Focus intensifies on high-need, high-cost Medicaid clients
Focus intensifies on high-need, high-cost Medicaid clients
With states facing a bleak economic forecast, attention to high-cost populations within Medicaid is growing. "Spending on Medicaid is highly concentrated on a small percentage of beneficiaries. Just 5% of the Medicaid population is responsible for 57% of program spending," says Molly O'Malley, a senior policy analyst with the Henry J. Kaiser Family Foundation in Menlo Park, CA. "This concentration of spending has been the basis for states' efforts to better coordinate care for high-cost cases."
The Rethinking Care Program (RCP) from the Hamilton, NJ-based Center for Health Care Strategies (CHCS), recently received a $2.5 million grant from Kaiser Permanente Community Benefit. The four-year program is using state-led pilots to test new care management approaches for its highest-need, highest-cost Medicaid beneficiaries. Currently, pilots are under way in Colorado, New York, Pennsylvania, and Washington.
"State Medicaid programs, and their beneficiaries, will benefit from RCP's lessons for better organizing, financing, and delivering higher-quality care for complex-need populations," says Allison Hamblin, CHCS' director of complex populations.
More than 80% of these high-cost beneficiaries have three or more chronic conditions, and up to 60% have five or more. "Yet, the majority of these patients are in fragmented fee-for-service care," says Ms. Hamblin. "By focusing quality improvement efforts on these high-need, high-cost populations, states and health plans can more effectively invest limited public dollars and improve health outcomes."
A key goal of the RCP is to build the evidence base about what works for improving care for Medicaid beneficiaries with complex physical, behavioral, and psychosocial needs. "Through the program and CHCS' earlier work in this area, we are learning more every day about the core elements that are critical for effective care management," says Ms. Hamblin.
Essential elements are identification and stratification by risk/need; integration of the full gamut of physical, behavioral, long-term, and social services; the use of patient-centered care approaches; provider engagement strategies; performance measurement and accountability; and aligned financial incentives.
Other state Medicaid programs will be able to use information learned from the pilots to develop their own initiatives, targeted to specific Medicaid beneficiary populations. "Since the RCP pilots are operating under various financing models, focusing on different delivery systems and population subsets, and incorporating a varied array of intervention strategies, states will have a mix of models from which to choose," says Ms. Hamblin.
In the last decade, a growing number of states have adopted new strategies for serving high-cost Medicaid beneficiaries, says Ms. O'Malley. Most of these efforts have focused on caring for individuals in the community, as opposed to more costly institutional settings.
Integration is key trend
More recent programs aim to integrate the delivery of primary acute and long-term care services, especially for people under age 65 with disabilities.
"For older Americans on Medicare, care coordination of acute and long-term care services has a longer history," says Ms. O'Malley. Programs such as the Program of All Inclusive Care for the Elderly (PACE), a capitated, managed care benefit for elderly patients, feature a comprehensive medical and social service delivery system. A number of integrated models, including Medicare demonstrations, state Medicaid waivers, and Medicare Special Needs Plans have developed to bridge the services offered by both Medicare and Medicaid.
"An emphasis on coordinating services across both acute and long-term care settings is a trend we are seeing across states," says Ms. O'Malley. This includes service delivery models of both Medicare and Medicaid benefits designed to improve quality of care, reduce unnecessary hospitalizations, and improve the efficiency of care delivery.
Typically, an interdisciplinary team of nurses, social workers, physicians and personal care attendants develop care plans and deliver all services. They help assess the patient's needs and provide information and support for Medicaid beneficiaries and their family caregivers. The team also coordinates transitions across settings, such as a patient receiving rehabilitation services and home care after a hospital stay.
"Care coordination is an important tool in helping high-cost Medicaid beneficiaries gain access to necessary services," says Ms. O'Malley. "It calls for a flexible approach to arranging health and supportive services."
Broad-based approach is success
While the first disease management programs focused on specific diseases or drugs, Illinois Medicaid took a more holistic, broad-based approach. Theresa Eagleson, Illinois' Medicaid director, says, "We have gotten lots of phone calls" from other states interested in their outcomes.
Illinois Medicaid's Disease Management program is population-based, as opposed to based on an individual disease, with the exception of asthma. "For the last couple of years, we have put our most complex and costly patients, including a lot of seniors with disabilities who aren't dually eligible for Medicare, into this program," says Ms. Eagleson. "We put the vendor at risk for part of their fees depending on the savings estimates, and we have a contractual way to reconcile whether the savings actually happened."
