Managed Medicaid: Our New Paradigm
1. We are headed for change! Before we look ahead, let’s look behind!
2. What our industry has already overcome:
a. Medicare was created in 1965
b. Medicare HMO’s evolved in the 1980’s
c. Hospice was added in 1982
d. 1983 DRG’s moved acute health care from a FFS model to case mix reimbursement
i. We had to be ready to admit patients sooner and sicker
ii. We increased our clinical skills and acuity to rise to the cause
e. 1989 Texas went from case mix to 12 levels of TILE reimbursement
f. 1998, we entered our PPS reimbursement (and thought we were going to die!)
g. Star Plus demonstration project in Harris Count (again we thought we were going to die)
h. 2006 entered Medicare PDP programs, yet another learning curve
i. 2010 Affordable Care Act passed, with all the many changes
j. 2008- 2010 Texas went from 12 TILE Levels to 34 Medicaid RUG reimbursement
3. March 2015 we are now facing another change, we will overcome: Managed Medicaid in the
4. Why all the changes?
a. When Medicare created average lifespan was 67 years, now current lifespan is 77 and
quickly heading to 85
b. Currently 52 Million Medicare Beneficiaries in the U.S.
c. Projecting 87 Million Medicare Beneficiaries by 2035
d. That’s 10,000 people turning 65 every day for the next 20 years!
e. Workforce diminishing = decrease in Social Security and Medicare contributions
f. We have got to stop the bleeding!
5. Overview of Senate Bill 7:
a. Passed in 83rd
b. Medicaid HMO carved into Nursing Home Reimbursement
c. Effects over 60K Medicaid recipients in our TX facilities
d. 19 other states have gone before us
i. Learning what works and what didn’t work
ii. To better prepare TX
e. HHSC sets the standards/regulations
i. To protect Medicaid recipients
ii. To protect facilities
iii. To protect MCO’s
f. Goal: To improve delivery and quality of care for Medicaid recipients
i. Better access and care coordination
ii. Improve outcomes
iii. Cost containment/Efficiencies
iv. Reduce Unnecessary Institutionalization
v. Reduce Hospital Readmissions
vi. Reduce Preventable Events
g. Eligibility is determined by the State
h. 5 MCO’s State wide:
vi. No more then 3 plans in a market, but minimum of 2 (rural markets)
1. See attached Maps
i. MCO’s will send out enrollment packets most likely in Dec. and Jan.
i. Will include grid for benefit comparison of all plans sold in market
ii. Recipients will select plan of choice
iii. If not selected, will be enrolled by default methodology
iv. Can make changes to another plan sold in market by the first of the new month
j. Each plan will provide a Care Coordinator
i. Care Coordinator must do face to face with Medicaid recipients quarterly
k. No PreCertification requirement for admission to facility or hospital
l. Reimbursement at 100% of the Medicaid RUG’s:
i. Includes Staffing Enhancement
ii. Liability Insurance
iii. Some Plans may have Skilled rates, to manage patients in-house rather then
m. Pay for Performance metrics will be established for incentive bonuses
6. What does this mean to our referral sources:
a. Education of our BDS/Marketing Liaisons
b. Education of how this will impact their discharge planning out of the hospital
c. Education to our physicians
7. As a Nursing Leader, what does this mean to me?
a. Understanding things are no longer the same
b. Understand the goal is to appropriately move residents out of the facility to a lower
cost care setting
c. Understand which services may require PreCert with the MCO’s and which services
d. Understand how the various plans operate, how they are similar and how they differ
8. As a Nursing Leader, what do I need to do now?
a. Prepare a list of the facility’s providers:
viii. Nutritional services
ix. O2 suppliers
b. Be available to meet with the MCO’s when they do their site visits
i. Ask questions
ii. Understand how their Care Coordinator model works and how engaged they
will with your facility
iii. Educate them on the needs of your residents (no one knows your residents like
iv. Educate them on the needs of your families
c. Coordinate MCO’s Provider Relations orientation to your facility, to include entire
d. Host Resident Council to educate your residents
i. Extend invitation to all MCO’s in your area
e. Host an Open House/Family Night to educate your families
i. Extend invitation to all MCO’s in your area
f. Review current admission process (see attached algorithm)
i. What changes need to be made at your facility?
ii. What changes need to be made with referral sources?
iii. What changes need to be made with physicians?
g. Review the current documentation on those high functioning patients (those will be the
first to be discharged)
i. Does the documentation accurately reflect the amount of care being delivered?
ii. During Care Plan Meetings, prepare families who’s loved one is at risk to
9. What does our Future look like?
a. More collaboration with our payors
b. Care Coordinators involved with all aspects and personnel within facility
c. Care Coordinators a part of our Health Care Planning Meeting and Family Meetings
d. Care Coordinators are responsible for Discharge Planning
e. Higher acuity
i. We will still have beds to fill
ii. Look at current clinical skill set within facility
1. What resources do you need to take your facility to the next level?
a. IV Certification
b. TPN Certification
c. 24/7 RN Coverage
d. Respiratory Therapy
e. Pulmonary Unit
f. Extensive Wound Care program
g. In patient Dialysis
10. We shall once again, OVERCOME!