Medicaid Delivery Systems Long Term Services and Supports (LTSS) 1 - - PowerPoint PPT Presentation

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Medicaid Delivery Systems

Long Term Services and Supports (LTSS)

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Where Does LTSS Fit Into Medicaid?

• Although LTSS is a significant cost driver, LTSS has

not always been at the forefront of healthcare reform at state level.

• Why not?
• Is this changing? Why?
• Survey of State Medicaid Directors

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The Triple Aim

Better health

• utcomes

Higher patient satisfaction Lower costs

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Role of LTSS in Promoting Triple Aim

BENEFICIARY

Primary & Specialty Care Services Acute & Ambulatory Care Services Behavioral Health Services Long-Term Services and Supports

INTEGRATED CARE

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The Road to Integrated Care

• Traditionally, there has been a lack of

coordination between medical and LTSS systems. Why?

– Different providers/different language – Different reimbursement sources – Lack of financial incentives for collaboration/integration – Barriers to information exchange – Concerns around “medicalizing” personal supports – Other?

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Our Discussion Goals

How are you designing your delivery systems to meet the Triple Aim for your LTSS populations? Successes, challenges and lessons learned? What do States need to be successful?

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Medicaid Payment Models

Fee for Service Capitation Value Based Payments

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Value Based Payments (VBP)

• Value-based care is a form of reimbursement

that ties payments for care delivery to the quality of care provided and rewards providers for both efficiency and effectiveness.

• Goal is to achieve better care, smarter

spending, and healthier people by incentivizing quality, health outcomes, and value over volume.

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Relationship Between Payment Models and Delivery Systems

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Areas of Focus

Focus will be on degree of alignment for achieving Triple Aim in:

• 1. Traditional Medicaid delivery system (fee for

service).

• 2. Medicaid Managed LTSS (MLTSS) (capitation).
• 3. Integrated Models for Medicare and

Medicaid Services.

• 4. Accountable Care Organizations.

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MEDICAID FEE FOR SERVICE

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Fee For Service

• Providers are paid established reimbursement

rates for providing Medicaid services to eligible individuals.

• Payment is triggered by service delivery and is

based on volume of services.

• Payment is not tied to quality or efficiency.

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Traditional Medicaid FFS Delivery System

• State determines provider qualifications.
• State enters into provider agreements with any willing

and qualified provider.

• State sets payment methodologies and established

payment rates

• Payment is triggered by delivery of service.
• Medicaid provider submits service claim directly to

Medicaid agency.

• Medicaid agency directly reimburses provider for

services.

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Challenges Inherent in a FFS System

• Incentives not aligned with outcome
• Providers may deliver more care and more

expensive care because they are paid by volume.

• Lack of comprehensive care coordination

across service providers and settings resulting in fragmentation of care.

• Lack of flexibility to meet individualized need.

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State Strategies for Better Alignment with Triple Aim?

• Allowable Medicaid reimbursement for care

coordination/case management:

• Optional State Plan Targeted Case Management.
• Case management/care coordination under HCBS waiver

authorities.

• Use of waiver authorities and optional State Plan

services to increase flexibility (e.g. eligibility, covered services and other State Plan requirements)

• Use of State funded wrap-around services and

additional programming.

• Other?

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Typical Cost Control Approaches in LTSS

• Examples of possible state strategies:
• Place caps on service use (hours/visits/cost).
• Require prior authorization of services.
• Base rates on Resource Utilization Groups that tie

payment to level of acuity.

• Other examples?
• Increasingly, states are moving to other

approaches to manage their Medicaid LTSS budgets…

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MEDICAID MANAGED LONG TERMS SERVICES AND SUPPORTS

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Managed Care Entities

• Managed Care Organizations (MCOs)

– Comprehensive benefit package – Payment is risk-based/capitation

• Primary Care Case Management (PCCM)

– Primary care case managers contract with the state to furnish case management (location, coordination, and monitoring) services – Generally, paid fee for service for medical services rendered plus a monthly case management fee

• Prepaid Inpatient Health Plan (PIHP)

– Limited benefit package that includes inpatient hospital or institutional services (example: mental health) – Payment may be risk or non-risk

• Prepaid Ambulatory Health Plan (PAHP)

– Limited benefit package that does not include inpatient hospital or institutional services (examples: dental and transportation) – Payment may be risk or non-risk

Source: https://www.medicaid.gov/medicaid/managed-care/entities/index.html

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Our Focus

• “Managed Care is a health care delivery system
• rganized to manage cost, utilization, and quality.

