Wisconsin Complex Care Management Project. Rebecca McAtee, Deputy Director, Bureau of Benefits Management, Wisconsin Medicaid

Transcription

1 Wiscnsin Cmplex Care Management Prject Rebecca McAtee, Deputy Directr, Bureau f Benefits Management, Wiscnsin Medicaid

2 Agenda Overview f NGA Plicy Academy Natinal Super-Utilizer Mdels Visin and Gals Wiscnsin s Prpsed Apprach Prcess t Date Stakehlder Engagement Defining the Target Ppulatin NGA White Paper Develpment Next Steps 2

3 NGA Super Utilizer Plicy Academy: Overview Backgrund: In June f 2013, the State f Wiscnsin was invited t submit a prpsal t the Natinal Gvernr's Assciatin t participate in their Plicy Academy n "Super-Utilizers." An NGA Plicy Academy is a highly interactive prcess designed t assist states in develping and implementing strategic actin plans that build n research and best practices. States participating in the Plicy Academy are expected t address a hst f issues related t hw state gvernments can systematically supprt cmmunity-based, prvider-led superutilizer mdels Purpse: T assist gvernrs in designing and imprving systems at the state level t ensure better prvisin f crdinated and targeted services fr peple wh are high-utilizers f health care services (super-utilizers) Expectatins: States participating in the NGA Plicy Academy will develp prficiency and best practices arund hw t imprve their systems t allw fr 1) better and timely identificatin f super- utilizers thrugh data analytics; 2) seamless prvisin f intensive clinical and nn-clinical interventins; 3) financing f prvider and cmmunity-based super-utilizer mdels; and 4) deplyment and use f care teams, which culd include cmmunity health wrkers 3

4 NGA Super Utilizer Plicy Academy: Objectives Over past year, Wiscnsin was tasked with designing a prgram t address super-utilizers The past year was intended t fcus n the tw circles n the left f the abve prcess flw NGA expectatins were that Wiscnsin wuld: Develp a Wiscnsin Strategic Plan by July 2014 By September f 2014, reprt n key actin steps twards implementatin f the strategic plan 4

5 Natinal Mdels fr Super Utilizers Camden, New Jersey The riginal super-utilizer prgram Camden Calitin develped a system f ht-sptting high-needs patients by lking at individuals with high inpatient admissins and high ER usage Embedded care managers and health caches int primary care settings t wrk ne-n-ne with identified patients The Camden Calitin/RWJF has helped t establish several similar pilt prgrams acrss the cuntry Allentwn, PA Aurra, CO Bstn, MA Cincinnati and Cleveland, OH Humbldt Cunty and San Dieg, CA Kansas City, MO Maine Western Michigan Other pilts have als been established in MN, WA and NC 5

6 Natinal Mdels: Key Lessns Learned Acrss the several pilt prjects that have been implemented, key themes have develped in cmmn: Aligning incentives acrss multiple stakehlders is essential Changes in the traditinal payment mdel are necessary t achieve success The ppulatin must be clearly defined and segmented, hwever segmentatin based n diagnsis is nt ideal Care mdels must incrprate nt nly the medical/clinical cmpnent, but als ther scial needs that may impact health (fd, husing, transprtatin, etc.) Data is integral t bth start-up and nging prcesses 6

7 Wiscnsin s Visin and Gals Visin: Creating a fiscally sustainable Medical Assistance prgram by better managing members with cmplex cnditins Gals: Imprve verall quality f life and reduce expenditures fr highneeds, high-cst ppulatin Establish a new mdel f care delivery that incrprates high-tuch, high-intensity interventins Develp a reimbursement structure that will ultimately lead t lwer csts ver time Strategy: Cntract with an entity(s) t deliver a new cmprehensive integrated care mdel, incrprating scial, behaviral and medical needs f a defined set f highneeds members Optins include: Prvider-based r HMO-led delivery system 7

8 Wiscnsin s Prpsed Apprach Wiscnsin's prpsal seeks t address the unique ppulatin and needs f Sutheast Wiscnsin, particularly Milwaukee Cunty Build ff f the significant cmmunity engagement and critical partnerships that have been established in this area, such as the ED Care Crdinatin initiative thrugh Milwaukee Health Care Partnership, as well as leverage the existing netwrks and successful care delivery mdels in place in Milwaukee DHS als prpses t build n the experiences f successful implementatins f ther initiatives prmting integrated care, such as Care4Kids and the AIDS/HIV Health Hme Cnvene a grup f multi-stakehlder wrking grups cmprised f advcates, cmmunity partners, prviders, payers and health systems t help develp and implement a strategy related t the verall missin f imprving quality f care and reducing verall health care csts fr identified high-cst, high-needs individuals 8

9 Prcess t Date Stakehlder Engagement Defining the Target Ppulatin NGA White Paper Develpment 9

10 Stakehlder Engagement September 25 th Kick-ff Meeting Met with key stakehlders in the Milwaukee regin Intrduced cncept Received feedback n rganizatinal structure Validated initial data apprach fr target ppulatin Established stakehlder wrkgrups and tiered schedule fr wrkgrup engagement Began meetings f the Cmmunity Advisry Cuncil Kicked ff Tier 1 Wrkgrups (Target Ppulatin, Scial Determinants, Clinical and Best Practice Mdels) Since September 25 th, the State has held ver 30 meetings with stakehlders related t the Cmplex Care Management prject 10

11 Organizatinal Structure 11

12 Initial Prject Timeline 12

13 Defining the Target Ppulatin Initial primary fcus n the Target Ppulatin Began refining definitins in Octber Full extract develped by ur fiscal agent Extract cmpleted in January Delivered t PwC t perfrm additinal analysis Wrked cllabratively with PwC t establish apprpriate filters and further refine the data and identify a ptentially impactable ppulatin Cmpleted first cut f the target ppulatin was develped fr a March 3 rd stakehlder meeting 13

