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Managed Long Term Services

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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Pam Coleman

Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Pam Coleman

Published in: Business, Health & Medicine

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Transcript

  • 1. Albert llav/ kins, Execctive C. cnmr'issi3rer Managed Long Term Services Texas Health and Human Services Commission Pam Coleman October 14, 2007
  • 2. What is STAR+PLUS? I Risk-based, capitated managed care I Began in Harris County (Houston) in 1998 I Integrates Medicaid funding and service delivery of long term and acute care I Serves the aged and disabled not in nursing facility
  • 3. STAR+PLUS Expansion I ST AR+PLUS expanded to 4 new areas in February 2007 I Bexar, Travis, Nueces and Harris Contiguous Counties I Over 152,000 currently enrolled
  • 4. Measures of Success The following slides outline some of the indicators that are used to measure the progress of STAR+ PLUS.
  • 5. Access to Services: Results Increased use of preventative and support services (32°/ o increase in attendant care, 38°/ o increase in adult day care) Decreased use of acute medical services (28% decrease in hospital admissions) Decrease in Emergency Room Visits Members rate their HMOs high on providing needed services, equipment, and assistance (8.2 on 10 point scale) Source — Irl§titute for Child Health Policy, 2003
  • 6. Personal Assistance Services STAR+PLUS Unique Members Receiving Personal Attendant Services 200009 200109 200209 200309
  • 7. Quality: Results External review completed July 2003 Sickest STAR+PLUS members were compared to equally sick people in a non-capitated primary care case management program Significant cost difference ($3,226 mo in STAR+PLUS vs. $13,160 mo in comparison group) Significant reduction in inpatient and ER use, especially in HMO with larger number of care coordinators Source: Institute for Child Health Policy, November 2003 ix
  • 8. ll’ ‘ _I_ l‘ [‘lIlj“ . '.. ~“. ; li'-l“ ,1 I; 1‘ 4?‘ k‘2r. '‘— . Jay ‘W. , “ 2. I . + ‘M Vim. ‘ . 1'»m'1~ IV ’, ‘: vi. _. Overall Expenditures 40000 35000 30000 25000 -353 Ulé $6 6% $3 10000 5000 Average Charges per Month Al Hczllhy S’g-rficanl Aculc Minor Chronic Dom in: mUM our: 1.1!: “alignancics 8 Chron c Chalaslropmc IT STAR+PLUS Experiment Group ' l STAR Control Group
  • 9. Challenges for Implementation Consumers Perspective I Perception of evil gatekeeper HMOs I Concern with HMO’s lack of experience with LTSS I Concern that the medical model with be emphasized over support and community service needs I Concern that high need consumers will be directed to NFs I Concern that gains in CDS will be lost
  • 10. Challenges for Implementation LTSS Providers I Many unsophisticated providers I Requires significant education for both providers and the health plan I Health plan claims payment systems will need to be adapted I Health plan must have provider outreach capacity 10
  • 11. Challenges for Implementation Automation issues I State eligibility systems must be able to accurately identify HMO LTSS members I Encounter system will need to recognize LTSS encounters I HMOs must have systems that can track HCBS members I HMO systems must be able to handle retroactive Medicare coverage
  • 12. Lessons Learned HMO Staffing I Staffing ratios exceed typical HMO levels by at least three-fold I Training should focus on chronic care versus acute model I Multi-disciplinary teams: SW, RN, BH I Significant f/ ‘e/ d-based activity and staff
  • 13. Lessons Learned Care Coordination I Health plans with more care coordinators have better performance I Care coordinators must be empowered to authorize LTSS I Care coordinators must be responsive accessible to members I Involvement of all caregivers in CC plan development I 24/7 on—line access to current care plan 13
  • 14. Lessons Learned Dual Eligibles I Must focus on inpatient even if not responsible for acute care — SNPs help address this issue I Anticipate needs in member's home during inpatients stays to facilitate subsequent discharge 14
  • 15. Lessons Learned Pharmacy I High intensity use and significant potential for drug—drug issues I Care management focus on client Rx compliance I Drug utilization review must be part of care coordination plan 15
  • 16. Lessons Learned Comprehensive Benefits I Pre—auth rules must be moderated I Transportation must be easy to access I Generous use of benefit substitution principle will encourage creativity in delivery system 16
  • 17. Lessons Learned Value Added Benefits I Potential incentives to select a plan I Must be scrutinized by the state to avoid risk selection impacts I May provide real value to members I Enables the marketplace to ‘work’ by educating consumers 17
  • 18. Final Thoughts I Integrated programs are challenging but offer many benefits to consumers and states I HMOs must treat this as a dedicated line of business, not an add-on to other I States must hire dedicated staff to manage these programs Massive, coordinated education required I Include consumers in design and implementation
  • 19. Medicaid & CHIP ~- “"i"‘, ""°'”"’, °,"‘__, Managed care Service Areas with N003 Msions (in rod) Tammi CSA I7: = - l Vic u ‘llll i’liIi' Daflas csg mr, v.. .., ».<i u: l ll| .. ,, , ,,, .,I, ,, . .~l . ‘i "r ‘l 4 . ._i. .i, ~.~iw . ' "" ' """"' “‘ " " l‘iillii-Ji'~Tll| i: ~ Lubbock SDA : ~l(| ’ll1: “Milli; || IIi | i| ~I»‘: H I ll'l‘i ‘, v.ii--rlltililil". .i. . ‘l‘IIl| 'l Travis CSA i, ii_: u A] -, y ‘ min i‘; _ '. sl i-. l'll. X "S siipmn i~. i i~ l‘: mu. .i ll| l'. inl; ~ II llilx -1.! ‘ JiIlI'_i””: ,lI'~-r : il)1.| “ ‘-Ii‘-Jltl ll: ilili i'| .niil M-‘. , I‘ iiii‘i Har'isVCH| F O-SA '. ni l I’l"yl‘| . iiuur 1-” c, v,_°_sA ‘ I ll . ll-4:. “ ‘” ‘ Hams CSA 'i; _mis ]}l_ . -;-. ui‘{"y e""'cSA lll(lll‘iiu'v -’i. RI EIIF ~. -. 'v'><ll"« -' lg ‘-‘ " 4 . .i. ii, -. Ll.4i. :i‘IliHlll: l' ‘i ‘ “‘ l "‘ l. :ii'u: i ‘ ‘ I i. m.m l, iii: >l‘. R(ll| l‘i ‘l l‘ l ll . i, ‘-»i'~‘ | -—< '57‘-K1|l1Y'l 1.-. ... l. > l. .lL'llI xi li I ‘ll l D11-Mr-M A. vskii-irsl-uii‘iiIl' NuecescsA I | ll| .|lll'iil| I ' . » igp ‘V D i; v~i= u. —‘ . i.lm. u . .-. v. .i' 5". I . — Wtrbb CSA . ‘ 3, , , H 3;: ,, . . ,,, ,, , -H". I'ilIi-um ml xl Mt iimgi I‘| | xi " T "T V ‘y H L». .- . i llil‘ l I i . -ii II. ‘-(I. .v. l_ , i.; .,l>, li-. m. i. . v I V H I-( | l]"'! ‘.“| lll4I . |li ‘I. -H ifl. i I l'. 'll H ' inrr ll . i-vr. i'ii. . l‘: .