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Disability Policy Consortium Special Update
Dear william,
Tuesday signaled a milestone in the planning for an integrated managed care system for duals eligibles in Massachusetts with a 2 hour presentation from MassHealth on the status of planning and MassHealth thinking to date.
Disability Advocates Advancing our Healthcare Rights (DAAHR) has been meeting regularly with MassHealth on implementing the 8 principles enunciated in the May response to the RFI. (Principles may be found on the list, here.)
This Special Updates includes 2 pertinent documents.
One is a text version of the Power Point presentation Robin Callahan used on October 11. Of course, we can't convey the many topics of discussion that ensured nor the answers. Questions may be addressed to MassHealth through email to duals@state.ma.us
The second document is a letter from DAAHR co-chairs Dennis Heaphy and Bill Henning to Dr. JudyAnn Bigby, Secretary of EOHHS. The letter highlights some of DAAHRS continuing concerns about the plan for integrating care for Medicaid and Medicare individuals.
However, it must be pointed out that the letter opened with an acknowledgement that discussions between MassHealth and DAAHR have open, honest and productive.
See you all again on Monday.
Bill Allan
Disability Policy Consortium
wfallan@dpcma.org| 617-542-3822
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MassHealth Status Update:
Open Public Meeting
October 11, 2011, 10 am - 12 pm
Transportation Building, Boston
MassHealth Demonstration
to Integrate Care for Dual Eligibles
Design Process Status
■Stakeholder engagement has shaped and improved overall approach and benefit design
■Submitted Letter of Intent to CMS Sept. 30 to use the 3-way capitated financing model
■Data use agreements in place to enable additional analysis; awaiting updated Medicare data
■Continuing stakeholder engagement as we finalize the design proposal
■Will post draft Design Proposal for public comment in the coming weeks
Design Proposal Key Sections
CMS requires that the proposal address certain core topics, including:
■Overall Approach (benefit design, delivery system, etc.)
■Stakeholder Engagement and Beneficiary Protections
■Financing and Payment
■Expected Outcomes
■Infrastructure and Implementation
■Feasibility and Sustainability
■CMS Implementation Support and Budget Request
■Interaction with Other HHS/CMS Initiatives
Benefit Design
■Bring added value to services currently available
-Integrated care management for provision of all services covered by Medicare and Medicaid State Plan - managed, coordinated and authorized by the entity
*Medicare Services: All Part A, Part B, and Part D services
*Medicaid State Plan Services, including dental (preventive, restorative and emergency), personal care assistance, durable medical equipment, vision, long term services and supports (LTSS)
■Expand benefits to target the needs of adult dual eligibles
■Explore option to exclude LTSS from ICE covered services for members in HCBS waivers
Benefit Design -
Behavioral Health Diversionary Services
■Mental health and substance use disorder services provided:
-as clinically appropriate alternatives to Inpatient Services, or
-to support returning to the community following a 24-hour acute placement, or
-to provide intensive support to maintain functioning in the community
■Community Crisis Stabilization
■Acute Treatment Services (ATS) for Substance Use Disorders
■Clinical Support Services for Substance Use Disorders
■Community Support Program
■Partial Hospitalization
■Psychiatric Day Treatment
■Structured Outpatient Addiction Program
■Program of Assertive Community Treatment (PACT)
■Intensive Outpatient Program
Benefit Design -
Community Support Services
■Access to Community Health Workers
-To recognize the diversity of our members
*Cultural
*Linguistic
*Racial / Ethnic
*Disability
-To recognize the importance of non-medical staff on care team
*Chronic disease self-management
*Wellness coaching
*Peer supports for mental health and substance use recovery activities
*Navigation
Benefit Design
Long Term Services and Supports (LTSS)
§Integrated Care Entities must:
§
-Employ community-based service providers (directly or through contracts) that advance independence of members and redirect to least restrictive settings
-Directly employ appropriately trained non-medical staff to ensure that LTSS are included in care plans to the extent needed and requested by members
-Have adequate connections to community-based agencies with population expertise, such as: Recovery Learning Communities, Independent Living Centers, Aging Service Access Points, Aging and Disability Resource Centers, others
-Employ community-based service providers (directly or through contracts) that advance independence of members and redirect to least restrictive settings
-Directly employ appropriately trained non-medical staff to ensure that LTSS are included in care plans to the extent needed and requested by members
-Have adequate connections to community-based agencies with population expertise, such as: Recovery Learning Communities, Independent Living Centers, Aging Service Access Points, Aging and Disability Resource Centers, others
Benefit Design
Long Term Services and Supports (LTSS)
§Integrated Care Entities will have flexibility to substitute other services in lieu of high-cost traditional services, such as:
-Personal care assistance (including cueing and monitoring)
-DME that includes equipment repair, modifications, environmental aids, and assistive technology
-Day services
-Home care services
-Respite
-Peer support / peer counseling
-Transitional assistance across settings
-Home modifications
Care Coordination and Management
