Managed CareLeadingAge Indiana Board Meeting

February 2015

Overview

• What is this mess?

• Where is it happening?

• How are providers responding?

• What can LeadingAge providers expect?

• How can LeadingAge provide support?

What is this mess?

Population Health Management

Managed Care

Medicare Advantage

Dual Eligible Special Needs Plans

Chronic Disease Special Needs Plans

Institutional Special Needs Plans

Managed Long Term Services and Supports

Accountable Care Organizations

Bundled Payments

Primary Care Medical Homes

Primary Care Case Management

Independent Practice Associations

Provider Hospital Organization

Health Maintenance Organization

Preferred Provider Organization

Program of All Inclusive Care for the Elderly

Continuing Care Retirement Communities

“the technical field of endeavor which utilizes interventions to help improve the morbidity patterns

and the health care use behavior of defined populations”. PHM is distinguished from disease

management by including more chronic conditions and diseases, by use of "a single point of contact and

coordination", and by "predictive modeling across multiple clinical conditions".PHM is considered broader

than disease management in that it also includes "intensive care management for individuals at the

highest level of risk" and "personal health management... for those at lower levels of predicted

health risk".

a variety of techniques intended to reduce the cost of providing health benefits and

improve the quality of care ("managed care techniques"), for organizations that use

those techniques or provide them as services to other organizations ("managed

care organization" or "MCO"), or to describe systems of financing and delivering health

care to enrollees organized around managed care techniques and concepts

("managed care delivery systems").

Population Health

Management

Managed Care

What is changing?Short term skilled care :

-traditional medicare

-private insurance

-medicare advantage

Long term services and supports :

-private pay

-traditional medicaid

-medicaid managed care

-long term care insurance

Delivery Reform & Payment Reform

Managed Care Models

• Medicare Advantage (skilled)

• Medicare Advantage Special Needs Plans (SNPs) (skilled)– Dual eligible special needs plans (DSNPs) (skilled)– Fully integrated dual eligible special needs plans (FIDE SNP) (skilled and LTSS)– Institutional Special Needs Plans– Chronic Disease Special Needs Plans

• Medicare – Medicaid Integrated Plans (MMPs) (skilled & LTSS)

• Medicaid Managed Care Plans (skilled, LTSS, both)

• Managed Long Term Services and Supports Plans (MLTSS)(LTSS)

• Specialty Health Plans (behavioral health, pharmacy) (LTSS)

Managed Care Models

• Accountable Care Organizations (ACOs) (skilled)

• Program of All Inclusive Care for the Elderly (PACE) (skilled & LTSS)

• Independence at Home Demonstration (skilled & LTSS)

• Bundled Payments (skilled)

• Care management organizations (skilled & LTSS)

• CCRCs (lifecare, extended contract, modified contract)

Indiana

22%

Indiana

Not Participating

Indiana

Medicare –Medicaid

Coordination Initiative

Indiana

Source: Avalere, April 2013

Medicare/Medicaid

Indiana

PrepActivity

Currently there are 343 “bundle pilots” in 26 states….

AND MORE BUNDLES ARE COMING: 4100 providers and 2,400 hospitals joined in the latest round of

CMS bundled payment

Acute/PAC

Payment

BPCI Model 2: Retrospective

Acute & Post Acute Care

Episode

1. 107 participant/awardees in BPCI Model 2

2. Episode of care will include acute care

inpatient stay and all related services.

3. Episode will end at either 30, 60 or 90 days

post hospital discharge.

4. Participants can choose up to 48 different

clinical condition episodes.

BPCI Model 3: Retrospective Post

Acute Care Only

1. 43 participants/awardees in BPCI Model 3

2. Episode of care results from acute care stay

and begins at initiation of post acute care

services (snf, irf, ltch, hha)

3. Episode can last between 30 and 90 days

4. Participant choice of 48 different clinical

condition episodes

Amedisys Holdings

Remedy BCPI Partners

Franciscan Sisters

HealthSouth

CHE Trinity

Genesis Care Innovations

BCPI Model 3

92%

Remedy BCPI Partners

Amedisys Holdings

Signature Medical Group

Premier

Navvis Healthcare

Community HealthSystems

18 %

BCPI Model 2

Indiana Participation In Bundled Payment Demonstration

62%

New Guys: Friend or Foe?

