Grant Recipients Outline Medicare and Medicaid Integration Plans
The 15 states that received an initial $1 million grant to design an integration plan for Medicare and Medicaid have been invited to submit an application to the Center for Medicare and Medicaid Innovation outlining how they would implement the integration plan. The states included in the original grant include: Minnesota, Massachusetts, Michigan, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington, and Wisconsin.
The implementation grants are designed to create integration between Medicare and Medicaid, and to allow the states to share in any savings created through Medicaid program design or funding that results in savings to Medicare. An example might include developing a more robust home and community-based program model that reduces hospitalizations, rehospitalizations, greater home care utilization, or skilled nursing facility placements.
The Minnesota Department of Health, one of the states pursuing this initiative, said in a statement how it proposed to improve care:
“A new CMS initiative, ‘State Demonstrations to Integrate Care for Dual Eligible Individuals,’ provides an opportunity for Minnesota to improve the integration of services for people who are dually eligible for Medicare and Medicaid services. Under this demonstration, the State of Minnesota proposes to re-design existing managed care programs for dual eligibles to promote aligned incentives for accountability for the total cost of care across both payers including provider based payment reform and care delivery innovations, with continued focus on person-centered individualized care coordination to achieve a seamless beneficiary experience … Integrated financing is the first step in aligning provider service delivery and purchasing arrangements, supporting provider level payment reforms, increasing provider accountability and improving outcomes to improve costs, accountability and outcomes of care. Integration is also critical to simplifying access and improving the experience of dual eligibles by reducing confusion.”
Application due date
The applications are due from the states by April 26, 2012, with the ability to implement the proposed integration program starting on January 1, 2013.
Based on Centers for Medicare and Medicaid Services (CMS) documents, there are 25 states currently in the process of developing integrated financial capitated contracting models for dual eligibles. The minimum savings that would accrue to CMS has not yet been set, but there are performance withholds of 1 percent in the first year, escalating to 3 percent by the third year.
Varied proposals for each state
Unlike many other states, Minnesota has enrolled Medicare/Medicaid beneficiaries in managed care for over 15 years, so the programs being proposed around the country will likely be very different. Each will have common elements, though. All will likely rely on Medicare savings to fund some of the changes to Medicaid benefits required under the Accountable Care Act and to support the needs of elders as their numbers grow.
Additionally, these programs will be designed to create greater integration and higher quality of care — right care at the right time — through integration, enrollment, and benefit design and simplification of service delivery processes. The lower costs will likely come from greater community care through medical homes, care coordination, support for family caregivers, or expanded home and community based services and through new financing mechanisms.
The models being proposed will vary widely, and it is not clear yet whether or not all 15 states will apply under the implementation grant. If New York participates, its model will likely drive all dual eligible beneficiaries to managed care, but the roles and relationships may be designed differently and may be more strongly influenced by health insurance regulations.
Vermont is moving to a single payer platform and it will also develop a benefit package and service model that will incorporate the payment reforms currently occurring in that state. The Massachusetts program is focused on developing comprehensive capitated managed care arrangements for the 21 to 64 aged beneficiary.
The Colorado program, initially called the accountable care collaborative has a vision that all dual beneficiaries will be enrolled in a single service delivery system that includes a medical home, and is assigned via a regional care collaborative organization.
Dual eligible beneficiaries white paper
Families USA has developed a white paper that summarizes the number of beneficiaries who are dual eligible, the kinds of integration models being developed, and the issues these models create for families and the beneficiaries.
The changes in service delivery, payment, and organizational relationships required to meet these changes will affect all parts of the health care continuum. Organizations should continue to evaluate the impact of these proposals on their care delivery model, payer contracting strategies, and their staff development programs. We appear to be on the very early waves of significant changes, which might just make sense if we can determine how to pay for them and manage our way through the changes.
Minnesota proposal details
For those who want to learn more about the Minnesota program — which is probably one of the more developed models — a short outline of the four models taken from materials developed and distributed by the Minnesota Department of Health is provided below:
- Model 1. Primary care health care homes (HCH) “virtual care systems”: Where all enrollees would be required to choose a primary care clinic, preferably a certified HCH, where available.
- Model 2. Alternative health care/home care systems: Some Minnesota senior health option managed care plans already have creative contracts with provider care systems (clinics or physician groups) that include prospective, full, or partial capitations or care coordination payments for all Medicare and Medicaid care coordination functions (including home and community based services case management). These plans would be grandfathered into the new system.
- Model 3. Integrated care system partnerships (ICSP): Under this model, the state will issue a request for proposal (RFP) for new ICSP contracting arrangements between providers and Medicare and Medicaid integrated care organizations (MMICO). The arrangement will provide integrated delivery of primary, acute, and long term care services to MMICO members that include primary care payment reform and risk/gain sharing with the state and CMS.
- Model 4. Potential special needs behavioral care (SNBC) mental and physical health integration partnership: Pending negotiations with CMS for transitioning SNBC plans to MMICOs under the dual demonstration, the Minnesota Department of Human Services would issue RFPs for a health home or HCH partnership between SNBC MMICOs, primary care, post-acute care providers, mental health providers and/or counties for SNBC enrollees with primary diagnoses of mental illness.
These four models continue the managed care processes for dual eligible beneficiaries, but have the potential to change benefit design and financial relationships between providers, payers, and the state. The models also could create new organizational relationships between payers and providers, or amongst providers across the continuum.