My Care Ohio: Can Integrated Financing Lead to Enhanced Integrated Care?
Donald Mack, M.D.Ohio State University Medical Center
Gregg Warshaw, M.D.University of Cincinnati College of Medicine
Dual eligible beneficiaries comprise 20% of the Medicare population and 15% of the Medicaid population in 2008
Dual Eligible Beneficiaries
9 million
Medicare37 million
Medicaid51 million
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.
Total Medicare beneficiaries: 46 million
Total Medicaid beneficiaries: 60 million
Under Age 65
39%Facility
13%
Mental Impairment
49%0 or 1
Chronic Conditions
25%
Age 65-74
26%2 Chronic
Conditions
20%
Age 75-84
21%
Community
87%
No Mental Impairments
51%3 Chronic
Conditions
20%
Age 85+
14% 4 or more Chronic
Conditions
35%
Age Type ofResidence
MentalImpairments
Number of Chronic
Conditions
Dual eligible beneficiaries are a diverse population
NOTE: Mental impairments were defined as Alzheimer’s disease, dementia, depression, bipolar, schizophrenia, or mental retardation. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey, 2008
26%
22%
44%
25%
44%
50%
55%
58%
Dual eligiblebeneficiaries
All other Medicarebeneficiaries
Dual eligible beneficiaries are sicker than other Medicare beneficiaries
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
3+ Chronic Conditions
In Fair or Poor Health
Cognitively or Mentally Impaired
Functionally Impaired
5
The Problem
Limited care coordinationFragmented CareCurrent system is confusing and difficult
to navigateMultiple health care needs and high costThe health care and long-term care
systems are not connected very well, even though people use both
MyCare Ohio
Demonstration to test integrated care and financing model for individuals with Medicare and Medicaid
May 2014 to December 2017Federal and State partnership How it will work:
Approved ICDS Plans will provide integrated benefits to Medicare and Medicaid enrollees in seven targeted geographic areas
Plans must provide all necessary Medicare and Medicaid-covered services, including Medicaid waiver services
Single identification card to access services
MyCare Ohio
Three-way contract (Health plan, CMS, State)Rolling start in mid-2014; passive enrollment
in Medicare delayed until January 1, 2015Capitated rates adjusted for State and CMS
upfront savings; also quality withholdComprehensive care plans required
incorporating client and family goals
Medicare Passive Enrollment (I)Beneficiaries must participate in MyCare Medicaid; but Medicare is optional
On 1-1-2015, individuals who have not indicated a choice, will be passively enrolled in MyCare Medicare with the same health plan as their MyCare Medicaid (integrated benefits and funding)
Medicare Passive Enrollment (II)Individuals can choose to stay with
traditional Medicare or another Medicare Advantage plan
Beneficiaries can switch from MyCare Medicare to traditional Medicare, or vice versa at anytime
This is all very confusing to consumers and public education has been poor
Benefits for Primary Care Providers
Identifiable care manager – phone and email contactAccess to all benefits and servicesOpportunity to enhance home and community-
based servicesWEB portal to access patient’s care planAssistance for your most complex patientsOpportunity to participate as part of Integrated
Care TeamPotential to shift hospital dollars to community-
based services
Continuity of Care and Transition Requirements
Health plans must ensure individuals have access to current providers and service levels at the time of enrollment.Length of transition period differs by service.
For prescription drugs, Medicare Part D transition requirements apply.Health Plans must provide a one-time fill- 30 day
supply- of an ongoing medication within the first 90 days of plan membership.
Residents in long term care facilities can receive multiple fills.
Continuity of Care Requirements (Continued)
During the transition, Health Plans will advise enrollees and providers that they have received care that would otherwise not have been covered.
Ongoing basis, Health Plans must contact providers not part of their network with information on being credentialed as in-network providers.
Health Plans must always reimburse an out-of-network provider of emergent or urgent care.
Details: Plan Payment Requirements
Ohio UHCAN (Ohio Consumer Voice for Integrated Care)Engaged in Monitoring implementation;
influencing consumer protectionsPassive enrollmentClinical networks; benefit limitationsLTSS, transportationConsumer engagement in plan implementation
UHCANOhio.org614 456-0060
MyCare Ohio Observations (I)Disruptive change: Impact on large number
of patients and their provider networksVery complex and the Ohio Medicaid office is
also expanding MedicaidCMS-State Medicaid Office-Health Plan
negotiations complexOhio has agreed to involve Area Agencies on
AgingHalf of the enrollees will be under 65; mental
health and disability groups very engaged
MyCare Ohio: Observations (II)Physician and provider reimbursement
stable, but for how long?Networks broad, but for how long?Health plans have limited experience with
this population across all settings of carePrimary care and geriatrics providers have
received limited education about upcoming changes
Critical Role of Provider and Consumer Engagement
Dual eligible patients will benefit from your participation in planning and direct care provision in MyCare Ohio
If MyCare Ohio is not successful, the alternatives may be less desireable for patients and providers
Primary care and Geriatrics providers’ clinical leadership, when combined with consumer advocacy efforts, is more likely to have an impact
How can Providers Get Involved? (I)
Learn about MyCare OhioDiscuss good and bad observations
with your health system, Area Agency on Aging, health plan medical directors, and State Medicaid office leadership
Join advocacy organization list-serves
Voices for Better Health: http://CommunityCatalyst.org
Why Learn More about MyCare Ohio?
YOU ARE:An important source of health system
infoA reliable and authoritative sourceAware of the clinical needs of the
personAware of the functional needs of the
personAware of the social needs of the person