Medicaid managed care provides for the delivery

• f Medicaid health benefits and additional

services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services”. -CMS

Source: https://www.medicaid.gov/medicaid/managed-care/index.html

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Key Elements of Managed Care Structure

• State enters into a contract with MCO to provide

benefits and services to Medicaid beneficiaries.

• State pays MCO a capitated per member per

month (PMPM) rate for each Medicaid enrollee.

• Plan contracts with Providers to provide services

to Medicaid enrollees.

• Plan and providers negotiate payment rates.
• Plan makes payments to providers.

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Varied Characteristics

• Populations covered
• Covered benefits
• Mandatory or voluntary enrollment
• Geographic coverage
• Number and types of Managed Care

Organizations (MCOs)

• Degree of integration with other services

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Statutory Authority for MLTSS

Authorities for implementing managed care delivery system:

• State plan authority (Section 1932(a))
• Waiver authority (Section 1915(b))
• Waiver authority (Section 1115)
• Section 1915 (a)-voluntary program

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In combination with:

• Any of the managed care authorities can be

paired with:

• State Plan HCBS benefits offered under 1905(a);

1915(i);1915(j); and 1915(k)

• HCBS waiver under 1915(c)
• Section 1115 waivers can also be used alone to

authorize the managed care delivery system as well as the HCBS benefits offered through that delivery system.

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Considerations in Choosing Authority

• Voluntary/involuntary enrollment?
• Choice of providers?
• Included populations?
• Types of beneficiary protections?
• Procedural/state administration considerations?
• Larger state Medicaid context?
• Other?

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MLTSS and the Triple Aim

• “By contracting with various types of MCOs to

deliver Medicaid program health care services to their beneficiaries, states can reduce Medicaid program costs and better manage utilization of health services. Improvement in health plan performance, health care quality, and outcomes are key objectives of Medicaid managed care.” –CMS

Source: https://www.medicaid.gov/medicaid/managed-care/index.html

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Caution!

• Risk-based capitation shifts state’s financial risk

for serving Medicaid participants on to a managed care organization (MCO) and provides more stability for state Medicaid budgets but…

• Risk-based capitation alone does not advance the

Triple Aim.

• Adequate planning process with broad stakeholder

input is critical element of program design.

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Other Essential Elements

• Robust stakeholder engagement
• Incorporation of person centered planning
• Support for participants and participant protections
• Coordinated and integrated set of benefits
• Strategies for ensuring provider capacity and

expertise

• Comprehensive quality strategy
• Alignment of payment structure with programmatic

goals

See CMS guidance

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And of course…

• Ensure that delivery system design supports

individuals to live in their homes and communities in the least restrictive and most integrated setting.

• Effectively manage LTSS so that services are

provided when and where they have the most benefit to reduce the need for avoidable institutional stays.

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New Managed Care Rules

Rule has specific LTSS provisions that align with delivery system goals. Rules includes among others standards for:

• Network adequacy for LTSS
• Assessment and care planning
• Stakeholder involvement
• Beneficiary support systems

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New Rules

• To further support state and federal delivery

system reforms, the final rules:

• Provides flexibility for states to have value-based

purchasing models, delivery system reform initiatives, or provider reimbursement requirements in the managed care contract

• Strengthens existing quality improvement

approaches with respect to managed care plans

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State Approaches for Aligning MLTSS Reimbursement Strategies with the Triple Aim

• Some examples:
• Withholding payment based on MCO performance
• n established quality measures.
• Requiring the MCO to include alternate payment

models in its contracts with its provider network.

• Establishing incentives for transitioning members

from nursing facilities.

• Discuss various state models and approaches.

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MODELS INTEGRATING MEDICARE AND MEDICAID (FFS AND CAPITATED)

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Source: Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid (MedPAC and MACPAC, 2017)

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Source: Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid (MedPAC and MACPAC, 2017)

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Medicare-Medicaid

• Receiving care from both Medicare and Medicaid

results in:

• Barriers to care coordination and fragmented care for the

beneficiary.

• Lack of financial integration between programs.
• Lack of financial alignment leads to cost-shifting

between Medicare and Medicaid and lack of incentive for program-combined cost-savings (e.g. providing lower cost LTSS to help reduce higher cost acute care)

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What Are Outcomes of Aligned Incentives?

• Allows health plans to pool resources from

both Medicare and Medicaid to cover the full scope of medical, behavioral health and LTSS.

• Provides health plans greater flexibility in use
• f funds
• Greater potential for providing non-covered items

and services that are considered necessary through the care planning process to meet the needs of the member.