■Care of every enrolled member is anchored in primary care with the competencies of a person-centered medical home (PCMH), including:
-Multi-disciplinary, team-based care
-Integrated behavioral health services
-Planned visits with the care team
-Easy and flexible access
-Person-centeredness, including cultural competence
-Care coordination and management
■Care Coordinator works with member and other participants the member chooses to develop care plan that address full range of member's needs
Care Coordination and Management
■Other Care Coordination activities include:
-Coordination with other case managers and/or service providers
-Assurance of appropriate referrals
-Linkages to community-based services
-Assisting the member to develop wellness and self-management strategies
■Clinical Care Manager works with members for whom intensive clinical monitoring and follow-up may be beneficial (e.g. a person with several chronic conditions), such as
-Medication review and reconciliation
-Self-management training and support
-Frequent member contact as appropriate
Enrollment Process
■Statewide with defined service areas
■Enrollment Process: Key Principles
-Voluntary opt-out; change default from Fee for Service to integrated care
-Neutral/impartial enrollment broker
-Sufficient time and information to make a choice
-Choice of plans
-Preserve connections to current providers and caregivers
-Documenting the enrollment process to ensure member protections
■Active outreach and marketing by MassHealth
-In partnership with CMS, advocates, community organizations and others
Enrollment Process: Key Principles
■Neutral/impartial enrollment broker
-Oriented toward member interests, not interests of contracted plans Providing clear, useful, accessible information about plan options
-Leveraging community organizations to support member choice
-Contracted by MassHealth or federal government
■Sufficient time and information to make a choice
-Time to select a plan
*Sufficient advance notice and information to eligible members
*Opportunity to select specific plan or FFS
*Timely confirmation of choice or auto-assignment before coverage begins
-Sufficient and knowledgeable member support (i.e. SHINE)
-Transparency about provider network's inclusion of members' current providers
-Opportunity for outreach to members' preferred providers and caregivers
-Clear member information and support when electing new or different providers
Enrollment Process: Key Principles
■Choice of plans
-Attract sufficient plans to enable member choice
-Voluntary opt-out system
*No default to FFS
*Members enrolled into the better plan
-No lock-in period
-Ability to change plans or disenroll
-Clear, useful, accessible information about how to change plans
■Preserve connections to current providers and caregivers
-MassHealth outreach to providers currently serving dual eligible members ages 21-64
-Require entities to continually enroll providers that meet network requirements
-Outreach to members' preferred providers and caregivers
■Documenting the enrollment process to ensure member protections
-Clear description in contracts and/or MOUs with CMS and plans
-Regulation
Beneficiary Protections
■Require entities to offer choice of providers
-Ensure enrollee choice of PCP and access to a broad array of specialists and other support service providers
-Outreach to members' current providers if not already in network
-Demonstrate capacity to provide, directly or through sub-contracts, full continuum of covered services
■Ensure robust internal and external complaints, grievances and appeals processes
-Unified set of requirements for entities' internal processes
-Single external process that meets all regulatory requirements and ensure rights of both Medicare and Medicaid are protected
■Require entities to operate enrollee customer services
-Accessible, toll-free telephone service; oral and TTY/comparable interpretation services available
-Training and clear expectations for providing information
Quality Measurement
■Assessment of entities' performance in key domains including:
-Access
-Person-Centered Care
-Health and Safety
-Comprehensive Care Coordination
-Integration of Services
-Administrative Simplicity
-Cost savings
■Actual measures to be chosen via multi-stakeholder process
Provider Network Requirements
■Capacity to provide full continuum of covered services
■Demonstrated ability to meet the needs of persons with disabilities
■Continuity of care
■Choice of providers in proximity to a member's home
■Inclusion of members' providers that are willing to join plan network
■Continual enrollment by entities of providers that meet plan requirements
■Outreach by entities to members' preferred providers and caregivers
Global Payments
■Entities will receive one actuarially developed, blended (Medicare and Medicaid) capitation rate for full continuum of benefits provided to an enrollee
-Use linked claims data (CY 2009 and 2010) to develop base capitation rates, plus data related to expanded services
-Higher rates paid for higher risk populations
■Possible use of incentive payments based on quality targets in care integration; shared savings
Impact on Medicare and Medicaid Costs
■Most profound impact on cost will be in the longer term, associated with helping members become and stay well
■There is also potential for savings in the short term
-Elimination of incentives for providers to shift costs by transferring patients from one service or setting to another
-Opportunity for MassHealth to share in acute care savings (such as decreased use of inpatient and ER) that would result from additional investments in care coordination, expanded behavioral health care and long term services and supports
-Opportunity for savings due to decreased use of institutional care
