MCM Commission

December 10, 2015 Legislative Office Building

Concord, NH

Nick Toumpas

NH Department of Health and Human Services

Agenda • Monthly Enrollment Update

– MCM – NH HPP – Step 2, Phase 1 Mandatory Enrollment Update

• MCM Update

• Pharmacy/NEMT Authorization Update

• MCM Opioid Policy/Authorizations

• Work Force Development

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Care Management Program December 1, 2013 –December 1, 2015

@ 25 Months

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Setting the Context

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Mem

bers

Total MCM

Non-MCM

Source: NH MMIS as of 12/2/15 for most current period; Data subject to revision.

Notes: Excludes members without full Medicaid benefits (Family Planning Only & Medicare Savings Plans) New NHHPP members who enrolled after 10/1/2016 were temporarily assigned to a Non-MCM benefit plan in anticipation of the Premium Assistance Program beginning on 1/1/2016, when they will be placed in a Qualified Health Plan. This caused a net decrease in MCM enrollment and a net increase in Non-MCM enrollment as of 12/1/2015.

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NHHPP

NH Medicaid Care Management Enrollment, 12/1/13 – 12/1/15

NH Medicaid Care Management Enrollment by Plan, 12/1/13 – 12/1/15

Source: NH MMIS as of 12/2/15 for most current period; Data subject to revision. 5

87,908

73,479

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Mem

bers

Well Sense

NH Healthy Families

Meridian

Note: New NHHPP members who enrolled after 10/1/2016 were temporarily assigned to a Non-MCM benefit plan in anticipation of the Premium Assistance Program beginning on 1/1/2016, when they will be placed in a Qualified Health Plan. This caused a net decrease in MCM enrollment and a net increase in Non-MCM enrollment as of 12/1/2015.

NH HPP Update 12/4/15

• Total Recipients – 44,135 – 41,109 are in the ABP (Alternative Benefit Plan) – 2,594 of Medically Frail are in the ABP – 432 of Medically Frail in standard Medicaid

• HIPP

– 231 enrolled in HIPP

• Enrollment by Health Plan – 20,426 Well Sense – 17,648 New Hampshire Healthy Families

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Step 2, Phase 1, Mandatory Enrollment Update

• Total Enrolled – 3,034

• 1,325 Well Sense • 1,709 NHHF

• Target= 8,423

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Contract Amendment

• Amendment required for MCO coverage of the Medically Frail to be effective 1/1/16

• Amendment targeted for 2/1/16 to enable a sub capitation arrangement between the MCOs and CMHCs

• Future amendment required to implement co-pays

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Why Care Management? • Goals

– Improve Access to Care – Improve Quality of Care and overall health status – Improve cost-effectiveness

• Legislature Established

– Chapter Law 125,Laws of 2011 (SB 147)

• Client Information Session – October 2013-NH DHHS

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Effective Operations Subgroup:

Pharmacy/NEMT Authorization Update

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MCM Pharmacy Claims, Authorizations & Appeals (Note: logarithmic scale y axis)

Source: NH MCM Quality Data as of 10/30/15; Data subject to revision.

688,255 796,063 892,249 974,270

11,080 8,200 7,549 10,496

4,011 3,197 3,065 4,025

243 174 200 293

60 54 53 120

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2014-Q3 2014-Q4 2015-Q1 2015-Q2

Total ClaimsTotal Requests Subject to Service AuthorizationDenied AuthorizationsAppeals of Denied AuthorizationsUpheld Appeals of Denied AuthorizationsAdministrative Appeals Filed for Upheld Appeals

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Drug Class Examples

• Dermatologicals: Hydrocortisone, Elidel, Protopic • Ulcer Drugs: Tagamet, Zantac • Proton Pump Inhibitors (Ulcer Treatments): Nexium,

Protonix • Anticonvulsants: Gabapentin, Neurontin • Central Muscle Relaxants: Baclofen, • ADHD/Anti-narcolepsy/Anti-obesity/Anorexiants: Ritalin,

Adderall, Xenical • Analgesics – Opioid: Morphine Oxycodone • Opioid Partial Agonists: Buprenorphine, Naloxone,

Naltrexone, Suboxone • Local Anesthetics – Topical: Lidoderm Patch, Lidocaine

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MCM Pharmacy Service Authorization Denials – Top 10 Drug Classes

No. Drug Category 2015-Q3 MCM SA Denials

1 Dermatologicals 470 2 Ulcer Drugs 230 3 Proton Pump Inhibitors 220 4 Anticonvulsants 200 5 Central Muscle Relaxants 192 6 ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants 181 7 Antidepressants 103 8 Analgesics – Opioid (i.e., Morphine, oxycodone) 98 9 Opioid Partial Agonists (i.e., buprenorphine, naloxone,

naltrexone) 92 10 Local Anesthetics - Topical 79

Source: NH MCM Quality Ad hoc Data; Data subject to revision.

