The Future of Integrated Care In New York State

Transcript of webinar

[Andrew Segal] A warm welcome to everyone here today. I´m Andrew Segal, the Director of the Division of Long Term Care in New York State. I´d like to welcome my team that´s here today: Erin Kate Calicchia, \inaudible\, Joe Shunk, Patrick Cucinelli, Brenda Mercado and Frances Ness who is diligently taking notes, and our partners in integration at CMS, thanks to Lindsay Bernette, Melissa Seeley, Tobey Oliver, Maria Baroski, here for helping to help facilitate this process. Lindsay will be presenting Medicare and Medicaid Financial Alignments Initiative after my presentation. We would also like to thank our special guests who are here today, Jim Verdier and Anne Mary Phillip, who are here from the Integrated Care Resource Center to offer us all some information about how other states have achieved high levels of integration without a \inaudible\. Lastly but not certainly least, we´d like to thank each and every one of you for being here today: all the stakeholders, the plans, the trades, and for all of you on the webinar including other DOH staff and interagency staff for your participation. We really think this is a strong demonstration of \inaudible\ commitment to \inaudible\ care in New York State.

This is our agenda for today. We do ask that you keep your questions until the end. We will have a discussion portion, and that will be monitored by Erin Kate Calicchia, the Bureau Director of Managed Long–Term Care, in order to get feedback and gather input from the stakeholders, so we ask that you please hold your questions until that time. Here you can see our DOH crystal ball. I don´t think any of us can look into our crystal ball and really know what the future holds, but I think that´s why we´re all here today, to have that conversation and that dialog, and to be participatory to really ensure that going forward everyone´s input within the stakeholder community is included in the future of integrated care. Today is really the first in a series of meetings in which we hope to begin to have the conversation on the future of integrated care in New York State and envisioning what the best vehicle is available to deliver the care necessary that is both high in quality and that is cost effective moving forward. We are starting, embarking upon this process because of the future of FIDA is unknown due to its nature, it is a time limited demonstration, and we want to plan for the future of integrated care with enough lead time for a smooth transition for those folks who are in various products.

Why is integration good? A lot of us have had experience managing and coordinating the delivery of care for dual eligible and those are of course the individuals who are both eligible for Medicare and Medicaid, and that has become the central focus in a lot of ways of our state´s health care reform effort, to coordinate and align care for these individuals. In many cases, the dual eligibles represent some of the most vulnerable elders confronting both economic and health challenges. Better coordination of services between the two programs of Medicare and Medicaid holds significant promise in terms of being able to improve the lives of millions of New Yorkers while achieving greater efficiency, value, and outcomes from our health care system. We just wanted to do kind of a quick look here at the current landscape for the next slide. What we see is the current landscape of integrated care in New York State. As you all know, the Medicaid redesign team made Medicaid and Medicare alignment and coordination an essential goal for New York Medicaid, and this prompted the FIDA demonstration and the pace and the map expansion. These integrated programs owe success in a lot of different areas– we´ve listed some of them here of which include individualized care planning and coordination of services, alignment and management of Medicare and Medicaid´s funding streams, enhancing the quality of community based care while minimizing the need for institutional care which is always an essential focus of the work that we all do, and enhancing the value proposition by achieving better outcomes on key quality indicators such as reducing emergency department visits and repeat hospitalization admissions, and lastly we all think about the ideals that it was an increasing health value and quality of life for the members and individuals who are affected by these programs. Just to continue on the current landscape of integrated care in New York State theme here, we have as I always say three distinct avenues in New York State for integration, and they include FIDA, MAP, and PACE. FIDA really, out of all the programs, is a product that offers the most robust service package available in New York State managed care programs. It delivers a seamless experience for participants which is really key, a key component that we´ve heard about and streamlined administrative processes on the provider side. It provides an individualized, person–centered care planning process \inaudible*1\ the IDT approach that benefits both parties, meaning participants and providers. One of the key components I think of the FIDA program that we´ve all touted and been a part of because there has been a stakeholder process and there has been a lot of input is the flexibility that is available in FIDA that we don´t have available in other programs, so there are less restrictive requirements for plan marketing and for networks, and there´s a very unique and fully integrated appeals and grievance process which you all know about. In many ways, FIDA achieves the most integration of the three programs, and it provides participation in IDT. It favors this collaborative approach that you often hear about. We also offer MAP in New York State. MAP combines the state´s standalone MLPC program with a Medicare Advantage Plan to offer both long–term services and supports and Medicare acute care, and it offers care coordination through a plan care manager. The benefit package includes MLPC benefits plus Medicare services but it does not include all the Medicaid physical health services, prescriptions, Medicaid HCBS waiver services, so it is more limited in scope. That was really one of the first attempts back in 2007 or 2008, a large–scale integration, integrated managed care, but it does provide less administrative integration than does let´s say a FIDA or a PACE. Speaking of PACE, lastly, we have the PACE model, a tried and true program which I believe started in the 70s and was established in New York in the 1980s. PACE has been around for a long time. PACE provides an individualized, person–centric care planning process and interdisciplinary team approach that benefits participants and providers for members who are age 55 and older or who would otherwise be in a nursing home. It achieves high integrated service deliver, but it is different in that the Medicare and the Medicaid and the LTSS services are provided in and centered around an adult day health center. The adult day health center is supplemented by in home and referral services in accordance with participants needs and health services are provided by a health care team of providers including doctors, nurses, social workers, and it really surrounds the member. New York is really set to lead in many ways, we´re proud to say, the nation in PACE advancement and growth with the PACE Innovation Act and two new PACE centers this year. We´re very excited about that.

