MassHealth Senior Care Options

1. MassHealth Senior Care Options Diane Flanders, Director, Coordinated Care Systems MA Division of Medical Assistance

2. Background • High rates of nursing facility utilization and expenditures • Primary, acute, long term care systems “generous” but fragmented • Need for coordination and accountability in care of high-risk population • Desire for integration between Medicare and Medicaid (MassHealth) • Strong provider interest

3. Program of All-inclusive Care for the Elderly: PACE • Series of federal legislative acts,beginning in 1987, to replicate OnLok • Originally Medicare and Medicaid waivers – now transitioning to provider status per BBA • Nursing home eligible enrollees • Adult day health model • Large interdisciplinary team

4. PACE: Medicare-Medicaid “Laboratory” • 6 Massachusetts PACE contracts developed since 1990 • 10 PACE centers served 1450 enrollees in 2002 • Transitioned demonstration PACE organizations to provider status effective November 1, 2003 per BBA requirements

5. PACE Has Done Well in Massachusetts • Performance measurement documents excellent results in preventable hospitalizations and long term nursing facility placement • Continuous quality management studies show performance above national benchmarks for diabetes and CHF care • Comparison with fee-for-service populations – no contest!

6. Complexities and Realities • Prescriptive, complex PACE structure (e.g. PACE interdisciplinary team, center, etc) • Potential enrollees’ resistance to changing doctors and entering the day care model • BBA regulations burdensome • Population limited to NF eligibles in the community • Aging industry unenthusiastic

7. Moving to Senior Care Options • Important lessons from PACE (state-federal interface, MIS, CQI, etc.) • Will serve populations PACE does not - community well & nursing facility residents • Rates vary reflecting levels of need & settings of care • Emphasis on home services • Keeping/choosing own PCP • Potential for statewide service areas

8. SCO Rate Development • Linked Medicare-Medicaid data • Six rating categories established for Medicaid per common utilization & cost groupings, with financial incentives to encourage community based care • Three rating categories negotiated with CMS and OMB per M+C and risk-frailty adjustors • Actuarially sound rates from historical data, trended and certified by Mercer.

9. SCO History Highlights • 1997: Initial waiver request to CMS • 1998: Addendum to CMS • 1999: Medicare Rate Agreement • 2000: DMA-CMS MOU • 2001: State Legislative Task Force • 2002: State Legislative Authorization • 2003: SCO Procurement

10. Key Components of Senior Care Options • Provider networks known as Senior Care Organizations (SCOs) • Medicare & Medicaid capitation payments-multiple rating categories • Incorporation of AAAs into model • Care management by PCP/PCT • Voluntary enrollment • Consumer sign-off on care plan • Aggressive quality management based on geriatric model of care

11. Benefits to MassHealth Seniors • Expert geriatric care from own doctor with the support of a PCT • Full spectrum of care from wellness to end-of-life • Support and education for families and caregivers • 24/7 access for help with health issues • “Peace of mind” as wishes are honored and carried out

12. SCO Time Lines • Jan 2, 2003 SCO RFR issued • Jan 23,2003 Responders Conf. • Mar 20,2003 Responses due • June 16, 2003 SCOs recommended • Sept 8-12, 03 Onsite reviews • November 2003 Contract(s) • December 2003 SCO enrollment begins