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Integrated Models Aligning Medicare and Medicaid

• Program for All-Inclusive Care for the Elderly

(PACE)

• Medicaid LTSS integrated with Medicare

Advantage

• Financial Alignment Initiative (capitated and

managed FFS)

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PACE Programs

• One of earliest and most integrated Medicare-

Medicaid models

• PACE programs serve individuals who are age 55 or older

and who meet nursing facility level of care.

• Payment is risk-based capitated payment system (includes

Medicare and Medicaid). The PACE program becomes the sole source of Medicaid and Medicare benefits for PACE participants.

• Nationally, 38,535 people served by PACE as of May

2017

• PACE Innovation Act of 2015-state interest?

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Medicaid and Medicare Advantage Plans

• Fully Integrated Dual Eligible Special Needs Plans

(FIDE-SNPs)

• Offers high degree of integration of Medicaid and Medicare services
• Managed care plan contracts separately with both Medicare and Medicaid

to provide an integrated set of services to dual eligible individuals

• FIDE-SNPs must contract with state to provide Medicaid LTSS under risk-

based financing.

• As of January 2015, there were 37 FIDE-SNPs operating in 7 states: AZ, CA,

HI, MA, MN, NY, WI

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Financial Alignment Initiative

• Authorized under the ACA in 2010 to test integrated

care and financing models for Medicare-Medicaid beneficiaries

• Ten states are testing a capitated model: CA, IL, MA,

MI, NY (2), OH, RI, SC, TX, VA

• Two states are testing a fee-for-service model: WA, CO
• As of May 2017, enrollment in demonstrations was

398,000

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Capitated FAI Model

• The State, CMS and a health plan (known as an

MMP or Medicare-Medicaid Plan) enter into a three-way contract and the plan receives a blended payment to provide comprehensive coordinated care

• Opportunity for shared savings and include other

financial incentives tied to quality measures.

• Integrated processes for enrollment, benefits,

beneficiary protections

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Managed FFS FAI Model

• A managed FFS model in which states are

eligible to benefit financially from savings resulting from initiatives that improve quality and reduce costs. In this model, Medicare and Medicaid continue to separately finance distinct services through FFS payments to providers.

• Opportunity for shared savings

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VALUE BASED PAYMENT ARRANGEMENTS

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Continuum of Integrated Care Models and Features

Source: Medicaid and CHIP (MAC) Learning Collaborative accessed at https://www.medicaid.gov/state-resource-center/mac- learning-collaboratives/downloads/vbp_continuum-brief-july-2012.pdf

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Role of the Accountable Care Organizations

• Mechanism by which states are aligning

provider and payer incentives to focus on value rather than volume.

• Medicare and Medicaid ACOs
• Our focus is primarily state use of Medicaid

ACOs

47 Source: Center for Health Care Strategies, Inc. (CHCH)

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Elements of an ACO

• ACOs are intended to improve care

coordination and service delivery by holding providers financially accountable for quality and outcomes.

• Three key components:
• Value-based payment structure
• Quality improvement measurement
• Data collection and analysis

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Tradition FFS – no responsibility for outcome MLTSS – responsibility for quality and

• utcomes rests

with MCO. ACOs- Responsibility for quality and

• utcomes

extends down to provider level.

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Aligning Financial Incentives through Value–based Purchasing

• Examples of ACO value-based payment

reimbursement models:

• Shared Savings Arrangement (gains only or risk-

based with gains/losses)

• Global budget model

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Key Ingredient: Quality Measurement

• Payment is tied to providers meeting certain

quality metrics:

• What do states typically requires of ACOs for

quality measures?

• How do states set benchmarks?

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“Data Data Data”

• To be effective, the ACO model requires timely

and accurate data collection to effectively deliver care coordination and target appropriate intervention.

• Key goal of providing “right care at right time”.
• Significant investment for both State and ACO

in infrastructure and technology.

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LTSS and Value Based Purchasing

• What is the readiness of LTSS providers to

participate in value based purchasing? Capacity? Infrastructure?

• State examples of value based purchasing and

LTSS

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Other Initiatives in Your State: Impact

• n LTSS?
• Delivery System Reform Incentive

Payment (DSRIP)?

• Medicaid Health Homes?
• Designated State Health Programs (DSHP)?
• Section 1115 demonstration waiver?

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What’s Needed for Strategic Reform?

A few thoughts:

• Leadership
• Human Resources
• Expertise
• Infrastructure Investments
• Culture Change
• Other?

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What does the Future Hold?

• Per capita caps?
• Block grants?

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Contact Information

Elizabeth Gattine

Senior Policy Associate Muskie School of Public Service University of Southern Maine Elizabeth.Gattine@maine.edu