We talk about integrated products. We think about the future of integrated programs. Why is there such an emphasis on integration? I think that really forces us to think about what the value is in integrating care. I think there is universal agreement in the industry that there is tremendous value in integrating, and it is one of the less, I think, controversial concepts that I´ve heard support for. The value of integration falls within a few different buckets. You have the experience of care. That´s a person centered plan, and interdisciplinary team model that focuses on services to an individual´s needs and preferences, and that ensures a collaborative and robust person specific approach. The IDT also provides data sharing which is very important in the world we´re living in. You hear more about data every day and the important of data, and knowing how to conduct interventions when you have data, so it is data sharing, collaboration, and communication across individuals, providers, and caregivers, which is important. Then, care management of course, which is an essential component of a lot of our products that take place in a coordinated manner to specific patient´s needs. Then you have comprehensive provider networks across a lot of plans that meet the broader needs of the target population. Then we have the experience of other providers which we know has not always been ideal in FIDA, and there has been a period of which we have tried to increase the education about the program and try to really tout some of the benefits for the experience of providers, and we see that there are several different elements to that including having direct and continued access to the care planning and care management staff are able to participate in the process and the providers are really involved in the planning in a holistic approach to every step in a patient´s care, and that´s what makes integration very unique. Two other buckets that highlight the value of integrated care as we see it are A: the alignment of incentives, and B: the total cost of care. When we talk about alignment of incentives, really, we´re talking about emphasizing the value of quality within the total cost of care model which are beneficial to the members and providers while also creating an incentive for the plan. These incentives provide really a financial benefit for the lines of the quality of care. Then we have the total cost of care, which really is integrated care, it helps us fill what we all hear about is the triple aim of health care, which is \improve\ patient experience, reduce costs, and improve the health of the population. Through our dual program individuals are able to live safely in their homes and in their communities, decreasing the higher costs associated with institutional care. Both the future of integrated care and value based payments will be playing an increasingly supportive role as we see it in the shape of health care as we move forward. As you all know, New York State right now is embarking upon the VBP journey if you will as laid out in the state´s VBP roadmap, and that is across all Medicaid products and integrated programs really in many ways to align with the total cost of care construct which emphasizes shared savings. Within that construct, integrated products and their respective components really emphasize better care coordination which leads to better outcomes and better value. We´re excited to be here today with CMS and obviously we will continue to reach for our ultimate goal to fulfilling full alignment with Medicare and VBP alignment. This brings us to the challenges that we have of many managed care products from where I sit and stand in this position, or this role, over the last year which is often times an abundance of choice leads to confusion among stakeholders. Because we have three integrated products in New York State, we often hear from stakeholders and from the community and from plans that some are favored over others, that they like the benefits of certain plans, that they think the component parts would be good to repurpose to maybe a new type of plan, or a fourth plan, or maybe one plan. I think really decreasing the confusion among stakeholders and participants is a key component of what we want to do moving forward. The other thing is that we want to ensure that there is not inefficiency in the system and that we aren´t duplicating efforts, because that can also lead to extra added costs and again confusion among stakeholders. Lastly, we think there is potential for cost shifting across payers for products that are not fully integrated and that´s really what the financial alignment demonstrations are about, to ensure that there isn´t cost shifting and that there is one coordinated payment. As we look to the future and we try to outline from the New York State perspective what some of the overarching goals are for full integration and the planning process, I think we can agree that we want to achieve the greatest level of Medicare and Medicaid physical, behavioral, long–term service and support integration possible while potentially consolidating some of the existing programs. Some of the smaller kind of subgoals of that are to identify the platforms for integration that permit the greatest possible level of integration, and that´s really a discussion, and that´s why we´re all here today to have that conversation and to jumpstart it so we can continue it moving forward, and then to incorporate the best elements from New York´s various existing integrated products that exist today. We also want to offer stakeholders opportunities to help the department build what we see is the future of integrated care and the integrated care platform. Most importantly, as we think about a person–centered approach that really addresses the care of individuals, we want to ensure that there is allowed enough lead times to plan for smooth transition for individuals in the community, obviously safety of individuals is always the most crucial for us, that´s our number one goal.

Just to kind of map out a strategy as we move forward... I think one of the things we want to do today is to learn about available platforms for integrated care, and Jim **Bird is here, and he is going to offer us all some information on how other states have achieved high levels of integration. This is a learning process for all of us, and I think we recognize that as a state, that FIDA´s demonstration has always said that it is a learning experience and we should all learn from the experience and think how we can move together in a very collaborative and \inaudible\ fashion that really incorporates what we´ve learned from some of the trials and tribulations of trying to integrate in the new program. Then I think we want to engage in a stakeholder process. That will really mean finding the best vehicle to drive one integrated care product or two, we don´t know what that is looking forward and we really want to hear your thoughts today, and incorporating the best features of existing programs into what could be our future programs for the state of New York. Then of course, as I said already, we want to envision what the transition process is for consolidating \inaudible\ members from existing programs if that´s applicable. We´re very excited that you´re all here to engage in this conversation, and we really look forward to hearing some of your ideas and working together. With that, I will kick it off to Lindsay Bernette who is going to present \inaudible\. Thank you everyone.

[Lindsay] Thank you, Andrew, and thank you everyone for inviting us to be here today. We´re very happy to be a part of the conversation around the future of integrated care in New York. I wanted to spend just a few minutes talking a little bit about the financial alignment initiative that we have at CMS, that obviously FIDA is a part of, just to provide a little bit of context on where we are nationally with the initiative and a little bit of what we´re thinking about in terms of how to help guide this process or work with the state on this process going forward.

