10/15/2019 Working Together to Improve Care, Outcomes and Health - PDF document

10/15/2019 Working Together to Improve Care, Outcomes and Health for Oregon Dual Eligibles Through Integrated Care CCO to MA Affiliation Contractual Requirements for 2020 Jennifer Valentine Medicare-Medicaid Policy Analyst Health Systems Division October 16, 2019 Health Systems Division CCO 2.0 Building Stronger Integrated Care For Duals • Opportunity to meet CCO 2.0 Triple Aim & contain cost growth with increased focus on Oregon Dual Eligibles • Fits with focus on ICC, IDT, Care Transitions, HIE platforms • Duals: High Needs Population – High Needs: need trauma informed approaches and outreach – Need for social determinants assistance – Duals more likely to have ADA issues or be minorities – High Unmet Behavioral Health Needs • Oregon Medicaid – Medicare Plan Alignment has only been 1/3 of FBDE –with the majority of aligned population being in the CCO and DSNP (@20,000 members) – Opportunities to create integrated provider networks and align benefits – Opportunities to align quality improvement projects (PIPs), metrics, and VBID – Opportunities to address social determinants impacting FBDE • Significant % of FBDE duals still in traditional Medicare FFS: Why? – In part, members don’t know options and benefits of integrated care: *Limited In‐Depth Choice Counseling annually on choice options *Limited # of CCOs communicating about alignment to FBDE *New enrollment opportunities still under‐utilized except by 2 DSNPs *Lack of outreach to FFS Medicare providers who serve FBDE 2 1

10/15/2019 Enrollment of Medicaid/Medicare eligible OHP clients in Medicare Advantage Plans ‐15 August 2019 Data based on the 15 August 2019 census of OHP run on 9/10/2019 6:22:25 AM % Affiliated Total % no Affiliated MMA no MMA non‐Affiliated Number MMA MMA Plan *1 Plan *2 CCO Plan MMA Plan of Clients Plan ADVANCED HEALTH (CCOA) 1,845 66 1,911 96.5% 0.0% ALLCARE CCO‐ INC. (CCOA) 1,727 310 1,256 3,293 52.4% 80.2% CASCADE HEALTH ALLIANCE‐ LLC (CCOA) 588 59 675 1,322 44.5% 92.0% COLUMBIA PACIFIC CCO LLC (CCOA) 1,507 102 423 2,032 74.2% 80.6% EASTERN OREGON CCO‐ LLC (CCOA) 3,607 63 50 3,720 97.0% 44.2% FEE‐FOR‐SERVICE (FFS) *1 6,851 2,687 9,538 71.8% 0.0% HEALTH SHARE OF OREGON (CCOA) 10,439 2,636 13,812 26,887 38.8% 84.0% INTERCOMMUNITY HEALTH NETWORK (CCOA) 2,477 570 1,390 4,437 55.8% 70.9% JACKSON CARE CONNECT (CCOA) 1,321 132 879 2,332 56.6% 86.9% PACIFICSOURCE COMMUNITY SOL GORGE (CCOA) 606 13 115 734 82.6% 89.8% PACIFICSOURCE COMMUNITY SOL INC (CCOA) 1,069 55 1,861 2,985 35.8% 97.1% PRIMARYHEALTH JOSEPHINE CO CCO (CCOA) 594 179 29 802 74.1% 13.9% TRILLIUM COMMUNITY HEALTH PLAN (CCOA) 4,241 1,530 2,149 7,920 53.5% 58.4% UMPQUA HEALTH ALLIANCE‐ DCIPA (CCOA) 914 86 1,190 2,190 41.7% 93.3% WILLAMETTE VALLEY COMM. HEALTH (CCOA) 2,775 1,273 3,134 7,182 38.6% 71.1% YAMHILL COMMUNITY CARE (CCOA) 1,375 492 18 1,885 72.9% 3.5% 41,936 10,253 26,981 79,170 53.0% 72.5% *1: FFS clients enrolled in an "Affiliated" MMA plan meaning in an MMA Plan affiliated with one of the OHP CCOA organizations *2: Percentage of clients Enrolled in an MMA plan who are in a plan affiliated with their CCOA plan % Affiliated MMA Plan *2 = Affiliated MMA Plan/(Affiliated MMA Plan+non‐Affiliated MMA Plan) 88% now enrolled in CCO A! (increased from 58% with Duals Passive Enrollment Initiative) Health Systems Division Q: Why does it matter if a dual eligible has aligned Medicare and Medicaid benefits? Oregon Data • Duals with aligned Medicare Advantage and Medicaid managed care (CCO) experienced an improvement in health service use and quality of care between 2011 and 2014. • When we compared duals with aligned plans to those with nonaligned Medicare Advantage and Medicaid managed care plans; we found that while care differed minimally between these two groups at baseline, it changed in a more desirable direction over time for duals with aligned plans. (highest percent of alignment in CCOs with DSNPs). • By the end of our study period, duals with aligned plans had lower emergency department visit and hospitalization rates and higher primary care visit rates , compared with those with nonaligned Medicare Advantage and Medicaid managed care plans. They were also more likely to receive diabetes HbA1c testing and LDL cholesterol screening . • Aligned Medicare and Medicaid programs might have a greater incentive to coordinate care and save costs to benefit both programs over time. “Comparing Care for Dual‐Eligibles Across Coverage Models: Empirical Evidence From Oregon” Kim, Charlesworth, McConnell, Valentine, and Grabowski, Medical Care Research and Review, 1‐17, 2017 Health Systems Division 2

