updated in real-time.

  • Through PCMHI, MassHealth is providing reporting to providers on patient characteristics, utilization and cost.

  • MassHealth program-wide initiatives to provide enhanced reporting and profiling to providers (via PCPR), are in the planning stages.


November 13 2012

Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)

GAP 1

Significant IT systems and staffing enhancements (for MassHealth, contractors and providers) may be needed to support enhanced data collection and reporting capabilities. MassHealth and its contractors must be able to give providers detailed information about their performance, care costs and trends that impact any shared savings component of their payment arrangements, including specific reports directly to the practices to support clinical care management, emergency department visits, hospital discharges, high risk patients, and member enrollment.


November 13 2012

Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)

GAP 2

Contractor-specific report formats, metrics and timeframes may not be coordinated with each other or with MassHealth program-wide initiatives, which limits usefulness for providers in managing their entire panel.


November 13 2012

Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)

GAP 3

Providers need continuing education and engagement to effectively use reports, profiles and other tools to manage their patients care.


Strategy effectively engage consumers in their care1

Strategy: Effectively engage consumers in their care

  • Current Program Capacity:

  • Contractors are already performing enrollee outreach, and have the structure in place to build upon and improve current consumer engagement strategies.

  • MassHealth has conducted significant consumer outreach engagement as part of the dual eligibles demonstration, including topics related to alternative payment methodologies.

GAP 1

Consumer advocate feedback indicates that there is some concern about the topics of alternative payment and delivery systems and how it might affect the experience of care, which indicates a need for education.


Strategy effectively engage consumers in their care cont d1

Strategy: Effectively engage consumers in their care (cont’d)

GAP 2

Additional member education and engagement at the program level, via stakeholder sessions or other outreach, will be necessary to understand the perspectives of members as MassHealth transitions to alternative payment methodologies.


Strategy effectively engage consumers in their care cont d2

Strategy: Effectively engage consumers in their care (cont’d)

GAP 3

Alternative payment and delivery models may require more intensive and more active care management (e.g., phone calls and face to face visits) which may require additional care management staffing for contractors and providers.


Strategy effectively engage consumers in their care cont d3

Strategy: Effectively engage consumers in their care (cont’d)

GAP 4

MassHealth may need to assess whether enhanced vendor contract requirements regarding enrollee education, outreach and engagement are necessary.


Strategy coordinate with community supports long term care and public health programs1

Strategy: Coordinate with community supports, long term care, and public health programs

Current Program Capacity:

MassHealth contractors are performing coordination services and have strong relationships with community organizations and social services

GAP 1

In many cases, referral relationships with social services, community organizations or other MassHealth programs are not formalized.


Strategy coordinate with community supports long term care and public health programs cont d1

Strategy: Coordinate with community supports, long term care, and public health programs (cont’d)

GAP 2

There are limited contract requirements related to formalized relationships with community supports, public health and long-term care; MassHealth may need to assess the extent to which changes are necessary.


Strategy coordinate with community supports long term care and public health programs cont d2

Strategy: Coordinate with community supports, long term care, and public health programs (cont’d)

GAP 3

Expansion of Health Information Technology to create opportunities for improving coordination.


Strategy coordinate with community supports long term care and public health programs cont d3

Strategy: Coordinate with community supports, long term care, and public health programs (cont’d)

GAP 4

MassHealth may need to assess whether enhanced vendor requirements related to transitions between MCO, PCC, SCO and ICO programs are necessary.


November 13 2012

Strategy:Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures

  • Current Program Capacity:

  • MassHealth is building program-wide capacity through its PCMH and PCPR initiatives.

  • MassHealth MCOs have operationalized payer-specific alternative payment structures and continue to develop new contracts using alternative payment methods.

GAP 1

Significant IT systems enhancements and data analytic capacity (for MassHealth, contractors and providers) may be needed to conduct analytics and support new payment structure. MassHealth and its contractors will need to process and pay claims based on an alternative methodology in addition to a fee-for-service approach.


November 13 2012

Strategy:Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures

GAP 2

Although alternative payment structures are in place, there may not be coordination of metrics, formats or methodologies between vendors or with MassHealth.


November 13 2012

Strategy: Provide care for specific populations, including those with behavioral health needs, disabilities, low English literacy

  • Current Program Capacity:

  • MassHealth contractors consider providing care for these populations to be a core strength.

  • MassHealth contracts include protections and requirements for providing and coordinating care for these populations.

  • MassHealth contractors have care management programs in place the address the needs of special populations.

GAP 1

Enhanced outreach efforts and staff resources (for MassHealth, contractors and providers) may be needed to work with members to make sure they are engaging with the medical home and able to access services.


November 13 2012

Strategy: Provide care for specific populations, including those with behavioral health needs, disabilities, low English literacy (cont’d)

GAP 2

There will be a need to ensure that care for these specific populations is strengthened and not compromised in payment and delivery system reform. Risk adjustment design, including considering socioeconomic factors, will need to be carefully considered. MassHealth may need additional measures of quality or patient experience specific to the special needs of these populations in its reporting efforts.


November 13 2012

Strategy: Program evaluation and dissemination of best practices, including strong and standardized quality measurement and reporting

  • Current Program Capacity:

  • Quality, as measured by HEDIS results and other objective measures, is strong.

  • Evaluation of the PCMHI in terms of impacts on utilization, quality and outcomes is underway.

GAP 1

There are limited contract requirements related to contractor dissemination of best practices among providers.


November 13 2012

Strategy: Program evaluation and dissemination of best practices, including strong and standardized quality measurement and reporting (cont’d)

GAP 2

Quality metrics, as used by MassHealth and contractors for provider profiling or for administering alternative payment methodologies, may not be coordinated across programs or initiatives.


November 13 2012

Strategy: Program evaluation and dissemination of best practices, including strong and standardized quality measurement and reporting (cont’d)

GAP 3

MassHealth may need to develop opportunities for multi-payer coordination and dissemination of best practices in improving quality and member experience. For example, in sharing the lessons learned from the PCMHI evaluation across contractors and providers in all MassHealth programs.


Strategy ensure responsible stewardship of resources including efficient contracting1

Strategy: Ensure responsible stewardship of resources including efficient contracting

  • Current Program Capacity:

  • Managed care contracts provide a mechanism for the Commonwealth to hold contractors accountable for cost, quality and care management requirements that meet MassHealth’s goals for the programs.

  • Contracts with MCOs provide for fixed costs; costs in the PCC program can increase or decrease and each of these constructs has its own advantages and disadvantages. In the PCC plan, the Medicaid program pays providers according to a fee schedule; in the MCO program, provider rates are negotiated between each MCO and the provider.


Strategy ensure responsible stewardship of resources including efficient contracting cont d3

Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)

GAP 1

Because of the contract and administration structure of the PCC and MCO programs, the coordination of data among the program’s multiple payment streams and methodologies may become more difficult to administer and monitor as the Commonwealth transitions to alternative payment methodologies.


Strategy ensure responsible stewardship of resources including efficient contracting cont d4

Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)

GAP 2

Payment structures that include elements such as quality outcome bonus, etc., may not allow for predictable and stable funding to plans and providers since they could vary period to period.


Strategy ensure responsible stewardship of resources including efficient contracting cont d5

Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)

GAP 3

Additional payments may be needed for care management, medical homes or quality incentive components of alternative payment methodologies.


Strategy ensure responsible stewardship of resources including efficient contracting cont d6

Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)

GAP 4

Funding and increased staffing is needed to develop the data and analytical infrastructure and support needed for the increased IT, analytic and reporting demands of new payment models.


November 13 2012

Questions and Discussion


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