I´ll start with just a little background about our office. I know there are a lot of familiar faces in the audience. Many of you are probably very familiar with the Medicare and Medicaid coordination office and what we do, but I feel like it´s always a good opportunity to take a couple of minutes to sort of say who we are and why we´re here. The Medicare and Medicaid coordination office, also known as the duals office, also known as the federal coordinated health care office, we have many names, was established by the Affordable Care Act, and the statute itself has a fairly lengthy list of things that we are tasked to do, but a lot of it really boils down to trying to improve quality of care and reducing costs for beneficiaries and improving the experience of care for individuals who receive both Medicare and Medicaid services.

How are we doing that? Our work typically focuses in a couple of main areas. We have what we call program alignment which is really looking at Medicare and Medicaid programs as they currently exist today and thinking about how we can try to get them to work better for the 10 or 11 million people that are served by both of them. We also work a lot on developing and testing new models of integration, and obviously that´s the primary focus of my discussion today, but underlying all of that effort is a desire to really try to improve the experience of care for individuals, and this slide just provides a very high–level set of principles that we have been focusing on over the last seven plus years in order to try to do that. I wanted to talk a little about the financial alignment initiative, which is probably the biggest of our demonstration opportunities that we currently have within the Medicare and Medicaid coordination office. It really is an opportunity for us at CMS to partner with states to develop and test integrated models of care for individuals. We have announced that back in 2011, and we have several different models that are underneath it. We have a capitated model which really focuses on a health plan, or a Medicare Medicaid Plan, or MMP as we call them at CMS, that is really focused on that plan being the one accountable entity that provides the full array of Medicare and Medicaid services for enrollees. The plans in the different states have entered into three way contracts, with CMS and the states, and we work together very closely with the states on all things related to oversight of the plan, trying to make sure that the individuals are really receiving the integrated care that we´ve envisioned. We also have a managed fee– for– service model which is really more geared toward state Medicaid intervention. One example is Medicaid health homes, giving those states an opportunity to share in any Medicare savings that result because of those Medicaid state interventions. It is a little bit more of an ACO type of approach compared to the capitated models, that´s how I like to think about it at least. Outside of the financial alignment initiative technically, although we tend to lump it in as we talk about the demonstration as an alternative model that we currently have with the state of Minnesota that really focuses on its longstanding Minnesota Senior Health Options Program, which is a \decent\ program that they´ve been running for probably 10 to 15 years at this point.

The next slide focuses a little bit on some of the key components of the capitated model at large. Obviously each \inaudible\ demonstration is a little different, both from a target population perspective and a service area perspective, as well as from a care model specific. They all require some type of assessment, a health risk assessment, but the time frames or the mode of those assessments may be different. The individuals who are required to be part of the interdisciplinary care teams may be different, care planning requirements may be different, things like that. Obviously as you all well know FIDA is unique. Every state is unique, FIDA is unique in a number of ways. One key thing that I like to always think about or point out is that the FIDA demonstration is the only one that we have that´s really focused on the long–term care population. The majority of our other demonstrations are much broader in terms of including both high long–term care needs as well as those that are kind of what we would call the community model.

This map shows you where we are from a financial alignment perspective. We have 14 demonstrations in 13 states. Two of those are in New York. We list them out here. You´ll see we have two demonstrations that are the managed fee– for– service model; Washington and Colorado. The remainder are capitated model demonstrations. As of June 2017, we have close to about 400 thousand individuals enrolled in the capitated model. You can see from the start dates of the various stages of implementation in each demonstration, we have some that started back in 2013, we have others like FIDA ITP which just really got launched last year. Part of the demonstration process which I´ll talk about in just a minute is an evaluation component, and initially the demonstrations were envisioned as three–year demonstrations. Given where we are from an evaluation and data collection perspective, back in 2015 we offered all of the state participants an additional two years for the demonstration to allow for some additional time to be able to really see whether or not these programs are being effective. Thus far, on the capitated model side, all but one of our states have either formally elected to move down that tier extension path or are still in discussions with us about that. That brings me to the evaluation. I will first say that even outside of the financial alignment initiative there is a growing body of studies and evidence over the years that have shown that more integrated products tend to perform better for dual eligibles. Last year, the HHS Assistant Secretary for Planning and Evaluation, ASPE, released a longitudinal analysis of the Minnesota Senior Health Options program which I mentioned we are also working with in the demonstration. The findings were not specific to the demonstration but sort of the broader program. It showed really fantastic results: 48% reduced risk of hospitalizations, less emergency department use, better access to home and community based services. We´ve seen with some of the work at MedPAC, the Medicare Payment Advisory Commission, has done over the last four or five years that shows that more integrated products tend to have better quality results and things like that. The financial alignment initiative evaluation... Because this is a demonstration, we are required to have an evaluation component to look at the impact to quality of care for individuals as well as the cost of the program, for the demonstration. We´ve contracted with RTI International to do that independent evaluation. It is kind of your typical evaluation that includes both qualitative and quantitative aspects. We are, as I eluded to a few minutes ago, in very early stages of getting results in. We released last fall the first annual report for our Washington fee– for– service model as well as our Massachusetts capitated model. We expect that we´ll be getting more out this year, and while the first couple of reports have shown some promising signs, the vast majority of what we have so far is still really descriptive in terms of analysis, so I think it´s definitely going to take us more time and data to really have a better sense of where we are from an actual... kind of findings and whether or not we can say with certainty that the demonstrations are, either individually or as a whole, what kind of impact they are having on quality and cost.