How are providers responding?

KINDRED'S CLEVELAND INTEGRATED CARE

MARKET SERVICESWhen people leave traditional hospitals they often need

continued care to recover completely. That’s where we

come in. Kindred’s expertise across a variety of post-

acute care sites of service helps us provide care for

patients in the most appropriate setting.

We specialize in delivering quality medical interventions

and successfully transitioning patients home or to a less

intense level of care that meets their needs and

enhances their quality of life.

In the Cleveland area, Kindred offers services including

aggressive care for medically complex patients, intensive

care and short-term rehabilitation through two transitional

care hospitals, a subacute unit, three nursing and

rehabilitation centers, home health and assisted living

services.

SUBACUTE UNIT

ASSISTED LIVING FACILITIES

TRANSITIONAL CARE HOSPITALS

TRANSITIONAL CARE AND

REHABILITATION CENTERS

HOME CARE

CARE TRANSITIONS PROGRAMWe are proud to offer an innovative, new approach to

care through our Care Transitions Program. The

program is a quality improvement initiative designed

for patients with medically complex conditions. We

provide patients with Care Transitions Managers,

patient advocates and navigators who communicate

directly with patients, caregivers and primary care

physicians or specialists every step of the way. They

facilitate transitions between settings and help fill in

communication gaps

Signature CommunitiesSignature HealthCARE has a vision to radically change the landscape

of healthcare forever. It’s more than a corporation… it’s a revolution.

Signature HealthCARE is a healthcare company providing skilled

nursing, rehabilitation and other services across the care

spectrum with 126 locations in 10 states and nearly 19,000 employees.

A growing number of Signature centers are earning five-star ratings

from the Centers for Medicare & Medicaid Services. In 2013, the

company was named one of Modern Healthcare’s ‘Best Places to

Work’ for the third time.

Signature’s organizational culture is founded on three pillars: Learning,

Spirituality, and Intra-preneurship.

To learn more about Signature HealthCARE, please visit

LTCrevolution.com.

Memory Support

Fitness Therapy

Balance Program

Aquatic Therapy

Stroke Rehab

Cardiac Care

Wound Care

Pain Management

Repiratory Therapy

Life Enrichment

Skilled Nursing and Rehabilitation Centers

Home Health

Veteran Services

Community Services

Assisted Living Centers and Independent Living Communities

Hospice

Patient PlacementPruittHealth Care Management starts with Patient Placement. Patient

Placement was established to help patients and families navigate the maze of

services and options. This program provides a centralized, single-source

solution administered by transition nurses who are a primary point of contact

for each patient, providing multiple patient services. The professionals within

Patient Placement act as care managers for private resources and payment

plans, such as commercial insurance, Medicare "replacements" and self-

payment.

Transition SupportIn order to decrease patient hospitalizations, our specially trained caregivers

utilize Transition Support, our rehospitalization prevention program. It provides

an amplified focus on decreasing patient hospitalizations through an

established model of high-quality care. Our proprietary set of procedures that

allows patients to better achieve their desired rehabilitation goals without the

often traumatic setback of a return hospitalization.

Home FirstPruittHealth Home First is a program designed to help patients receive care in

their home, rather than in an institutional setting. Nurse Care Managers

coordinate all aspects of patient care to ensure that the patient is able to

remain home as long as possible. Services include adult day health,

emergency response, home meal delivery, support services and more.

Payment options include private pay and the SOURCE (Service Options Using

Resources in a Community Environment) Medicaid waiver program that is

offered in certain areas of Georgia.

Your ally for innovative home health solutions.

For nearly 20 years, we have acted as agents for smart

change, forging holistic relationships with payors to

create a more seamless process,

improve patients’ outcomes, drive leading-edge

solutions and offer significant savings.

CareCentrix offers comprehensive, home health management solutions. Through our network of credentialed,

quality providers, we manage care to the home in a coordinated way, helping to ensure that patients receive the

care they need, when they need it, for the right cost — in the comfort of their home.

