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

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

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

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

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

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

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

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

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

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

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

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