1. Positioning for Integration
Building Plan Capacity
SNP Alliance Leadership Forum
November 2, 2012
Catherine Anderson, MPA
National Vice President, Strategy and Development
Medicare-Medicaid Enrollees

2. Embracing the opportunity
States have unprecedented interest in addressing the needs of their most complex populations
Fiscal realities balancing political opposition
Political interest is expanding
Specialty and complex populations no longer off the table
Timing may be tiered to address unique populations
Comprehensive solutions seem to be gaining interest
Reduces administrative burden
Creates comprehensive incentives
Demonstration authority re-energizing states
Removal of historic barriers provides incentives 2

3. Creating an integrated health plan
Few plans have comprehensive experience in managing Medicare-Medicaid Enrollees
Most plans are likely to be challenged by developing certain capabilities to support integrated solutions
Many plans are still learning what it means to be integrated

4. The competencies of integrated plans
Medicare
Medicaid
LTSS

5. Medicare develops to Medicaid
Medicare plans are well positioned to meet the CMS filing requirements
Medicare plans are well positioned to deliver acute networks
SNPs may be better positioned based on more intimate relationships with providers
Growth Opportunities
Establishing Medicaid regulatory infrastructure and oversight
Interacting with Medicaid agencies is much more direct than Medicare oversight
Reporting requirements are often more onerous and state-specific
May need to adjust provider networks to incorporate historic Medicaid providers
Likely more challenging for non-SNP Medicare plans

6. Medicaid develops to Medicare
Medicaid plans have established processes for interacting with state regulators
Medicaid plans understand Medicaid delivery models and safety net systems
Multi-state Medicaid plans understand state variances
Growth Opportunities
Understanding and maneuvering through Medicare filing requirements
Managing Medicare benefits and medical necessity
Part D (filing, formulary development, MTMP, reporting)
Reconciling provider networks to address historic Medicare provider use

7. Developing LTSS competencies
LTSS competencies vital to comprehensively managing the population
Developing LTSS networks unlike traditional Medicare and Medicaid networks
Payment terms
Codes
Credentialing
Community based organizations\
Provider relations
Assessing for functional and social needs unique from physical and behavioral health
Aligning LTSS benefits directly to needs vital to ensuring viability
Intimacy in care coordination
High volume of staff

8. Stretching overall plan competencies to match trends
Person Centeredness
Active participation of individuals and/or family
Consumer Engagement
Learning new language
Meaningful member advisory involvement
Delivery Flexibility
Leveraging Community Based Organizations
Multi-entity inter-disciplinary care teams
Primary Care
Supporting expansion of role of primary care
Filling gaps for primary care case management
Payment Flexibility
Meaningful incentives
Up and down stream engagement
Non-traditional providers

9. Additional considerations for plans
Risk stratification
Vital to resource allocation
Needs breadth to uncover hidden risks/opportunities
Assessments
Comprehensive tools are necessity
Physical, behavioral, functional, and social indicators must be adequately reviewed
Linking need to benefits/services key to managing LTSS, preparing for Fair Hearing and avoiding overturn decisions
Transition monitoring
System-wide transition planning essential
Quality monitoring
Non-traditional measures

10. Additional considerations for plans
Care coordination
Monitoring and inter-rater reliability
Comprehensive care planning tools
Interfaces to systems/providers outside of plan
Provider payment
Clear appreciation for total payments and historic trends
Addressing cross over payments
Increased access
Moves beyond finding another physician for network
Rapid member engagement
Passive enrollment + opt-out ability requires need to have timely member touch points
Real-time monitoring and adjustment
Trigger events key due to comprehensive risk

11. Preparing for the populations
In many instances the populations targeted for integrated models have been historically unmanaged
Requires plans to develop engagement strategies to demonstrate value of managed care
Requires engagement with stakeholders, providers, and CBOs to serve as influencers on value proposition
Complexities of population and delivery systems have to be assessed
Specialty populations such as DD or AIDS generally access the system in unique ways
Managed care must demonstrate flexibility and sensitivity
Interaction with waiver services and non-waiver services vital to comprehensive approach to care

12. Network and provider considerations
Blurring the lines between Medicare and Medicaid delivery systems
Community Health
Traditional Medicare/Commercial providers
Increasing expectations of provider engagement
PCMH HH
Increasing health plan oversight for providers
ADA
Primary care impacts on LTSS
Expanding the view of quality in incentive structures
Moving beyond acute utilization to address comprehensive concerns

13. Ensuring the success of integration
Demonstrations and other integration activity is unique and unprecedented opportunities for complex populations
Failure of demonstrations to improve quality, create community access and increase community placement, aligning incentives, and creating sustainability will lead to long-term consequences
Plans have significant responsibility to understand the complexities and ensure an ability to support the needs of the population