Successfully managed care for over 2 million* services in the home and prevented over 450 people

from being readmitted to the hospital;

Delivered client savings, through both utilization and network management, of up to 15% per year;

Implemented specific programs to manage care to the home and improve patient outcomes, including:

1. A Wound Management program that reduced patient days on therapy by 19% and

decreased nursing days needed to heal wounds by 21%;

2. Sleep Management programs that managed sleep testing and therapy in the lower cost

home setting, resulting in more than a 3-1 return on investment for our clients;

3. An Infusion Solutions program that managed infusion in the home, as opposed to more

costly outpatient and hospital settings, when clinically appropriate, saving 40-50% per

case. This can result in up to $120,000 savings per patient in any given year.

Join Our Network

Thanyou for your interest in joining the CareCentrix provider network!

As a participating provider with us, you will enjoy a number of benefits:

Diversify your revenue base by gaining access to patients insured through our national client base

Reimbursement at 100% of your contracted rate – no chasing member co-pays!

Electronic tools to make working with us simple

Electronic claims submission

Provider Portal for you to submit authorization, re-authorization, and add-on requests, in addition to claim and authorization status

lookup features!

In order to join the Carecentrix provider network, we ask that you complete the questionnaire below, and upon submission, a

member of our Network team will reach out to you for next steps.

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What can LeadingAge providers expect?

A Road Map for Implementing MLTSS in Pennsylvania

October 18, 2013

This article was tagged:

Mco

Pennsylvania's Medicaid Managed Care Organizations have recently

developed a detailed recommendations paper relating to the implementation of

a MLTSS program model in Pennsylvania.

This paper has been shared with the Administration and provider and advocacy

groups, with the goal of promoting the implementation of this innovative and

successful model in Pennsylvania. A copy of this document may be found here.

Function Traditional FFS Managed Care Risk Opportunity

Rate setting 1. States reimburseproviders on fee schedule which is updated according to state policy.

2. Shortfalls in state funding can impact rates. Providers get paid for the volume of services billed.

3. States do not know full expense picture until claims have finished processing 6-12 months after end of the year.

1. States reimburse managed care entities on a full or partial capitation basis.

2. MCOs receive a per member per month payment based on historical fee for service data and, in some cases, are risk adjusted for the complexity of care and disease burden associated with an individual member or group of members.

3. State generally knows up front what its expenses will be for the year based on the budget and enrollment. MLR requirements and profit caps becoming more common.

1. For complexpopulations that are new to managed care rate setting is challenging. Historical data does not reflect unmet need.

2. Risk adjustment methodology is largely untested.

3. Pent up demand can play a large role in expense overruns. Inadequate risk adjustment can lead to steep losses for special populations.

4. Risk corridors can be implemented to protect MCOs and states from upside and downside extremes.

1. CMS and Administration very invested in these models, want them to work don’t want to see plans fail.

2. New programs tend to be more generous to attract participation (MA, SHMO)*

3. Unmanaged populations have significant opportunity for improving gains

4. Some states building in risk corridors

Network Adequacy/Participation

1. Any willing providermeeting State standards of participation.

1. Contract with providers to develop a network that meets State standards. State/MCO agreements can include “any willing provider” provisions.

2. MCOs increasingly looking to narrow networks of high quality providers that will assist in meeting their cost and quality goals.

1. Simply meeting State requirements is no longer a guarantee of network participation. Providers must demonstrate quality and efficiency with data.

2. Clinical capabilities that differentiate the provider and lead to positive outcomes (quicker discharge from hospital/snf, provision of IV antibiotics/fluids in house instead of hospital, reduction in hospital admissions/readmissions) will play significant role in network participation.

1. If you are a high quality provider in a narrow network you could experience increased volume based on your participation.

2. Opportunity to focus clinical competencies in the areas of need for the MCO.

Function Traditional FFS Managed Care Risk Opportunity

Contracting 1. No provider contract needed, just meet state requirements.