14 Defining the Target Ppulatin Ppulatin specificatins fr initial extract: SSI/EBD Medicaid enrllees Nt enrlled in Managed Care/HMO (less than 5 mnths in an HMO) Ages 19 and ver Nn-institutinal setting Based ff f member cunty f residence CY The full extract includes data Statewide, but fr the purpses f this initiative s target ppulatin, the fllwing criteria was als applied: N dual eligibility Sutheast Wiscnsin 14

15 Defining the Target Ppulatin: Selectin Criteria Distributin f Regin 6 claimants by number f ER visits Fr analysis, Super Utilizers were identified as individuals with multiple emergency rm (ER) visits r very high annual csts (hereafter referred t as the target ppulatin) ER visits are identified by a revenue cde f r 981, r prcedure cde f n a claim All claims n the day f an ER visit were cmbined fr cunting and cst determinatin Apprximately 46-48% f the ttal SSI eligible ppulatin have at least ne ER visit acrss the three-year perid Percent that are high ER utilizers is cnsistent acrss years Abut 40% f ER users have ne visit in a year, while 60% have tw r mre Annual ER Claimant Cunt % f Claimants Visits % 0.2% 0.4% % 0.3% 0.4% % 0.7% 0.8% % 3.9% 3.6% % 9.3% 10.2% % 4.6% 5.5% % 6.9% 7.4% % 12.7% 11.9% % 21.0% 20.3% 1 1,429 1,446 1, % 40.3% 39.4% Ttal 3,614 3,588 4, % 100% 100% 15

16 Defining the Target Ppulatin: Selectin Criteria The pilt ppulatin was defined based n ccurrence f at least 3 ER visits in a 6-mnth perid r annual cst greater than $100,000 In Regin 6: The percentage f ER users in the pilt ppulatin increased frm 10.4% in the first half f 2010 t 11.5% by the secnd half f 2012 Abut ne third f the high cst claimants were identified as having 3 r mre ER visits in a 6-mnth perid Target ppulatin csts have increased ver the three-year perid frm 35% in CY2010 t nearly 41% in CY2012 f ttal SSI csts Perid / Year Claimant with 3 r mre ER % f all claimant Regin Jan-Jun % 2010 Jul-Dec % 2011 Jan-Jun % 2011 Jul-Dec % 2012 Jan-Jun % 2012 Jul-Dec % Perid / Year Claimant Claimant >$100k Allwed % f all claimant Regin Jan-Dec 6, % 2011 Jan-Dec 6, % 2012 Jan-Dec 7, % Nte: claimants were limited t thse wh d nt have cancer, HIV, AIDS, r develpmental disabilities 16

17 Defining the Target Ppulatin: CDPS Cnditins The Chrnic Illness and Disability Payment System (CDPS) was used t identify the diagnstic cnditins Claimants with HIV, AIDS, and develpmental disabilities were carved ut as existing prgrams target these individuals; individuals with cancer as a primary diagnsis withut the presence f ther c-mrbidities were als excluded Mst prevalent and ften c-mrbid CDPS cnditins Cardivascular Psychiatric Pulmnary Skeletal Gastrintestinal Substance Central Nervus System Diabetes Metablic Additinal CDPS cnditins t be cnsidered: Renal and Depressin Psychsis Biplar An additinal analysis was dne n severity within the CDPS cnditins shwing that many f the cnditins within the ppulatin were at lw r mderate severity. 17

18 Defining the Target Ppulatin: PMPM Summaries Average PMPM f the target ppulatin chrt is increasing mre rapidly cmpared t the nn-targeted grup 18

19 Defining the Target Ppulatin: Demgraphics 19

20 Defining the Target Ppulatin: Demgraphics 20

21 Defining the Target Ppulatin: Demgraphics 21

22 NGA White Paper Develpment As a requirement f the Plicy Academy, each participating state must submit a draft strategic plan t the NGA incrprating the fllwing cmpnents: Visin fr the prgram Stakehlder Engagement Target Patient Ppulatin Mdel Design (including delivery mdel and payment apprach) Infrmatin Exchange Evaluatin Methdlgy Lessns Learned 22

23 NGA White Paper Develpment DHS has taken the apprach t use the white paper as a descriptin f an ideal state, which will help us t further define measurable, lng-term gals fr the prject. The paper als reviews the feasibility f varius ptins fr addressing the cmplex needs f the target ppulatin based n feedback that we have already gathered frm ur stakehlders. The paper des nt pinpint ne specific ptin as the best r nly ptin. Rather, it presents a variety f ptins that have been identified as feasible strategies fr stakehlders t cnsider. 23

24 Highlights f NGA White Paper Care Mdel: Wiscnsin identified themes cmmn t successful mdels bth within the State and natinally Team-based care that is flexible t meet specific member needs Rapid access t multiple services, c-lcatin f services is ideal Care teams must have access t patient medical recrd Tiered prgram where level f engagement will decrease as member takes cntrl f their care HMOs wuld mst likely serve as the administrative entity fr implementatin in SE Wiscnsin Payment: Cnsidering a shared savings cncept 24

25 Lessns Learned and Next Steps Timelines have shifted Cmpeting pririties Alignment with ther state initiatives Tier 2 and 3 wrkgrups have nt yet cnvened After submissin f the cncept paper t the NGA, DHS will cntinue t wrk with external stakehlders t arrive at a final recmmendatin and implementatin strategy At this time, DHS des nt intend t implement the pilt any earlier than January

26 QUESTIONS? 26