For FY 2007, about $34 million was saved, and in FY 2008, that increased to $104 million. In July 2009, about 10,000 additional enrollees were put into the program, such as seniors in the program's Home- and Community-Based Service Waivers who aren't dually eligible.
Ms. Eagleson says there is interest in additional expansion of programs targeting this population. "The place where you have both the majority of your costs and the opportunity for pretty intense case management and quality improvement is that same population of patients with disabilities and seniors," says Ms. Eagleson. "So, we are seeing what our options are there. We may want to test a more mandatory form of managed care. We are definitely looking at additional management techniques for that population."
Beneficiaries not well connected
Through its Chronic Illness Disease Program (CIDP), part of the national Rethinking Care initiative, New York Medicaid is implementing seven regional demonstration pilots that will test an interdisciplinary model of care to improve health care quality, ensure appropriate use of services, improve clinical outcomes, and reduce the cost of care for beneficiaries with medically complex conditions.
According to Deborah Bachrach, New York's Medicaid director and Deputy Commissioner of the Office of Health Insurance Programs for the New York State Department of Health, "We chose to focus on our high-need, high-cost beneficiaries, because they are exactly thathigh need and high cost," she says. "When we examined their care patterns, we learned that despite their extraordinary level of need, these beneficiaries were not well connected to the health care delivery system."
For example, there were high-rates of emergency department use and avoidable hospitalizations. "Here was a real opportunity both to improve care for Medicaid enrollees and cut costs for the Medicaid program," says Ms. Bachrach. New York's Medicaid program has several initiatives to better manage the care of its highest-need enrollees. These include:
Expansion of the Medicaid managed care program to Supplemental Security Income (SSI) beneficiaries.
New York's Medicaid managed care program began in October 1997 with the enrollment of non-SSI Medicaid beneficiaries. In October 2006, the Centers for Medicare & Medicaid Services approved New York's request to expand the mandatory managed care program to Medicaid beneficiaries who qualify for SSI.
Prior to this date, nearly 100,000 SSI beneficiaries had voluntarily joined a managed care plan. Today, the SSI mandatory managed care program is operational in 37 counties of the state plus New York City. As of June 2009, SSI enrollment had grown to nearly 267,000 statewide.
A survey of New York City SSI enrollees who had transitioned into managed care was conducted in spring 2008. Regarding continuity of care, 69% of respondents indicated that they stayed with the same doctor after joining a health plan, and 9% indicated they did not have a doctor prior to joining managed care.
"With regard to access to care, a majority of respondents stated that it was easier or as easy to get appointments with their doctors since joining a plan and that the quality of care they received was the same or better since joining their health plan," says Donna Frescatore, deputy director of the Office of Health Insurance Programs for the New York State Department of Health.
Implementation of a chronic illness demonstration program.
The seven pilots within the CIDP are targeted at the small percentage of Medicaid beneficiaries (20%) who account for a significant percentage (75%) of program expenditures. These beneficiaries have multiple comorbidities, are medically complicated, and a significant number also have mental illness and/or chemical dependency diagnoses.
"Enrollees eligible for the CIDP are not enrolled in Medicaid managed care," says Ms. Frescatore. "They are identified using a predictive model that uses service utilization, diagnoses, and patient characteristics to score patient risk. Patient participation in the CIDP is strictly voluntary."
Awardees will be responsible for providing care coordination for patients who choose to join their demonstration. They must establish an integrated health care delivery network, including community providers, to ensure that beneficiaries have access to the continuum of medical, mental health, chemical dependence, rehabilitative care, and social services required to meet the needs of this complex population.
"The demonstrations will be subject to a rigorous independent evaluation to assess their effectiveness in improving patient care and reducing costs," says Ms. Frescatore.
Retrospective utilization review of all fee-for-claims, using evidence-based guidelines.
Patterns of over- and underutilization will be identified, so that interventions can be targeted to providers and beneficiaries demonstrating patterns outside the norm.
"Examples of overutilization would include frequent use of emergency room services or duplicative or unnecessary tests. An example of underuse would be a diabetic patient who did not receive the recommended eye exams," says Ms. Frescatore. "We expect that the program will improve patient care and safety and avoid unnecessary costs."
Contact Ms. Bachrach at (518) 474-3018 or [email protected], Ms. Eagleson at (217) 782-2570, Ms. Frescatore at (518) 474-8646 or [email protected], Ms. Hamblin at (609) 528-8400 or [email protected], and Ms. O'Malley at (202) 347-5270 or [email protected].
With states facing a bleak economic forecast, attention to high-cost populations within Medicaid is growing.Subscribe Now for Access
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