Just because you don´t have the evaluation results doesn´t mean we don´t have a sense of some sort in terms of how things are going. Nationally, I´d say that we feel cautiously optimistic. There is definitely positive momentum. First and foremost, we´ve seen a huge increase in the number of dual eligibles that are in fully integrated or total cost of care models. Back in 2011 before the demonstrations started, there was something like 160 thousand duals nationally that were in some type of integrated program, not even necessarily a fully integrated one. Fast forward to 2016 and we have over 720 thousand duals in more integrated products. A large driver of that are our demonstrations, which I think is really amazing in and of itself. In addition, we have seen hundreds of thousands of people receive health risk assessments as part of the demonstrations, most of which may not have received those assessments outside of the demonstration infrastructure. We´ve also seen major investments both on the state and the health plan side in terms of providing care coordination, again things that may not have happened outside of the demonstration construct. Not mentioned on this slide, I will also say that we now have in the last year two years of data for the first five states that started our demonstration, so those that started in 2013 and 2014, in terms of consumer experience data, so the CAP survey for those who may be familiar with it. I think we´re seeing improvement in those five states year over year–incremental improvement, there is certainly still opportunities for greater improvement there as well, but all of that is to say that I think the things we are seeing, even if they are not really the most rigorous of quantitative analysis at this point, they are making us feel good about the direction that we´re going. That is not to say that we haven´t had challenges. I think one of the early implementation results from RTI as well as other MedPAC members that have been looking at the demonstrations nationally is that integration is hard and it takes time. I mentioned that the Minnesota results, just in the previous slide, while those results were fabulous and something we can all hope that we will see through these demonstrations and other similar types of programs, it is important to remember that they´ve been in that business for more than ten years and are now seeing these results. It´s something that we need to always kind of remind ourselves that this stuff takes time. While we´re seeing good progress, it´s not something that we´re going to necessarily see results overnight with. I think our other lessons learned, the early implementation timings, again from RTI and others, reinforce some things that we kind of instinctively already knew which was the critical importance of engaging consumers and providers and other stakeholders as early and as often as possible. I think we certainly learned in FIDA and in other demonstrations the need to do that type of outreach and education all along the process, not to take for granted that people really understand what we mean when we talk about integrated care. I have to remind myself that not everybody has been working, eating, and breathing this stuff for ten years like we have, or I have, and that often times we need to take a step back to think about what is important for individuals, what is important for providers, and how can we make sure we are creating that value proposition that Andrew talked about in his presentation as well.

I know I spent all of this time talking about financial alignment from a national perspective, but I´m sure you´re all thinking what about FIDA, we want to know what´s going on with FIDA. Similar to everyone else, we still have a lot of only preliminary information and unfortunately given the enrollment of a number of the plans sort of hindered us in being able to have some of the capitated data and things like that because enrollment levels are required for this type of reporting, however I will say that I think we similarly see some of that positive momentum especially in the last year as we´ve gotten over some of the humps as a rollout and some of the changes that were made in collaboration with the state and the plans and others here in this room. I think we´ve seen things really stabilize. I will say that in 2016, the HRA completion rate was 97% for the FIDA plan. We see very low levels of unable to reach individuals which is in stark comparison to some of our other demonstrations where we´ve seen much higher... care plan completions and things like that also seem to be really improving, and again that sort of positive momentum based on some of the metrics we are gathering I think have been really encouraging. As I said at the outset we very much are supportive of this discussion and hope to be able to continue to be part of the process going forward. I would echo a lot of what Andrew said on his side in terms of what the goal of this process is. I think that we would certainly suggest that, collectively at the state level and with all of you, it´s important to think about what are those overarching goals for integration, what are the lessons learned from FIDA or MAP or PACE or other state programs that you all think will work well for New York and for New York consumers, and focus on that and then kind of take a step back and think about what vehicle best works based on those goals and priorities. I wish I had that crystal ball that apparently DOH has. If you could tell me where you got it, I would love to have it, to have one of my own. It´s hard to know exactly what will be available in the coming years, but that´s part of the reason why in some ways it´s good to focus on where do you want to go and then think about how we then fit that into the available options are at that point in time. Then, I would just say in terms of opportunities for growth, I think we share the goal of DOH of trying to get as many people into integrated, person centered products as possible. I would say I´m really excited that Jim and Anne Mary are here from ICRC to talk a little bit about different levers that other states have used to try to look at that and think about those opportunities for growth in hopes that it will at least provide a helpful roadmap of things to consider as you all embark on this process. With that, I will stop and turn things over to Jim and Anne Mary. Thank you very much.

[Anne Mary] Hi everyone. I´m Anne Mary Phillips from the Integrated Care Research Center. My home organization is actually the Center for Health Care Strategies. I´m here with my colleague Jim Predire from Mathematic Policy Research. We are really excited to be here, and thank you for having us. We are here on behalf of the Integrated Care Research Center. We work very closely with Lindsay, Melissa, and others from the Medicare and Medicaid coordination office to provide support to states who are advancing integrated care, whether that be through a financial alignment initiative or through other models that we´ll get into in a little bit. We work very closely with New York as well, so we´re excited to be here. I just want to point out that we do have several resources that are on our website. Please feel free to take a look at them. They may be helpful in just giving you some background. There are also some ideas on what other states are doing that you may be interested in. I am going to give you a quick overview of who the dually eligible population is, Medicare and Medicaid enrollees. I think it´s helpful to have a sense of what are the national statistics, what does the population look like what are their needs, as you´re planning programs that serve this population and address their needs. I´ll also give a quick overview of various integrated care options that are out there more nationally. I know you all have several integrated care options here for dually eligible beneficiaries in New York, but I´ll give you a national overview. Then, I´m excited that Jim is here to give you some strategies that other states are doing when they´re operating concurrent integrated programs, and we know that you all are very interested in hearing about that. Again, going over some national statistics... There are 10.5 million Medicare and Medicaid enrollees nationally. That´s one–in–five Medicare enrollees–that´s a lot. In New York State, I think it was Andrew or Melissa who mentioned 856 thousand, a little more than that, dually eligible beneficiaries in New York State. Most of those beneficiaries are actually full benefit dual eligibles, so they do require all Medicaid \inaudible\. This is a faster growing demographic than the Medicare only population. Dually eligible beneficiaries are more likely than Medicare only or Medicaid only enrollees to have multiple chronic physical conditions and mental health conditions as well. They also have higher increased functional limitations that require Medicaid covered long–term services and support, so it is important to think about when you´re talking about integrated care programs, you can´t not talk about long–term services and supports. This population also requires higher rates of Medicare coverage services. I also want to point out when we´re talking about dually eligible beneficiaries, we´re talking about a very diverse population. You have the over 65 dual population as well as the under 65, and their needs could be very different. There is a lot of under 65 dually eligible beneficiaries: about 40% of duals are under age 65 and qualify due to a disability requiring increased LPFS, and more than 40% of the under age 65 dually eligible beneficiaries have a behavioral health disorder as well.