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Results: Pharmacy

• Pharmacy – The overwhelming majority of pharmacy claims do not require service

authorization and very few claims are denied or appealed – One primarily behavioral health medication is in the top 10 denied

drug categories – Ad hoc reporting (previously presented to the MCM Commission July

2015) indicates : • 46-59% of denials are being given for business reasons (i.e., a preferred

drug is available, there is no coverage for the drug requested) • 41-53% of denials are for clinical indications (e.g., medical necessity not

met)

– Beginning October 1, 2015, each MCO will be running their own pharmacy drug lists (and not required to strictly adhere to the NH Medicaid Preferred Drug List)

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MCM Non-Emergent Medical Transportation Requests, Authorizations, Appeals, & Grievances

(Note: logarithmic scale y axis)

Source: NH MCM Quality Data as of 10/30/15; Data subject to revision.

94,886 115,151 131,027 94,886 115,151 131,027

78,918 103,610 125,010

819 678 478

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2014-Q4 2015-Q1 2015-Q2Total RequestsTotal Requests Subject to AuthorizationRides DeliveredDenied AuthorizationsAppeals of Denied AuthorizationsUpheld Appeals of Denied AuthorizationsAdministrative Appeals Filed for Upheld AppealsGrievances Filed

0 0 0 0 0 0

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MCM Non-Emergent Medical Transportation Rides Delivered by Service Type

Source: NH MCM Quality Data as of 10/30/15; Data subject to revision.

4,066 7,507 5,148 7,418

12,354 12,218 9,502

20,684

14,740 19,351

23,786

31,401

16,637

21,577

34,190

45,266

62,048

76,209

1,099 1,474 4,294

6,883 5,422 5,182

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Mental Health ProviderMedical ProviderMethadone TreatmentOther (eg. Hospital and Pharmacy)

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NHHPP Program begins

Results: NEMT

• NEMT – NEMT utilization has increased since the onset of the MCM program,

primarily due to NHHPP population – All NEMT requests undergo authorization review – Very few NEMT are denied – Very few NEMT appeals, fair hearings and grievances – Grievance trend indicated issues with one MCO’s transportation

vendor; a new transportation vendor was began in 2015 Q3

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MCM Opioid Use Contract Standards & Quality Measurements

Source: NH MCM MCO Contract Amendment #6; Data subject to revision.

Contract Standards (Section 14.1.11.4) • October 1, 2015 -- MCOs shall require prior authorization for high dose opioids

prescriptions • Beneficiaries with diagnosis of Substance Use Disorder (SUD) and all infants with diagnosis

of neonatal addiction syndrome (NAS) will be referred by MCO to care coordination to support the coordination of their physical and behavioral health needs and for referral to SUD treatment

• Beneficiaries in an MCO lock-in program will be evaluated for the need for SUD treatment

New SUD Quality Measures – • Rate of referral to case management for all patients receiving buprenorphine or methadone

SUD treatment • Rate of referral to case management for all infants with a diagnosis of neonatal abstinence

syndrome • Percent of prior authorized fills and refills for high dose opioid prescriptions

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DHHS Mission

“To join communities and families in providing opportunities for citizens to achieve health and independence.”

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DHHS Strategic Initiative Workforce Development

• Mission -- Put the right skilled nurses, and health workers, in the right places,

inclusive of New Hampshire Hospital, the community, and homes, for the best possible outcomes for those in need and their families.

• The First Step -- to prepare for future needs is to begin to recruit a multi-skilled, diverse workforce now to keep pace with the state’s integrated health care delivery that reflects emerging population trends and needs.

• Establish a DHHS Workforce Development Program -- to support the Granite state's integrated health care delivery system by educating, preparing, and advancing multi-skilled workers ensuring high quality health care.

Commissioner Toumpas -- Governor’s Commission on Medicaid Care Management – December 10, 2015

Questions?

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