Medicaid Delivery Systems Long Term Services and Supports (LTSS) 1 - PowerPoint PPT Presentation

Medicaid Delivery Systems Long Term Services and Supports (LTSS) 1

Where Does LTSS Fit Into Medicaid? • Although LTSS is a significant cost driver, LTSS has not always been at the forefront of healthcare reform at state level. • Why not? • Is this changing? Why? • Survey of State Medicaid Directors 2

The Triple Aim Lower costs Higher patient satisfaction Better health outcomes 3

Role of LTSS in Promoting Triple Aim Primary & Specialty Care Services Long-Term Acute & Services Ambulatory B ENEFICIARY and Care Supports Services INTEGRATED Behavioral Health Services CARE 4

The Road to Integrated Care • Traditionally, there has been a lack of coordination between medical and LTSS systems. Why? – Different providers/different language – Different reimbursement sources – Lack of financial incentives for collaboration/integration – Barriers to information exchange – Concerns around “medicalizing” personal supports – Other? 5

Our Discussion Goals How are you designing your delivery systems to meet the Triple Aim for your LTSS populations? Successes, challenges and lessons learned? What do States need to be successful? 6

Medicaid Payment Models Fee for Service Capitation Value Based Payments 7

Value Based Payments (VBP) • Value-based care is a form of reimbursement that ties payments for care delivery to the quality of care provided and rewards providers for both efficiency and effectiveness. • Goal is to achieve better care, smarter spending, and healthier people by incentivizing quality, health outcomes, and value over volume. 8

Relationship Between Payment Models and Delivery Systems 9

Areas of Focus Focus will be on degree of alignment for achieving Triple Aim in: 1. Traditional Medicaid delivery system (fee for service). 2. Medicaid Managed LTSS (MLTSS) (capitation). 3. Integrated Models for Medicare and Medicaid Services. 4. Accountable Care Organizations. 10

MEDICAID FEE FOR SERVICE 11

Fee For Service  Providers are paid established reimbursement rates for providing Medicaid services to eligible individuals.  Payment is triggered by service delivery and is based on volume of services.  Payment is not tied to quality or efficiency. 12

Traditional Medicaid FFS Delivery System • State determines provider qualifications. • State enters into provider agreements with any willing and qualified provider. • State sets payment methodologies and established payment rates • Payment is triggered by delivery of service. • Medicaid provider submits service claim directly to Medicaid agency. • Medicaid agency directly reimburses provider for services. 13

Challenges Inherent in a FFS System • Incentives not aligned with outcome • Providers may deliver more care and more expensive care because they are paid by volume. • Lack of comprehensive care coordination across service providers and settings resulting in fragmentation of care. • Lack of flexibility to meet individualized need. 14

State Strategies for Better Alignment with Triple Aim? • Allowable Medicaid reimbursement for care coordination/case management:  Optional State Plan Targeted Case Management.  Case management/care coordination under HCBS waiver authorities. • Use of waiver authorities and optional State Plan services to increase flexibility (e.g. eligibility, covered services and other State Plan requirements) • Use of State funded wrap-around services and additional programming. • Other? 15

Typical Cost Control Approaches in LTSS • Examples of possible state strategies:  Place caps on service use (hours/visits/cost).  Require prior authorization of services.  Base rates on Resource Utilization Groups that tie payment to level of acuity.  Other examples? • Increasingly, states are moving to other approaches to manage their Medicaid LTSS budgets… 16

MEDICAID MANAGED LONG TERMS SERVICES AND SUPPORTS 17

Managed Care Entities Managed Care Organizations (MCOs) • Comprehensive benefit package – Payment is risk-based/capitation – Primary Care Case Management (PCCM) • Primary care case managers contract with the state to furnish case management (location, – coordination, and monitoring) services Generally, paid fee for service for medical services rendered plus a monthly case management – fee Prepaid Inpatient Health Plan (PIHP) • Limited benefit package that includes inpatient hospital or institutional services (example: – mental health) Payment may be risk or non-risk – Prepaid Ambulatory Health Plan (PAHP) • Limited benefit package that does not include inpatient hospital or institutional services – (examples: dental and transportation) Payment may be risk or non-risk – Source: https://www.medicaid.gov/medicaid/managed-care/entities/index.html 18

Our Focus • “Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services”. -CMS Source: https://www.medicaid.gov/medicaid/managed-care/index.html 19

Key Elements of Managed Care Structure • State enters into a contract with MCO to provide benefits and services to Medicaid beneficiaries. • State pays MCO a capitated per member per month (PMPM) rate for each Medicaid enrollee. • Plan contracts with Providers to provide services to Medicaid enrollees. • Plan and providers negotiate payment rates. • Plan makes payments to providers. 20

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Varied Characteristics • Populations covered • Covered benefits • Mandatory or voluntary enrollment • Geographic coverage • Number and types of Managed Care Organizations (MCOs) • Degree of integration with other services 22

Statutory Authority for MLTSS Authorities for implementing managed care delivery system: • State plan authority (Section 1932(a)) • Waiver authority (Section 1915(b)) • Waiver authority (Section 1115) • Section 1915 (a)-voluntary program 23

In combination with: • Any of the managed care authorities can be paired with:  State Plan HCBS benefits offered under 1905(a); 1915(i);1915(j); and 1915(k)  HCBS waiver under 1915(c) • Section 1115 waivers can also be used alone to authorize the managed care delivery system as well as the HCBS benefits offered through that delivery system. 24

Considerations in Choosing Authority • Voluntary/involuntary enrollment? • Choice of providers? • Included populations? • Types of beneficiary protections? • Procedural/state administration considerations? • Larger state Medicaid context? • Other? 25

MLTSS and the Triple Aim • “By contracting with various types of MCOs to deliver Medicaid program health care services to their beneficiaries, states can reduce Medicaid program costs and better manage utilization of health services. Improvement in health plan performance, health care quality, and outcomes are key objectives of Medicaid managed care.” –CMS Source: https://www.medicaid.gov/medicaid/managed-care/index.html 26

Caution! • Risk-based capitation shifts state’s financial risk for serving Medicaid participants on to a managed care organization (MCO) and provides more stability for state Medicaid budgets but… • Risk-based capitation alone does not advance the Triple Aim.  Adequate planning process with broad stakeholder input is critical element of program design. 27

Other Essential Elements • Robust stakeholder engagement • Incorporation of person centered planning • Support for participants and participant protections • Coordinated and integrated set of benefits • Strategies for ensuring provider capacity and expertise • Comprehensive quality strategy • Alignment of payment structure with programmatic goals See CMS guidance 28

And of course… • Ensure that delivery system design supports individuals to live in their homes and communities in the least restrictive and most integrated setting. • Effectively manage LTSS so that services are provided when and where they have the most benefit to reduce the need for avoidable institutional stays. 29

New Managed Care Rules Rule has specific LTSS provisions that align with delivery system goals. Rules includes among others standards for:  Network adequacy for LTSS  Assessment and care planning  Stakeholder involvement  Beneficiary support systems 30

New Rules • To further support state and federal delivery system reforms, the final rules:  Provides flexibility for states to have value-based purchasing models, delivery system reform initiatives, or provider reimbursement requirements in the managed care contract  Strengthens existing quality improvement approaches with respect to managed care plans 31

State Approaches for Aligning MLTSS Reimbursement Strategies with the Triple Aim • Some examples:  Withholding payment based on MCO performance on established quality measures.  Requiring the MCO to include alternate payment models in its contracts with its provider network.  Establishing incentives for transitioning members from nursing facilities. • Discuss various state models and approaches. 32