With respect to the needs and costs associated with this population, this slide just shows the spending on this population is disproportionately higher than enrollment, so within both Medicaid and the Medicare program, spending is much higher for this population than enrollment, and there are higher costs associated with this population. I think the spending mostly reflects the significant costs associated with a population that tends to have multiple chronic conditions and needs compared to other Medicare beneficiaries. This population is more likely to be hospitalized and in need of emergency room treatment.

With all the vulnerabilities that are associated with this population, it´s not surprising that states are trying to think through ways to better integrate care for this population and better integrate Medicare and Medicaid services. Without integration for this population, as we mention they are some of the most vulnerable enrollees that are out there among the Medicare and Medicaid programs, it´s really difficult to navigate unaligned Medicare and Medicaid systems. Not only across Medicare and Medicaid, but this population requires services across behavioral health, LPFS, physical health, it´s hard. If your providers aren´t talking to each other, it´s really hard to navigate these various systems that weren´t really created to talk to each other. I know Lindsay gave a really great overview of the financial alignment initiative, which is one way that \saves us time to\ integrate Medicare and Medicaid. I´ll say, the financial alignment initiative... I think it really aims to integrate on three pillars, the financial, clinical, and administrative pillars. I think when we´re talking about integrated care we are talking about programs that address all three of those things, so we might want to keep that in mind as we continue to sink through integrated care options here in New York. As Lindsay mentioned, the financial alignment initiative has two different models, the capitated model and the managed fee– for– service model. The capitated model really revolves around a health plan, a Medicare and Medicaid plan, or as you call them in New York your FIDA plans, serving as the one entity that provides all Medicare and Medicaid benefits under a three–way contract, which is unheard of––prior to the financial alignment initiative this opportunity wasn´t there. The financial alignment demonstrations really provide an opportunity for beneficiaries to receive all of their services in a very integrated manner from one health plan. This we would say is the most integrated and coordinated option available to dually eligible beneficiaries.

We talked a little bit about Medicare advantage \DESNPs\. These are MA plans that are specialized in serving beneficiaries who are dually eligible for Medicare and Medicaid. Many states have DESNPs in place. They integrate to varying degrees with their DESNPs. So, these MA DESNPs have contracts with the state and with CMS, and different states can require their health plans to integrate to varying degrees using these contracts which we call \MITHA\ contracts... I won´t get into all the details. States really have an opportunity to align their DESNPs with their existing Medicaid plans, their Medicaid LPFS plans. In New York you will have your MAP program and your FIDESNPs. So FIDESNPs, another long acronym, Fully Integrated Dual Eligible Special Needs Plan: these are a subset of DESNPs, essentially the DESNPs will apply to become a FIDESNP, and will CMS approval will become a FIDESNP based on the acuity level of their enrollees, they receive a frailty adjustment in their capitation rate. This I would say is a comparable option to the financial alignment initiative demonstration. It´s another way that states are integrating Medicare and Medicaid to a pretty high level of integration. I´ll get into an overview of who are the states that are doing this, but I wanted to give you a sense of what this is if you´re not familiar with the acronym. I´ll quickly go over PACE. I know Andrew also gave you an overview of what PACE is and what that looks like in New York. PACE enrollees have to be age 55 or older, they must live in the service area of a PACE organization, they must be eligible for nursing home care, and they must be able to live safely in the community. PACE is a program that I think a lot of beneficiaries enjoy. PACE becomes the sole source of services for Medicare and Medicaid for this population. You are limited in how much you can expand PACE, because as Andrew mentioned it is \spicy\. That is something else to consider.

This slide shows enrollment across integrated programs across the country. We see June 2011 on the left to June 2017, so over the last six years, how much enrollment has grown across these integrated care programs over the past six years. The demonstrations are the newer model that is out there. The first state to enroll beneficiaries in their demonstration was Massachusetts in the capitated model in 2013. So really, in four years, nationally we´ve reached almost 400 thousand enrollees in programs similar to FIDA here in New York. New York is one of ten states that are pursuing these capitated model demonstrations. As I mentioned earlier, there are many states that have contracts with DESNPs. They contract with their DESNPs and are able to reach varying levels of integration, so there´s 41 states, D.C. and Puerto Rico, that have DESNPs in place, but it´s really the FIDESNPs that are able to achieve the highest level of integration on this DESNP platform. Lastly, we all see that there´s been an increase in inpatient enrollment as well.

This map looks kind of similar to the map that Lindsay had, but we also included states that have DESNPs and FIDESNPs in place. I wanted to point out–there´s a lot going on, a lot of states are pursuing integration. New York is not alone. I do want to point out the states that are \sprites\. New York is one of six states that operates on both financial alignment demonstrations and DESNPs. Those are California, Texas, Illinois, Massachusetts, and New York. Jim will get into a little bit more detail about what those states are doing as they´re operating concurrent demonstrations and DESNPs. They have different strategies for how they separate out their populations, separate out service area, different contract requirements they may have... so I will turn it over to Jim who can give you a little bit more detail about those state strategies.

