10/15/2019 Working Together to Improve Care, Outcomes and Health - - PDF document

10/15/2019 1

Health Systems Division

Working Together to Improve Care, Outcomes and Health for Oregon Dual Eligibles Through Integrated Care

Jennifer Valentine Medicare-Medicaid Policy Analyst Health Systems Division October 16, 2019

CCO to MA Affiliation Contractual Requirements for 2020

CCO 2.0 Building Stronger Integrated Care For Duals

• Opportunity to meet CCO 2.0 Triple Aim & contain cost growth with increased focus
• n Oregon Dual Eligibles
• Fits with focus on ICC, IDT, Care Transitions, HIE platforms
• Duals: High Needs Population

– High Needs: need trauma informed approaches and outreach – Need for social determinants assistance – Duals more likely to have ADA issues or be minorities – High Unmet Behavioral Health Needs

• Oregon Medicaid – Medicare Plan Alignment has only been 1/3 of FBDE –with the

majority of aligned population being in the CCO and DSNP (@20,000 members)

– Opportunities to create integrated provider networks and align benefits – Opportunities to align quality improvement projects (PIPs), metrics, and VBID – Opportunities to address social determinants impacting FBDE

• Significant % of FBDE duals still in traditional Medicare FFS: Why?

– In part, members don’t know options and benefits of integrated care:

*Limited In‐Depth Choice Counseling annually on choice options *Limited # of CCOs communicating about alignment to FBDE *New enrollment opportunities still under‐utilized except by 2 DSNPs *Lack of outreach to FFS Medicare providers who serve FBDE

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Health Systems Division

Enrollment of Medicaid/Medicare eligible OHP clients in Medicare Advantage Plans ‐15 August 2019

Data based on the 15 August 2019 census of OHP run on 9/10/2019 6:22:25 AM CCO no MMA Plan non‐Affiliated MMA Plan Affiliated MMA Plan *1 Total Number

• f Clients

% no MMA Plan % Affiliated MMA Plan*2 ADVANCED HEALTH (CCOA) 1,845 66 1,911 96.5% 0.0% ALLCARE CCO‐ INC. (CCOA) 1,727 310 1,256 3,293 52.4% 80.2% CASCADE HEALTH ALLIANCE‐ LLC (CCOA) 588 59 675 1,322 44.5% 92.0% COLUMBIA PACIFIC CCO LLC (CCOA) 1,507 102 423 2,032 74.2% 80.6% EASTERN OREGON CCO‐ LLC (CCOA) 3,607 63 50 3,720 97.0% 44.2% FEE‐FOR‐SERVICE (FFS)*1 6,851 2,687 9,538 71.8% 0.0% HEALTH SHARE OF OREGON (CCOA) 10,439 2,636 13,812 26,887 38.8% 84.0% INTERCOMMUNITY HEALTH NETWORK (CCOA) 2,477 570 1,390 4,437 55.8% 70.9% JACKSON CARE CONNECT (CCOA) 1,321 132 879 2,332 56.6% 86.9% PACIFICSOURCE COMMUNITY SOL GORGE (CCOA) 606 13 115 734 82.6% 89.8% PACIFICSOURCE COMMUNITY SOL INC (CCOA) 1,069 55 1,861 2,985 35.8% 97.1% PRIMARYHEALTH JOSEPHINE CO CCO (CCOA) 594 179 29 802 74.1% 13.9% TRILLIUM COMMUNITY HEALTH PLAN (CCOA) 4,241 1,530 2,149 7,920 53.5% 58.4% UMPQUA HEALTH ALLIANCE‐ DCIPA (CCOA) 914 86 1,190 2,190 41.7% 93.3% WILLAMETTE VALLEY COMM. HEALTH (CCOA) 2,775 1,273 3,134 7,182 38.6% 71.1% YAMHILL COMMUNITY CARE (CCOA) 1,375 492 18 1,885 72.9% 3.5% 41,936 10,253 26,981 79,170 53.0% 72.5% *1: FFS clients enrolled in an "Affiliated" MMA plan meaning in an MMA Plan affiliated with one of the OHP CCOA organizations *2: Percentage of clients Enrolled in an MMA plan who are in a plan affiliated with their CCOA plan % Affiliated MMA Plan*2 = Affiliated MMA Plan/(Affiliated MMA Plan+non‐Affiliated MMA Plan)

88% now enrolled in CCO A! (increased from 58% with Duals Passive Enrollment Initiative)

Health Systems Division

• Duals with aligned Medicare Advantage and Medicaid managed care (CCO) experienced

an improvement in health service use and quality of care between 2011 and 2014.