■Detailed actuarial analysis to come following receipt of Medicare data in November
Alignment with State-level Payment Reforms
■MassHealth's payment reform goals:
-Create payment models that hold providers accountable, reward high quality
-Support a delivery system built on PCMHs, that integrates services, provides care coordination, and incorporates transparent and robust quality measures
-Move to global payments
Ongoing Stakeholder Engagement
■Continue public meetings throughout CMS negotiation and implementation phases
■Maintain web site and email box
■All posted information available in alternative formats for individuals with disabilities, and
-Designed to be easily understood by persons with limited English proficiency
-Translated into prevalent languages
■Monitor beneficiary and provider experience and satisfaction through surveys, focus groups, and data analyses
■Require entities to operate meaningful consumer input processes, including governing or advisory boards that include beneficiaries or representatives
Draft Implementation Timeline
■Submit final Design Proposal in fall 2011
■CMS negotiations
-Flexibility will be necessary to ensure maximum administrative integration, clear accountability, and shared financial contributions
Global Payment Rates
■CMS Decision by Spring 2012
■Procurement Spring 2012
■Enrollment packages to members beginning October 2012
■Begin enrollment January 2013
Naming Contest
■Thanks to everyone for the creative suggestions!
■Visit us at www.mass.gov/masshealth/duals
■Email us at Duals@state.ma.us
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DAAHR Letter to Dr. Bigby
October 11, 2011
Secretary JudyAnn Bigby
EOHHS
One Ashburton Place
Boston, MA 02108
Dear Sec. Bigby:
This letter contains a status report of the ongoing work and communication between Disability Advocates Advancing Our Healthcare Rights (DAAHR) and the team overseeing the development of the Dual Eligibles Initiative in Massachusetts. At the outset, it is important to inform you of the positive and productive nature of our communications. And while we do not always agree on key points, the discussions are respectful, informative and yield better understanding by all of the complexity of the undertaking. In this regard, DAAHR is committed to remaining in dialogue with Robin Callahan, Christine Griffin, Rosalie Edes, and Dr. Julian Harris, among others, focusing on places of agreement as much as possible. For the purpose of simplicity, we will go through the process to date using the principles submitted by DAAHR in our RFI response last spring.
1. Participant Enrollment - DAAHR has not reached consensus with MassHealth on active enrollment of dual eligibles. DAAHR is deeply concerned that passive enrollment will result in the creation of a defacto Managed Care system. And while we understand the pressure being put on MassHealth by CMS for large numbers, we also fear these large numbers will come at the expense of quality and long-term increased cost. DAAHR membership is also concerned that passive enrollment will lead to disruptions in delivery of services and the movement of people with complex medical and/or behavioral issues into delivery systems that lack a record of culturally competent care to these communities. And even where competency exists, there is concern over the capacity of competent providers to take on the volume of new participants over a short period of time. Six percent of the duals account for thirty-seven percent of costs-these astounding numbers speak loudly to the need for an extremely moderated enrollment process. Rather than focusing on statewide roll out, piloting outreach to this 6% of duals may yield the level of impact CMS and EOHHS seek at the start of the demonstration project. And while DAAHR does not endorse any particular provider, Boston Community Medical Group, the model on which much of this initiative based, needs to recognized as such in the rollout of the demonstration projects and shaping of expectations of ICEs.
2. Person-Centered Care - A great deal of movement has taken place in deepening the understanding of the needs of different populations comprising the larger population of dual eligibles. In the broader sense, we are on the same page in discussions of person-centered care as a relationship between enrollee and provider in the context of a care team that focuses on the whole person. Within this we recognize philosophy of care as critical. For people with mental health issues this is recognized as the "Recovery Model Care" which focuses on the person's potential, not his or her current functional limitations. More discussion needs to take place with MassHealth regarding enrollee choice as a philosophy of care. Choice includes open networks to enable enrollees to receive care from the competent providers available to them even if they are not part of a network. This is particularly important given the complex nature of dual eligibles. For example, an ICE may not have a neurologist in network with the expertise necessary to care for a person with a particular form of Multiple Sclerosis.
Choice also includes care team composition. For DAAHR inclusion of a representative from a community-based organization to advocate for and with an enrollee as a paid member of the care team is essential. In addition to having an external advocate free from entanglement with an ICE, enrollees need control over composition of the care team. Beyond the primary care provider, the enrollee must have the ability to define the membership of the care team. This is particularly important for people with mental health issues who may or may not want an occupational therapist, for example, to have access to his or her broader medical history.