Oh, I have one more slide, sorry. Just in New York, this is what your enrollment looks like across your integrated care program. You have a lot of options, but I think it will be helpful to hear what other states have done when they´ve operated multiple programs similar to New York´s and how they´ve separated out their strategies for these different \integrated\ programs. Thank you.

[Jim] This slide just goes through the major integrated care challenges nationally for both states and health plans. For both health plans and state staff, the biggest hurdle is developing expertise in Medicare, especially Medicare managed care issues, if you started out as a Medicaid plan and all people in states don´t have any particular reason to know anything about Medicare absent these demonstrations, so there is a learning curve on the Medicare side for the state staff as well. If you started out as primarily a Medicaid plan, Medicare Advantage managed care is really, really complicated. It looks at a very high level a lot like Medicaid, so it is easy to be confused if you think they are the same, but they are really, really different at a lot of levels of detail beneath that. One of the benefits in a sense in helping you learn about this is everything in Medicare is written down, somewhere, you just have to know where it is. They have manuals online, and they have regulations, and all sorts of stuff, and it will really answer most of your questions if you know where to look, but it is not too easy to do, so there is a steep learning curve on both sides depending on where you start. For the Medicare Advantage plans that primarily have operational experience in Medicare, if they go into a state and work on a dual eligible demonstration or if they are setting up a DESNP that is linked to a state Medicaid MLTSS plan, they have a steep learning curve in the Medicaid program in each of those states. Again, the state programs are very, very broadly similar at a high level, but if you look at things like how long–term supports and services, home community based services, state plan services like personal care assistants, nursing facilities and how they´re reimbursed and what they cover, and what level of care needs people have, they differ from state to state. You can´t assume if you´ve operated as a Medicaid plan in one state that you automatically know how to hit the ground running in another state because you probably don´t. There is a learning curve for the Medicare Advantage plans as well. For states, the challenge is really designing programs that fit each state´s history and context and Medicaid and Medicare delivery systems. You have a lot of states where there is a lot of resistance among long–term supports and services providers, nursing homes, HCBS waiver providers, any form of managed care, so you have to work with those providers to sort of bring them along and get them to work with you and understand what you´re trying to do and what the benefits might be for their enrollees and for themselves in managed care. Lots of states have behavioral health services that are provided often times through different state agencies, a whole different set of providers, frequently carved out or not included in managed care, so a whole separate set of behavioral health delivery systems that existing states, and again those have to be taken into account when you´re designing one of these kinds of integrated care programs. That whole set of how do we fit it into our history kinds of issues you have to deal with, then the next set of issues is kind of working with the health plans that you end up selecting and however you select them through a competitive procurement or otherwise to implement the integrated programs that are attractive enough for people to enroll in and stay enrolled in. on the Medicaid side, you can mandate enrollment for dual eligibles like you can for any other Medicaid population, but you can´t mandate enrollment on the Medicare side. People have the freedom to get their Medicare services from traditional fee– for– service, original Medicare, they can get it from any Medicare Advantage plan they want not necessarily the plan that is linked to or aligned with the DESNPs that you contract with. That´s a significant challenge, a continuing challenge, in all states that set up these integrated programs including the financial alignment demonstrations, and I´ll come back to a little more on that in a minute. The next set of challenges is just monitoring and reporting on health plan performance and quality, because that´s how you build in incentives for the plans to improve over time, and you can compare plans to each other in terms of their performance and help enrollees make the decision on which plan they want to enroll in or stay enrolled in based on how they perform on these various kinds of measures that you´re familiar with. The integrated care challenges for the health plans themselves, the integrated plans once they´re in place and operational, is really demonstrating to both their current enrollees and potential enrollees that an integrated plan is better for them than whatever arrangement they are currently in, whether it´s original fee– for– service or some non–integrated form of Medicare. That can be hard to do, because integration is a very abstract notion. You can tell people about maybe extra benefits, but if they´re not benefits that they perceive at that point in time that they are going to need, they´re not going to give sufficient weight to them. One of the things we learned from some interviews that we did with integrated DESNPs that had been operational for like ten years or so in various states and had steadily grown their enrollment over that period of time in a purely voluntary arrangement, because these were all sort of Medicare Advantage plans, and what they uniformly told us was the single most important thing you need to do is get the enrollee linked to an individual human being who is their care coordinator, their care manager, the person who answers all of their questions, the person who helps them navigate all of the complexities of this system. That´s the single most important thing, and you need to do it within two or three weeks, because if you don´t then people don´t tangibly see the value of integrated care. It keeps being an abstraction to them, and it´s just a whole series of sort of benefit package stuff in a handbook. That´s a really important takeaway that we got from those plans. Plus, the other really important thing is you have to work with their providers, especially the physicians, because those are the people that people ask about what kind of a plan they should be in or should they stay there, and if a provider doesn´t like the plan they´ll encourage the enrollee to go somewhere else, so that´s another really important issue that all plans have got to deal with that are operating in this integrated environment. The last but most important thing is you got to deliver on the promise of integrated care, and you have to have better coordination than people would otherwise get. Information exchange is absolutely critical. That is the single most important ingredient in effective integrated care is for everybody to know what everybody else is doing or not doing. You got to have better access and enrollee satisfaction and outcomes and all of those kinds of things. There is no secret about how to do this. Everybody kind of knows in general terms who operates in the managed care area how to do it. It´s blocking and tackling, but it turns on how effective is your organization designed and managed, how good are the people that you got in the plan, how good are your information systems, how easy are they to use, how much of a focus do you have on the enrollee and quality of their care and making the providers in your networks happy and more effective and better reimbursed, and less administrative hassle, and otherwise... All of those things, in theory, are easy to understand but they are really hard to do.