1. State contracts with MCO. MCO contracts with provider. Provider now has multiple contracts with varying provisions.

2. Provider must be more savvy in analyzing, negotiating, implementing and evaluating multiple contracts and educating staff at all levels.

1. Administrative complexity related to varying contractual provisions(reimbursement, billing, authorizations, quality measures).

2. Increased expense if consultants are hired to assist in contract review.

3. Some MCOs use “boiler plate” contracts and there is little to no room for negotiation –“take it or leave it” strategy.

1. Under traditionalFFS there is no negotiation of rates. High quality providers are paid the same as sub par providers. In managed care environments high quality providers and/or providers in rural areas could see increased reimbursement based on MCO need.

2. New models of payment can also be options – pay for performance, gain sharing, capitation. New opportunities for business growth.

Function Traditional FFS Managed Care Risk Opportunity

Quality Monitoring 1. States and Feds monitor providerquality.

2. States and Feds will now also monitor MCO quality which will include provider outcomes and additional measures.

1. Many MCOs willincorporate the current provider quality measures into their oversight programs.

2. Additional measures will be added to ensure they meet their contractual requirements and financial incentives with the State and Feds. Examples of new measures include functional outcome scores, hospital admissions and readmissions, length of stay.

3. States will need to educate and add staff to ensure sufficient MCO monitoring is in place.

1. States may lack staffing and sophistication for quality oversight. Sub par plans may remain under contract.

2. Providers may experience increased administrative burden from collecting and reporting new measures. Could see lack of consistency among plan reporting requirements. Data collection for new measures may be burdensome, largely manual processes.

1. Sophisticatedproviders have the opportunity to differentiate themselves and potentially get higher reimbursement for their quality.

Function Traditional FFS Managed Care Risk Opportunity

Function Traditional FFS Managed Care Risk Opportunity

Case Management 1. Case management fragmented. Each individual provider responsible for managing their piece. Coordination left to patient/family.

2. Provider by default can end up coordinating care beyond their four walls without adequate reimbursement.

3. Provider not privilege to each others’ information.

1. Pre authorization required and length of stay can be reduced.

2. Need to understand prior authrequirements, documentation requirements, assessment requirements.

3. Some assessments and case management will take place on site some telephonically

4. MCO has robust warehouse of data on each member that cuts across provider settings

1. Administrative burden associated with prior authorization, pre payment documentation submission and follow up, post payment review and billing requirements.

2. Reduction in overall length of stay resulting in decreased reimbursement.

3. MCO staff in care settings – disruption

1. Look to get case managementdelegated for current residents and/or specific populations

Function Traditional FFS Managed Care Risk Opportunity

Reimbursement

1. Case management fragmented. Each individual provider responsible for managing their piece. Coordination left to patient/family.

2. Provider by default can end up coordinating care beyond their four walls without adequate reimbursement.

1. Reimbursement can vary by MCO (ffs, RUGs, levels of care).

2. Payment timeliness can vary. Contractually MCOs usually follow Medicare prompt payment rule of 30 days.

3. Some MCOs have onerous pre payment documentation review that can lengthen time to reimbursement. MCO not always clear about what documentation is required.

4. Post payment review can take place.

5. Reimbursement level can be determined by the MCO, not based on or loosely based on the facility MDS.

6. Pre authorization required and length of stay can be reduced.

1. Lower reimbursement rates than under ffs.

2. Frequency of high level reimbursement can be drastically reduced.

3. Cash flow can be negatively impacted by less than Medicaid/Medicare timely payment, pre payment and post payment review.

4. Administrative burden associated pre payment documentation submission and follow up, post payment review and billing requirements.

5. Reduction in overall length of stay resulting in decreased reimbursement.

6. Potential inability to recoup Medicare bad debt payment.

1. Reimbursement could increase based on higher acuitypatients and services. Shorter length of stay can lead to greater turnover and overall number of skilled days.

2. If bad debt included in reimbursement could be included in claim vs cost report settlement.

3. MCO could have responsibility for collecting patient pay.

4. MCO could assist in facilitating collection of patient pay for provider.

What can LeadingAge do?