• When we compared duals with aligned plans to those with nonaligned Medicare

Advantage and Medicaid managed care plans; we found that while care differed minimally between these two groups at baseline, it changed in a more desirable direction over time for duals with aligned plans. (highest percent of alignment in CCOs with DSNPs).

• By the end of our study period, duals with aligned plans had lower emergency

department visit and hospitalization rates and higher primary care visit rates, compared with those with nonaligned Medicare Advantage and Medicaid managed care plans. They were also more likely to receive diabetes HbA1c testing and LDL cholesterol screening.

• Aligned Medicare and Medicaid programs might have a greater incentive to coordinate

care and save costs to benefit both programs over time.

Q: Why does it matter if a dual eligible has aligned Medicare and Medicaid benefits? Oregon Data

“Comparing Care for Dual‐Eligibles Across Coverage Models: Empirical Evidence From Oregon” Kim, Charlesworth, McConnell, Valentine, and Grabowski, Medical Care Research and Review, 1‐17, 2017

10/15/2019 3 What is Medicare – Medicaid Alignment & How Do We Get There?

• Communication
• Population Health Management

(Using Data!)

• Care Coordination
• Care Transitions
• Health Promotion
• Member Engagement
• Health Equity & Social

Determinants of Health Lens Across All These Areas

Key Areas To Impact Outcomes

CCO 2.0 Alignments & Expectations for Full Benefit Dual Eligibles (FBDE)

• All CCOs to have MA alignments for 2020 to meet contractual requirements:

Some examples include:

– address billing crossovers, – review of authorization requests to limit delay of needed services, – integrate care coordination with LTSS and Medicare benefits, – ensure access to behavioral health, integration of Medicaid/Medicare benefits – monitor preventive service and screenings, including those for behavioral health – ensure providers are following balance‐billing rules, – ensure providers address disability & language access – provide members with communication about integrated care alignment opportunity – where possible develop and use integrated Medicaid/Medicare member materials; – work to ensure smooth transitions of care – build models that incorporate social determinants of health focus

• Processes to achieve greater alignment to be further discussed at CCO CMS Alignment

meetings

Health Systems Division

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Exhibit B – Statement of Work – Part 3: Patient Rights, Responsibilities, Engagement, Choice

Health Systems DIvision

• 1. Member and Member Representative Engagement in Member Health

care and Treatment plans

• Agreement should include any expectations and processes to ensure member/member

representative involvement in care planning and the process by which to access items in (a) – (g) specific to CCO to MA relationship

• More on Intensive Care Coordination Plans (ICCP) and Treatment Plans in Exhibit B Parts

2 and 4, Exhibit M

4., 5. and 6. Member and Potential Member Information

• New OARs 410-141-3580 and OAR 410-141-3585
• Contractor shall communicate to provide FBDE members with written communications

regarding opportunities to align benefits with Affiliated MA or DSNP plan(s).

• Communicate with providers serving FBDE about care coordination needs, ICC, etc.
• Identify opportunities to streamline communications to FBDE members to improve

coordination of Medicare & Medicaid Benefits (might include Member handbooks, Provider Directories, Integrated ID Card formats)

• Integrated materials will be required to receive Medicare and Medicaid approvals as

appropriate

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63%

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9 10

48%

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Behavioral Health Conditions Are Highly Prevalent among Dually Eligible Beneficiaries

Source: MedPAC‐MACPAC. “Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid.” January 2018. Exhibit 8. Available at: http://medpac.gov/docs/default‐source/data‐book/jan18_medpac_macpac_dualsdatabook_sec.pdf?sfvrsn=0

Behavioral health conditions are more prevalent among dually eligible beneficiaries under age 65 than among those age 65 and older.

Behavioral Health Condition (CY 2013) % Under 65 % 65 and Older Anxiety Disorders 24% 15% Bipolar Disorder 15% 3% Depressive Disorder 33% 22% Schizophrenia and Other Psychotic Disorders 13% 7%

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Dually Eligible Beneficiaries with Mental Health Conditions Have High Physical Health Comorbidity Rates

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Source: CMS. “Physical and Mental Health Condition Prevalence and Comorbidity among FFS Medicare‐Medicaid Enrollees.” 2014. Table 25. Available at: https://www.cms.gov/Medicare‐Medicaid‐Coordination/Medicare‐and‐Medicaid‐ Coordination/Medicare‐Medicaid‐Coordination‐ Office/Downloads/Dual_Condition_Prevalence_Comorbidity_2014.pdf