Here´s some examples of how other capitated financial alignment demonstration states have dealt with the coexistence of DESNPs and the dual demonstration. All of the capitated financial alignment states have some DESNPs, and California, Massachusetts, New York and Texas have the so called fully integrated dual eligible plans, FIDESNPs, or they have DESNPs that are aligned with Medicaid plans in the state, and they are what we call companion plans. When you do that, especially if they are coexisting in the same geographic area, the state has the challenge of helping beneficiaries make meaningful and informed choices about which of those options would be better for them. Often times, the two options would be operated by a managed care organization with the same name, so you´ve got a United FIDESNP and you´ve got a United in the demonstration, you´ve got an \AmeriGroup\ FIDESNP and an \AmeriGroup\ Medicaid plan, so there´s the challenge of helping people make those decisions. The challenge of working over time with health plans and stakeholders to improve these integrated care options over time and the states that have been doing this, who have been in this business for a long period of time like Arizona, Minnesota, Tennessee and some others, they will uniformly tell you that the collaborative working arrangement between the state and the health plans is crucially important. They learn from each other and they can build increasing capacity over time in this kind of collaborative way. It can´t be completely kumbaya, you´ve got to have some performance measures and some quality measures and you´ve got to compare the plants to each other, so even if they´re sort of nice and friendly and cooperative, but they´re not performing, you don´t necessarily want to allow that situation to keep going. Then there is the issue, and I´ll come back to this in a second with a couple of examples, these models, especially the Medicare part of these models, are really complicated, and there is only so much bandwidth and staff that states have to do these things. If you´re trying to simultaneously develop a really robust \MITHA\ contract with your DESNPs and get them linked to Medicaid plans, that´s a whole set of complicated issues, then there´s another set of complicated issues that are similar but different in the demos. That´s a consideration in states that have got that arrangement.

In general how it works in these states is that DESNPs and MMPs, the demonstration plans, are allowed to coexist in the same geographic area, typically, but the dually eligible beneficiaries in DESNPs are not passively enrolled into MMPs because they are already in an integrated coordinated arrangement that they have chosen for themselves, but they can choose to disenroll from a DESNP and get into an MMP arrangement that they consider a better fit for them or better integrated or whatever, but that´s their choice to do, and states like Arizona that I will say a bit about in a minute do a variety of things to encourage enrollees to choose a more integrated option or at least make them aware of the benefits of a more integrated option. California has probably the most detailed formal policy, and it dates back to 2014 and it´s on their website at the link shown there, but what they basically do is that DESNPs that are affiliated with plans that are in their dual eligible demonstration are not allowed to enroll new enrollees who are eligible to be enrolled in the demonstration. Those people are sort of passively enrolled into the demonstration. Now, if they did actually want to go back into the DESNP they could do that. You have freedom of choice in Medicare in all cases.

The next slide has a couple more examples. Massachusetts is not a problem, really, because the FIDESNPs and their senior care options program which has existed since 2004 are just people 65 and over, and people in the demonstration are all 65 and under, so there is no overlap in the populations. Illinois is an example of a state that had some of that staff bandwidth issue. They are doing a demonstration and they are also contracting with three DESNPs, but they sort of have limited staff to deal with that, but more importantly they were not able to get a lot of value out of their contract with the DESNPs because they have kind of the world´s oldest \MSIS\ claims processing system which really wasn´t capable of making capitated Medicaid payments to these DESNPs for anything even like beneficiary cost sharing, so they just had these DESNPs existing in isolation with no real meaningful integration with Medicaid at all, and they decided we´re not getting any value out of it, it´s taking up time which we could better spend on our MMPs, so starting next year the three DESNPs are gone and they have their seven MMPs. Texas is another example where the dual eligible demonstration and aligned dual eligible special needs plans aligned with their Star Plus Medicaid managed long–term supports and services program operate essentially in the same geographic areas. There are about 40 thousand enrollees in their five MMPs in mid–2017, and we also asked Texas to give us some data on how many people were enrolled in the four health plans they had last year that were aligned so that beneficiaries could in theory get both of their Medicare and their Medicaid benefits from these aligned plans, and we were able to identify about 22 thousand who were in that kind of aligned arrangement back then. Again, these plans operate in kind of the same area and the state doesn´t make any particular effort to steer people one way or the other into these options. They´re just kind of there.

This is what a lot of sort of non–demonstration states have been doing, and those are the primary examples of non–demonstration states. Virginia actually has been a demonstration state and it´s going to shift to a dual eligible DESNP platform in January of this year primarily because the demonstration was set up to operate in only portions of the state and subsequent to that their legislature said no we want Medicaid managed long–term supports and services to be state wide. The only way that they were able to do that was to do what a number of these other states have done which is to set up this new Medicaid managed long–term supports and services program and require that the plans who bid on that actually have DESNPs or be in the process of setting DESNPs up, and they also said we are no longer going to contract with DESNPs that do not have a Medicaid managed long–term supports and services plan in the state, so if for example you bid on this Medicaid managed care long–term supports and services program and didn´t win, then you got to close down your DESNP. These other states all do variants of that. You cannot be a DESNP in the state unless you also operate a Medicaid plan. You can´t operate a Medicaid plan unless you also have a DESNP. They have to be operating in the same geographic area, so people have the option of enrolling in that integrated arrangement if they want it. There are some states, Arizona is probably the most prominent example, where they do actually do a fair amount to get people into these kinds of aligned arrangements. Enrollment is mandatory on the Medicaid side for duals, people can choose to enroll in the companion DESNP, they can choose to enroll in fee– for– service, they can choose some other Medicare Advantage plan. Despite Arizona´s best efforts, probably 55% of people choose a non–integrated arrangement. Sometimes if they are in a DESNP and they choose to be in a non–integrated arrangement, the state one–time will put them into an integrated arrangement. Despite that one time effort, if the enrollee definitely wants to be in something not integrated, then they don´t bother them anymore. They let them stay in that sort of non–integrated arrangement. They end up with about 45% of dual eligibles enrolled in an aligned arrangement and the rest of them either are sort of off in Medicare fee– for– service or some other Medicare Advantage plan.