10/15/2019 What is Medicare – Medicaid Alignment & How Do We Get There? Key Areas To Impact Outcomes  Communication  Population Health Management (Using Data!)  Care Coordination  Care Transitions  Health Promotion  Member Engagement  Health Equity & Social Determinants of Health Lens Across All These Areas CCO 2.0 Alignments & Expectations for Full Benefit Dual Eligibles (FBDE) • All CCOs to have MA alignments for 2020 to meet contractual requirements: Some examples include: – address billing crossovers, – review of authorization requests to limit delay of needed services, – integrate care coordination with LTSS and Medicare benefits, – ensure access to behavioral health, integration of Medicaid/Medicare benefits – monitor preventive service and screenings, including those for behavioral health – ensure providers are following balance‐billing rules, – ensure providers address disability & language access – provide members with communication about integrated care alignment opportunity – where possible develop and use integrated Medicaid/Medicare member materials; – work to ensure smooth transitions of care – build models that incorporate social determinants of health focus • Processes to achieve greater alignment to be further discussed at CCO CMS Alignment meetings Health Systems Division 3

10/15/2019 Exhibit B – Statement of Work – Part 3: Patient Rights, Responsibilities, Engagement, Choice 1. Member and Member Representative Engagement in Member Health care and Treatment plans • Agreement should include any expectations and processes to ensure member/member representative involvement in care planning and the process by which to access items in (a) – (g) specific to CCO to MA relationship • More on Intensive Care Coordination Plans (ICCP) and Treatment Plans in Exhibit B Parts 2 and 4, Exhibit M 4., 5. and 6. Member and Potential Member Information • New OARs 410-141-3580 and OAR 410-141-3585 • Contractor shall communicate to provide FBDE members with written communications regarding opportunities to align benefits with Affiliated MA or DSNP plan(s). • Communicate with providers serving FBDE about care coordination needs, ICC, etc. • Identify opportunities to streamline communications to FBDE members to improve coordination of Medicare & Medicaid Benefits (might include Member handbooks, Provider Directories, Integrated ID Card formats) • Integrated materials will be required to receive Medicare and Medicaid approvals as appropriate Health Systems DIvision 63% 8 4

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10/15/2019 11 Behavioral Health Conditions Are Highly Prevalent among Dually Eligible Beneficiaries Behavioral health conditions are more prevalent among dually eligible beneficiaries under age 65 than among those age 65 and older. % Under 65 % 65 and Older Behavioral Health Condition (CY 2013) Anxiety Disorders 24% 15% Bipolar Disorder 15% 3% Depressive Disorder 33% 22% Schizophrenia and Other Psychotic Disorders 13% 7% Source: MedPAC‐MACPAC. “Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid.” January 2018. Exhibit 8. Available at: http://medpac.gov/docs/default‐source/data‐book/jan18_medpac_macpac_dualsdatabook_sec.pdf?sfvrsn=0 6

10/15/2019 Dually Eligible Beneficiaries with Mental Health Conditions Have High Physical Health Comorbidity Rates • Physical health Chronic Physical Health Comorbidity for Those with Mental Health comorbidities are prevalent Conditions (CY 2008) Prevalence among individuals with Hip/Pelvic Fracture 61% mental health conditions Other Metabolic Disorder 55% • One or more mental health Stroke 54% Lung Disease 52% conditions were found to Anemia 47% co‐occur in over 50% of Musculoskeletal Disorder 46% those with: Kidney Disease 45% • Hip or pelvic fracture Diabetes 42% • Metabolic disorder Heart Condition 42% • History of stroke and Neoplasm 40% • Lung disease Eye Disease 39% Source: CMS. “Physical and Mental Health Condition Prevalence and Comorbidity among FFS Medicare‐Medicaid Enrollees.” 2014. Table 25. Available at: https://www.cms.gov/Medicare‐Medicaid‐Coordination/Medicare‐and‐Medicaid‐ 13 Coordination/Medicare‐Medicaid‐Coordination‐ Office/Downloads/Dual_Condition_Prevalence_Comorbidity_2014.pdf 14 7