Chronic Physical Health Comorbidity for Those with Mental Health Conditions (CY 2008) Prevalence Hip/Pelvic Fracture 61% Other Metabolic Disorder 55% Stroke 54% Lung Disease 52% Anemia 47% Musculoskeletal Disorder 46% Kidney Disease 45% Diabetes 42% Heart Condition 42% Neoplasm 40% Eye Disease 39%

• Physical health

comorbidities are prevalent among individuals with mental health conditions

• One or more mental health

conditions were found to co‐occur in over 50% of those with:

• Hip or pelvic fracture
• Metabolic disorder
• History of stroke and
• Lung disease

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Exhibit B -Statement of Work Part 2: Covered and Non-Covered Services

• 1. Covered Services

Health Systems DIvision

• 2. Provision of Covered Service: As applicable to ensure FBDE members receive care that

meets expectations in sections (a) (b) (c) (g).

• 3. Authorization or Denial of Covered Service*:
• Contractor shall work with their affiliated or contracted MA or DSNP plan to process authorization

requests collaboratively for FBDE members enrolled in both plans to not create undue delay in review and notification of coverage determinations, especially where member’s health condition requires timely processing of requests.

• Authorization of services for Members with Special Health Care Needs or receiving Long Term

Services and Supports

• mechanism in place to allow Members to directly access a specialist (for example, through

a standing referral or an approved number of visits)

• services authorized in a manner that reflects the member's ongoing need for such services

and supports and do not create a burden to Members needing medications or services to appropriately care for chronic conditions

*See also requirements under Exhibit B -Statement of Work Part 8: Accountability and Transparency of Operations: 6. Medicare Payers and Providers

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Exhibit B -Statement of Work Part 2: Covered and Non-Covered Services

Health Systems DIvision

• 4. Covered Services: NEMT
• Ensure processes for meeting access requirements and verifying Medicare appointments and services

for FBDE members use of NEMT to access those services s noted under (d) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) with CCO NEMT Broker/Contracted provider(s)

• 6. Covered Services: Preventive Care, Family Planning, PHEC
• Ensure clarity on authorization processes and communication to ensure FBDE members can access

the full-scope of preventive care, family planning and other OHP services by adopting shared protocols for authorization, and claims processing.

• Contractor shall ensure that all Member’s post-discharge services and care needs are in place prior to

discharge from PHEC, including but not limited to DME, medications, HCBS, discharge education or home care instructions, scheduling follow-up care appointments, and instructions with reminders:

• Attend already scheduled appointments or schedule appointments with providers for follow-up
• 7. Covered Services: Medication Management as noted:
• To ensure FBDE members receive appropriate medications necessary for treatment of physical or

behavioral health conditions, Contractor shall coordinate with FBDE members MA, DSNP or Part D plan to ensure members are connected to Medicare medication management services.

Exhibit B -Statement of Work Part 2: Covered and Non-Covered Services

Health Systems DIvision

• 4. Covered Services: Intensive Care Coordination
• Process to access CCO (a) Intensive Care Coordination (b) (c) (d) and other services through CCO
• utlined in item 9 or 10. New OAR 410-141-3870 Intensive Care Coordination
• Specifies populations of duals at risk for ICC assessment and services
• Also OAR 410-141-3865 Care Coordination Requirements
• And OAR 410-141-3860 Integration and Coordination of Care

Opportunity to Create Care Alignment with MA plans

DSNP Model of Care (MOC):

• MA Plans that are Dual Special Needs Plans are required to address similar issues in their

required Model of Care so there’s great potential for alignment of care management

• Health risk assessment tool (HRAT)
• Interdisciplinary care team (ICT)
• Care management team: staff & provider roles
• Individualized care plan (ICP)
• Care coordination
• Goals for providing seamless transitions of care
• Goals for improve use of preventive health services

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Exhibit M—Behavioral Health Services

Health Systems DIvision

Opportunity to Address Unmet Behavioral Health Needs:

• -Screenings and Assessments and Links to Treatment
• Comprehensive BH Assessment Tools,
• Specific Tools (i.e. recognized cognitive assessment tools) that might be indicated for

specific needs like Dementia; Suicide Assessment

• Screening for adequacy of supports in the home
• Link to screening for Medicaid funded LTSS services
• Screening for medically appropriate and evidence-based treatments for those with both

substance use and mental illness

• SBIRT screening points of contact
• Crisis Management System
• Link to ICC/ICCP, Medication Management
• Transitions of Care

Collaborative Relationships

Exhibit B -Statement of Work Part 4: Providers and Delivery System

Health Systems Division

Section 1: Integration and Care Coordination

• Health Risk Screening

Collaborative Relationships

• Continuum of Care that supports integrated care such as use of screening tools, treatment standards,

guidelines and coordination

• Coordinate to reduce duplication as required by CFR 42§438.208 (b) (2) and (5)