Delivery Systems - Given the needs of people with complex physical disabilities and people with persistent, severe behavioral health issues the current definition of medical home lacks the robust features necessary to be a truly "medical home" for people with complex physical and/or behavioral/intellectual needs. For example, a medical home for people with physical disabilities may require provision of primary care in the home and also such services as physical therapy and occupational therapy. For a person with a visual impairment in a rural area medical moment require provision of transportation.
Of great concern is protection of Long-Term Services and Supports from incursion by ICEs. DAAHR is adamant that Long-Term Support Services remain the domain of community-based entities free from financial interest by an ICE. DAAHR is exploring different delivery models with all of them rooted in a strong community-based system of service providers and resource centers. The models will require that ICEs maintain contractual agreements with community-based entities capable of providing long-term support services, coordination of support and services, oversight of evaluation, and assessment of plan of care functions to ensure that services and supports are provided in the least-restrictive, most-integrated setting appropriate to enrollees' needs. Sufficient start-up resources for community-based organizations will be essential.
Cultural Competency - DAAHR agrees with MassHealth about the importance of culturally-competent care and services. Further discussion is necessary to determine a definition of culturally-competent care as well as how potential ICEs will prove competence prior to contracting and continue to demonstrate competency in the future. Of particular concern are practical areas of competency that include compliance with the Americans with Disabilities Act, including meeting the highest standards of quality and equal care with respect to administrative procedures, diagnostic procedures, treatment, communication, use of appropriate medical equipment, training of staff, and removal of architectural barriers. How will compliance be determined and will there be proactive outcome measures put in place for compliance that will protect potential enrollees prior to their being enrolled in an ICE? We are also in agreement about the need for health disparities to be addressed. What requires further discussion is how addressing health disparities must become central to the mission of an ICE.
Prevention Services - More discussion needs to take place about prevention of secondary disability within the scope of responsibilities of an ICE. This would include, for example, employing peers for people with mental health issues to decrease hospitalizations and flexible policies around use of durable medical equipment to help prevent skin breakdown and isolation for people with physical disabilities. For DAAHR it is also critical that tobacco use be decreased and that nutrition, physical inactivity and obesity be addressed, particularly as they are included in the CDC Winnable Battles effort.
Consumer Voice - DAAHR is enthusiastic about the level of engagement currently taking place with MassHealth. This engagement must be transformed into actual long-term involvement and the creation of both external and internal community-based entities to protect the rights of dual eligibles and to provide long-term support services. This includes grants to community based entities that will increase their capacity to advocate for dual eligibles in the new delivery system and to become Medicaid vendors of Long-Term Support Services in the community.
Financing Mechanisms - More discussion needs to take place about risk adjustment and the role it will take in financing ICEs. DAAHR is certain that a one-size-fits-all model of health care delivery will not work for the dual eligibles population. In this regard, systems must be created that enable smaller providers caring for the costliest duals to receive appropriate risk adjustment. DAAHR believes that risk adjustment must go beyond actuarial data based on diagnoses and claims to include functional status, with an emphasis on community integration, and comorbidities. This information is necessary to determine primary care provider, enrollee ratios, reimbursement rates and quality measurements.
Quality Measurement - DAAHR has submitted a number of quality measurement tools to the MassHealth team. Further discussion about how the tool supplied by DAAHR will be integrated into the Dual Eligibles Initiative still needs to take place. One example of an issue needing further discussion is collection of data on race, ethnicity and diagnosis (behavioral health, intellectual disability etc.) in order to tie quality to reduction in health disparities. Another is the need to measure quality based on enrollee confidence, the ability to live and receive care in the least restrictive setting and involvement in the community.
In addition to our extensive work with EOHHS and MassHealth staff, we also want you to know that DAAHR is working with legislators to seek potential protections for consumers that we fear may not be addressed in the submission to CMS. We hope our issues eventually can be satisfied, but the level of concern around critical elements such as the definition of voluntary opt-in, open networks, and protection of community based Long-Term Services and Supports necessitates that we pursue a broad-based approach. It would be beneficial, we believe, to further discuss these matters with you, and toward that end we wish to request a meeting with you. The Duals Initiative is big, bold, and can be a linchpin to improving healthcare for people with disabilities in Massachusetts. Continued, strong interaction between committed advocates and you and your staff remains key to the process.
We look forward to meeting with you soon.
Sincerely,
Dennis Heaphy, co chair
Bill Henning, co chair
Cc: Christine Griffin, Julian Harris, Robin Callahan, Rosalie Edes
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