Value Based Payments & Medicaid Managed Care: Risk Management Model

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Christine McGee
5 years ago
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1 Value Based Payments & Medicaid Managed Care: Risk Management Model Todd Pinkus, Executive Director Gilbert Louis, Board Member Elizabeth Corrigan, Research Consultant April 12,

2 Background NYS Medicaid Expenditure: q $60 Billion for 6 Million people NYS Medicaid Expenditure for People with Intellectual and Developmental Disabilities (IDD) q $6.6 billion in LTSS q $1.1 billion in Medical q 127,000 Persons with IDD This small group is consuming ~13% of the total NYS Medicaid budget 2

3 Section 1 Patient Population IDD population is high cost } Yet, q No systematic care coordination q No universal IT support q No evidence based practices in place. Meaningful NY comprises an integrated network of 10 agencies q Starting population are those individuals who are receiving Medicaid Service Coordination or live in a certified residences (n = 5,000)

4 Section 2 Stratification Model q Tier 0: Low risk: 0 conditions / Low Touch / Cost equivalent to rate; q Tier 1: Basic: 1-3 conditions / Moderate touch / Cost equivalent or slightly higher than rate (up to 9%); q Tier 2: Intermediate: 3-6 conditions / Higher Touch / Higher Cost total cost of care is 10 to 25% higher than peers; q Tier 3: Extended: 7-9 conditions / High Touch / High Cost total cost of care is 26 to 40% higher than peers / Super-Utilizers; q Tier 4: Complex: 10+ conditions / High Touch / High Cost total cost of care is at least 41% higher than peers / Super-Utilizers Adapted from The Mayo Clinic

5 Section 2 Stratification Model Cont d What Constitutes High-Risk? Based on analysis of claims data to be provided by NYS OPWDD as well as clinical data: q Annual cost of care is greater than 25% of average annual cost for IDD Services q Annual cost of care is greater than 25% of average annual cost for healthcare services q Multiple medical diagnoses ( 4) q Multiple chronic conditions ( 4) q Secondary psychiatric diagnosis or behavior disorders q Multiple ED visits and hospitalizations per year ( 3) on average for the past three years q Polypharmacy ( 5 medications) 5

6 Section 3 Data Data points q Demographic data q Claims data (NYS DOH and NYS OPWDD) q Clinical and Programmatic data (CAS; DDP2; ACO, FIDA) Data collection entities: q NYSDOH & NYS OPWDD q Some data are collected by provider agencies Data Accuracy: q Fragmented system -some with providers, other with hospitals or NYSDOH q No real time data Ease of Data Access: q Varies no EHR Needed Reports and Frequency: q Clinical reports that include real time information- e.g., medication, cost of pharmacy, PCP

7 Section 4 Risk Management / Intervention Model: Overview of NYS Value Based Purchasing Structure 7

8 Section 4 Risk Management/Intervention Model Interventions needed to support target population: q EHR q Care coordination platform q Policies and Procedures q Staff training Resources needed by individuals with IDD of varying levels of acuity: q An acuity tool or risk scoring tool - this is currently being developed Resources already in place: q Clinicians including physicians, nurses, psychologists q Filing cabinets full of paper!! Gaps to be addressed: q Coordinated Assessment System tool q Repository where real time data can be viewed and linked to right clinician for action

9 Section 5 - Timeline and next steps Timeline is contingent on: q Whether or not the CAS gets validated and shared with the IDD field q Funding for this pilot project Next Steps: Develop long-term strategic plan that includes how we do risk stratification and risk management Identify physicians who are skilled with aging and complex populations with multiple disorders, good at triaging, and educating direct support workers Assess provider readiness Retool QA Allow data collection to inform new hires going forward Workforce Development with focus on direct support staff Gather clinically actionable data 9

10 Section 6 Staffing and Operational Gaps Care Crisis or Care Gap Direct Support Workforce Development: q Care Management q Medical Care q Behavior Support q Information Technology q Medication Administration q Person Centered Planning Attract and retain Direct Support Workers: q Living Wage q Pathways to Growth q Work-Life Balance q Valued Contribution

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