1. Medicare/Medicaid Eligibles Integrated Care Initiative June 28, 2012

2. Today’s Agenda Context Key features of Integrated Care Demonstration
The beneficiary’s perspective
Notes on revisions made in final submission 2 2

3. Context CMS quality and cost initiatives
Medicare Advantage (MA) plans (capitated)
Physician Group Practice (PGP) Demonstration
first CMS pay-for-performance initiative that encouraged physicians to coordinate overall care delivered to Medicare beneficiaries
646 Demonstrations (e.g. North Carolina)
physician/hospital integrated care and pay-for-performance initiative 3 3

4. Context Affordable Care Act - CMS “Triple Aim”:
improve the health of the population
enhance the individual’s experience of care (quality, accessibility, reliability)
control the rate of increase in, and where possible reduce, the per capita cost of care 4 4

5. Context Connecticut Medicaid reforms:
Transition to ASO: Effective January 1, 2012, Medicaid medical services were transitioned to an Administrative Services Organization (ASO), CHN-CT
Member support
Utilization management
Predictive modeling based on Medicaid data
Intensive Care Management (ICM)
Quality management 5 5

6. Context Connecticut Medicaid reforms:
Launch of Person-Centered Medical Home (PCMH) pilot: Effective January 1, 2012, the Department implemented a PCMH pilot to support primary care practices along a developmental curve toward certification under NCQA standards
Enhanced reimbursement and technical assistance to support practice transformation
Performance payments for achieving benchmarks on identified measures 6 6

7. Context Connecticut Money Follows the Person (MFP):
transitions of individuals from institutional settings to the community
applied practice of person-centeredness and the dignity of risk
nursing home modernization and diversification
workforce initiatives 7 7

8. Today’s Agenda Context
Key features of the Integrated Care Demonstration
The beneficiary’s perspective
Notes on revisions made in final submission 8 8

9. Goals
Connecticut’s overall vision for the Demonstration is to create and enable value-based systems through which MMEs will receive integrated, holistic, person-centered services and supports that address the entirety of their needs (physical, behavioral, and non-medical) 9 9

10. Goals (cont.) improved health outcomes improved care experience
controls on the rate of growth of (and if possible, reductions in) costs of care 10 10

11. Profile of population to be served
Connecticut MMEs have complex, co-occurring health conditions
roughly 88% of individuals age 65 and older has at least one chronic disease, and 42% has three or more chronic diseases
58% of younger individuals with disabilities has at least one chronic disease
38% has a serious mental illness (SMI) 11 11

12. Profile of population to be served (cont.)
Connecticut MMEs use a disproportionate amount of Medicaid resources and Connecticut is spending much more than the national average on MMEs
the 57,568 MMEs eligible for the Demonstration represent less than 10% of Connecticut Medicaid beneficiaries yet they account for 38% of all Medicaid expenditures 12 12

13. Profile of population to be served (cont.)
per capita Connecticut Medicaid spending for the 32,583 MMEs age 65 and over and the 24,986 MMEs with disabilities under age 65 is 55% higher than the national average 13 13

14. Profile of population to be served (cont.)
comparatively high spending alone on MMEs has not resulted in better health outcomes, better access or improved care experience
illustratively, in SFY’10 almost 29% of MMEs were re-hospitalized within 30 days following a discharge, and almost 10% were re-hospitalized within 7 days following a discharge 14 14

15. Profile of population to be served (cont.)
MMEs have reported in Demonstration-related focus groups that they have trouble finding doctors and specialists that will accept Medicare and Medicaid, and often do not feel that the doctor takes a holistic approach to their needs 15 15

16. Historical barriers Lack of integration between Medicare and Medicaid
Lack of provider connections across the care continuum
Situational care planning
Access barriers related to:
Ethnicity, disability, language of origin, culture, values
Costs of care
Coverage rules 16 16

17. Means of Achieving Results
The Demonstration will integrate Medicare and Medicaid long-term care, medical and behavioral services and supports, promote practice transformation, and create pathways for information sharing through key strategies including:
data integration and state of the art information technology and analytics
person-centered Intensive Care Management (ICM) and care coordination in support of effective management of co-morbid chronic disease 17 17

18. Means of Achieving Results (cont.)
expanded access for MMEs to Person Centered Medical Home (PCMH) primary care
electronic care plans and integration with Connecticut’s Health Information Exchange to facilitate person-centered team based care 18 18

19. Means of Achieving Results (cont.)
a learning collaborative approach designed to enhance the capability of providers to support the needs and preferences of MMEs
a payment structure that will align financial incentives (advance payments related to costs of care coordination and supplemental services, as well as performance payments) to promote value 19 19