Section 2: Access to Care

As noted in 2(a)(b)(c)(d)(e) (f) (g) (h) (i) (j) (k) (l) (m) (n) (p) Coordinate linkages with MA Plan to ensure FBDE members are provided access to OHP services

• Standing referrals/authorization of services to ensure access for those with disabilities/chronic

conditions or receiving LTSS

• Production of Integrated Treatment or Care Plans (ICCP)—2(a)(6) {and elsewhere}
• Requirements to ensure assessments completed to determine needs
• Assurances to meet needs unique to members (cultural, linguistic, ADA)
• Item O: Create integrated policies and procedures for FBDE members with affiliated MA plan.

Section 3: Delivery System and Provider Capacity

Elements of Integration for FBDE–(1) (2) (3) (4) (5) (6) (7)

• Ensure process for Medicare providers to enroll for crossover billing
• Section 8 Care Coordination: Processes to ensure OHP FBDE members receive integrated care as

set forth in (a) (b) (c) (d) ; where applicable inclusion in (e); (f) (g)

• 9. Care Integration: processes to ensure integrated care OHP FBDE

as set forth in (a)(1) (2) (3) (4) and (b) Primary Care Relationships

10/15/2019 11 CCOs important to Primary Care Home Enrollments

Enriched Understanding of High Need Members: Duals documented to have high SDOH needs & trauma history

• The relevance to health of Adverse Childhood Experiences (ACE): troubled

lives lead to troubled health over a lifetime; people get derailed early in life and

• ne bad thing leads to another.
• Complex care needs to address social determinants (housing, food,

transportation, etc) as well as the effects of trauma

• Creating systems of care that ensure screening, support, SDOH, outreach

Mechanism by Which Adverse Childhood Experiences Influence Health and Well-being Throughout the Lifespan

• Trauma-Informed Care

https://traumainformedoregon.org/

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Other Links to Build Stronger Integrated Approaches for Duals

Health Systems DIvision

SDOH & Health Equity

• Community Advisory Council –Membership & Meetings,
• Demographic Report and Community Health Assessment (CHA)/Community Health Improvement

Plans (CHP)

• SHARE Initiative: SDOH & Equity Spending
• Health Equity Deeper Dive on Duals Disparities/Unique roles for THWs

Exhibit J: Health Information Technology—Links to HIT Roadmaps

• Hospital and Skilled Nursing Facility Event Notifications
• HIE Provider Referrals and Integrated Care Planning –ensure you are linking Medicare providers with

Behavioral health providers for example

• Building greater use by providers across system to reduce silos of care

Quality Improvement & VBID

Exhibit B –Statement of Work Part 10: Transformation, Quality and Performance Metrics

• Affiliation agreement should outline any expected involvement in transformation and quality

strategy requirements (see specific requirements for DSNPs in sample DSNP COBA Agreement) to address FBDE member health improvement projects or Performance Measurement reporting)

• Opportunity to create a shared Medicare‐Medicaid TQS project for Duals with Special Health Care

Needs VBID/APM ‐‐

• Opportunity to create alignment for providers in VBID or APM models

MOUNTAIN CLIMBING OREGON STYLE…ARE WE AT THE TOP OF THE MOUNTAIN YET?

CCO 1.0 in the rear view, PCPCH Success Continues to Build ACA Expansion Integration of Behavioral Health and Dental Health CCO & LTSS MOUs EDIE/Event Notifications & HIE

In In Oregon, Oregon, we se set our goals high! t our goals high! Ne New oppor pportunities unities to creat reate more

• re int

ntegrat egrated care are and and alignment lignment for duals! uals!

10/15/2019 13 Quick Follow-Up on Recent Webinar 2021 Contracting Cycle: D-SNP COBA with OHA

• Plans notify OHA of plan to request a

COBA (Coordination of Benefits Agreement) for FY2021 no later than January 1, 2020 –or sooner if you can

• This includes any requests to include

additional counties or any geographic changes

• D‐SNP Contractors’ Medicare Plan

meetings scheduled for Feb, March and May 2020

• All final contracts signed in June 2020

for FY 2021

• OHA made changes to 2020 D‐SNP

contracts to align with CCO 2.0 and address elements of Bi‐Partisan Budget Act

• Will be determining any additional

elements needed for FY 2021 to incorporate

• We won’t be aligning Grievances &

Appeals at this time, but are asking all to use Integrated Denial Notice (IDN) for aligned FBDE members

• Contact Jennifer at OHA if you would

like to set up technical assistance for your plan with ICRC

Health Systems Division