Association Assessment:

1. Membership makeup/diversification (heavily loaded in one provider area or breadth of

services)

a. # of beds

b. % medicare revenue, medicaid etc

c. Number of citizens touched by services (patients/residents/employees)

d. Independents vs multi site

e. Clinical, administrative and technical levels of sophistication

f. Quality, outcomes

g. Best practices

2. Staff resources(expertise & numbers)

3. Data collection/analysis capabilities

4. Relationships with and knowledge of other stakeholders

a. State

b. Area agencies on aging

c. Disability community

d. For profit ltc associations

e. Health plans

f. Hospitals/ACOs

Environmental Assessment:

1. Medicare Advantage penetration

2. Integrated health systems/ACOs

3. State/federal innovation

4. Medicaid managed care

5. State plans for Medicaid/long term care

6. Who are the health plans? (commercial, medicare,

medicaid, quality, enrollment)

7. What does State Medicaid budget look like (growing, stable,

underfunded)

8. Who are the largest long term care players?

9. Legislative views on ltc, managed care, medicaid

10. What are neighboring states doing?

11. Successful models of managed long term care

(policies/provisions/outcomes)

12. Federal incentives (ACA demonstration programs, waiver

flexibility etc)

Resources:

1. Kaiser Family Foundation State Health Facts

http://kff.org/medicare/state-indicator/enrollees-as-a-of-

total-medicare-population/ CMS Medicare/Part D

Enrollment Data http://www.cms.gov/Research-

Statistics-Data-and-Systems/Statistics-Trends-and-

Reports/MCRAdvPartDEnrolData/Monthly-Contract-

and-Enrollment-Summary-Report.html

2. CMS Innovation Center ACOs

http://innovation.cms.gov/initiatives/ACO/

3. CMS Innovation Center http://innovation.cms.gov/

4. State Medicaid website, Kaiser Family Foundation State

Health Facts http://kff.org/medicaid/state-indicator/total-

medicaid-mc-enrollment/, CMS Medicaid Enrollment

Report http://www.cms.gov/Research-Statistics-Data-

and-Systems/Computer-Data-and-

Systems/MedicaidDataSourcesGenInfo/MdManCrEnrllR

ep.html

Contract provision protections

1. Any willing provider

2. Medicare and Medicaid reimbursement as the floor (including applicable bad debt)

3. Prompt payment in line with current Medicaid and Medicare processes

4. Standard clean claim definition

5. Claim submission timeframes

6. Timeframe for requests for additional information (received and reviewed)

7. Retroactive denials

8. Payment methodology – defined and standardized

9. Term and termination

10. Patient pay liability

11. Specialized care services

12. Use of contracted vendors (lab, pharmacy etc)

13. Credentialing

14. Quality reporting (measures and collection methodology)

15. Continuity of care provisions

16. Product lines included in contract

17. Lessor of clause

18. Prior authorization and determination of medical necessity

19. Assessment tool to be used

20. How to determine elibility

21. Requests for additional information – timeframes, frequency, volume

Resources:

Managed Care: Preparing for Change, CliftonLarsenAllen, October 30, 2013,

http://www.leadingage.org/Managed_Care_Readiness_Toolkit.aspx

Tools/Resources

1. Members with documented discussions of care goals

2. Members with first follow up visit within 30 days of discharge

3. Number of community dwelling members who transitioned to a nursing facility

4. Number of nursing facility members who returned to the community

5. Total number of plan transitions (members moving to the hospital)

6. Total number of unplanned transitions (members moving to the hospital)

7. Total number of inpatient hospital admissions from a nursing facility

8. Total number of discharged with documented participation in the discharge plan by the care

coordinator of participation of the member or the member’s representative.

MCO Quality Measures

1. The number of critical incident and abuse reports for member’s receiving LTSS

2. Members with Severe Mental Illness receiving primary care services

3. Total number of members receiving nursing facility services

4. Emergency room behavioral health service utilization

5. Screening for clinical depression and follow up plan

6. Total number of members for whom a transition record was transmitted to the facility or pcp

designated for follow up care within 24 hours of discharge

7. Members with an assessment completed timely (by the MCO)

Next steps