20. Structure CMS model alternatives:
CMS has permitted States to choose between two financial alignment models in support of integrating care for Medicare-Medicaid enrollees:
a capitated approach
a managed fee-for-service (FFS) approach
Connecticut has selected the FFS approach 20 20

21. Structure (cont.)
Connecticut’s Demonstration will build upon existing Medicaid reforms:
enhancements to current ASO capability
member services
predictive modeling based on Medicare data
Intensive Care Management (ICM)
quality management
integration of Medicaid and Medicare data
electronic tools to enable communication and use of data
expansion of the PCMH program (both models) 21 21

22. Structure (cont.) Two models:
Model 1 (Administrative Services Organization) will seek to improve health outcomes and care experience of MMEs by enhancing the strengths of Connecticut’s medical and behavioral health ASOs
Model 2 (Health Neighborhood) will launch a new local, person-centered, multi-disciplinary provider arrangement called the Health Neighborhood (HN) 22 22

23. Structure (cont.) Enrollment:
a subset of the MMEs that participate in the Demonstration will be passively enrolled in HNs based on receiving primary care or behavioral health care from a participating HN provider
beneficiary protections:
neutral enrollment broker
beneficiary notice and educational materials
option to decline to participate 23 23

24. Structure (cont.) Enrollment:
the remaining population of MMEs, with the exception of those who are enrolled in a Medicare Advantage (MA) Plan, or aligned with an Accountable Care Organization (ACO) as of December 1, 2012, will be attributed to Connecticut’s medical or behavioral health Administrative Services Organizations (ASOs) under Model 1 24 24

25. Structure (cont.) Model 2: Health Neighborhoods (HNs)
Department will seek to procure 3 – 5 HNs
HNs will be comprised of a broad array of providers, including primary care and physician specialty practices, behavioral health providers, LTSS providers, hospitals, nursing facilities, home health providers, and pharmacists 25 25

26. Structure (cont.)
Each HN will identify a “Lead Agency” that will provide administrative oversight, performance monitoring, coordination of provider members, identification of the means through which ICM and care coordination will be provided, and distribution of shared savings
May require behavioral health agency “co-Lead” 26 26

27. Structure (cont.) HN financing model: start-up payments
advance payments to support care coordination and supplemental services (APM II)
performance payments (retrospective) 27 27

28. Today’s Agenda Context Key features of Integrated Care Demonstration
The beneficiary’s perspective
Notes on revisions made in final submission 28 28

29. The Beneficiary’s Perspective
Advantages of joining a Health Neighborhood (HN)
HN will use a person- and family-centered, personalized, team-based approach that is consistent with the MME’s needs and preferences
MME will select his/her preferred care coordinator
a consistent team of providers will support the MME and his or her family member/caregiver in planning and coordinating care 29 29

30. The Beneficiary’s Perspective
Advantages of joining a HN (cont.)
HN will provide specialized supports to identified populations
HN will provide additional benefits and services:
Chronic illness self-management education
Nutrition counseling
Falls prevention
Medication therapy management
potentially also, recovery assistant and peer support 30 30

31. Who will benefit?
An older adult with COPD who lives alone and who has experienced multiple unexplained falls and associated hospitalizations within the past six months will be able to work with her Access Agency care manager and a team of providers (e.g. primary care physician, cardiologist, pharmacist, home health nurse and OT) to examine the reasons for the falls and implement interventions that will reduce or eliminate her need to go to the hospital. 31 31

32. Who will benefit?
A younger individual with diabetes and bipolar disorder will be able to enlist his behavioral health care manager and a multi-disciplinary team to work on strategies for understanding his conditions and effectively managing them. 32 32

33. Who will benefit?
Providers that have historically had few opportunities and tools to do so will have means and opportunity to be in direct contact and to collaborate. 33 33

34. Today’s Agenda Context Key features of Integrated Care Demonstration
The beneficiary’s perspective
Notes on revisions made in final submission 34 34

35. Summary of Revisions
provided greater detail to distinguish between Models 1 (ASO) and 2 (Health Neighborhood)
reserved the concept of a separate, behavioral health co-Lead Agency for each HN for further discussion
clarified the means by which individuals will be passively enrolled in HNs
provided additional detail on the proposed care coordination process 35 35

36. Summary of Revisions revised Performance Payment Program:
Year 1: Performance Payment Pool
Year 2: Quality Bonus Pool and Value Incentive Pool
inserted a summary of the public comments that were received 36 36

37. Next steps . . .
The Department submitted final application to CMMI on May 31, 2012
Application is posted on Department’s web site:
Further work will be done on HN composition, care coordination, performance measures
Implementation anticipated January 1, 2013 37 37