That just lists a variety of resources that are on the ICRC website. The main one is the report on state contracting with dual eligible special needs plans that we updated in November of that year. That´s got a detailed analysis of the so called \MITHA\ or DESNP contracts in about 13 states, and they are the leading states in this area that we´ve been talking about. There´s also a really good data book which is essentially national data on all aspects of dual eligibles that MedPAC and MacPAC put out, and finally we have a technical assistance resource on the Medicare basics that we updated last month, and that´s on our website as well. That is a help for people who are in states or in health plans who are starting out in Medicaid and starting down the road of learning about Medicare. That resource is there as well. That´s our presentation.

[woman**] The next thing we´re going to enter into is the "no slide" presentation, but I think maybe we should keep it up in case there are questions about the slides as they come up. What we would like to do for the first part of the rest of our time is take questions from anyone who has them including the webinar, so Francis let us know if there´s any, you can type them into the text box on the webinar for those of you there, let us know if there are questions there, or people in the room, just raise your hand, and–oh I´m so glad to see hands up because otherwise you´ll have to listen to all of my questions, and by the tenth or twelfth you´ll be bored. Go ahead.

[question asker] (question inaudible)

[???] A high level \MyCare\ does have a large enrollment, and I think one of the /inaudible\ that we at CMS sort of attribute some of that too is the fact that as they were rolling out the MyCare demonstration, they were also rolling out a mandatory Medicaid long–term supports and service program which they also call MyCare. I think there was a lot of stickiness in terms of people being in a Medicaid plan and then kind of including the dual thing and they were kind of already a part of it, it made sense \inaudible\ Medicare portion of that plan product or /inaudible\ sucked a little bit more for lack of a technical term. That´s at least sort of what we think, because they had seen a lot more enrollment and penetration in terms of market penetration in terms of how many people are actually eligible and how many \inaudible\ highest of all demonstrations.

[???] As a little bit of follow up to that, Lindsay or even Jim, I think some of us are probably curious about what other states \inaudible\ whether they are presently enrolling or choosing not to because I think \inaudible\ we have seen benefits this \past enrollment\ being that there is a higher enrollment number which is good, usually it is less. On the flip side, we´ve seen a pitfall of a high number of opt–outs of past enrollment. Could you \inaudible\

[11:49:07] Sure. I can say at least that the outset of the demonstration virtually all the demonstrations may \inaudible\ exceptions given in unique circumstances, had some type of passive enrollment process. Now, who was possibly enrolled and on what schedule and things like that all differ from state to state. The opt–out rates that we have seen, and unfortunately it has been very difficult for us to have sort of a national opt–out rate because every state looks at enrollment \inaudible\ a little bit differently and we don´t always have the greatest sense \inaudible\, but it looks like it has varied quite a bit from demonstration to demonstration. Over all, I think we´ve seen somewhere in the 30–35% opt out rate. Some states have been much higher. Some counties in some states have been much higher depending on those unique circumstances. It has definitely seen a lot of variation from state to state in terms of how that process went. Of course there was a large phase in past enrollment in probably the first year or so of the demonstration when they were getting up and running where we had a number of states that do what we call "on billing" passive enrollment on a monthly basis, and that is generally speaking people who are dually eligible, so as people who are on Medicaid age into becoming Medicare eligible, some states are then as they become eligible for Medicare putting them into an MMP through the \inaudible\. Some are not. Some of that has to do with just the technical process. If we are able to identify those people early enough to reach out to them and notify them before they are assigned to a Part B plan or other things like that, so there is variation in terms of what is happening from a passive enrollment perspective. [inaudible]

[Ralph] My question is directed to both DOH and CMS. It was started off by Jim´s comment earlier about cost–effective care management, a connection to a real person, what they´re going to do for you. From my perspective is from the standpoint of \inaudible\, individual family \inaudible\ for people that use the services, and also research evaluation \inaudible\. One important thing is where can you start to say where we might go next with engaging more families and individuals right at the front end that these things are designed, but the problem obviously is high turn here, \inaudible\, a high disenrollment once people are either not given information about what doctors and other providers are in a plan, that work [inaudible\ in a real way, or they have bad experiences and very importantly they don´t have a care manager who has really helped them. That´s a problem in the local situation with New York. There was a lot of groups that testified for the Office of Community Living said the blind and other specific groups /inaudible/ that were very, very concerned losing a case manager who was very connected with them frequently and did very practical things to help them out. That kind of care model is done in private managed care plans, but that is not going to help us help this population. My question is really about where DOH is going to go to help stakeholders get families \inaudible\ find a plan, and is CMS going to allow some slippage that when raised a year ago in Emblem and \inaudible\ population. There was some mention of what health plans they want \inaudible\ restricting options to disenroll, the length of time someone would be required to be enrolled in a plan once they did enroll. There are great concerns about that process. My name is Ralph Warren, and \I´m an individual advocate\.

[11:53:58] We appreciate your comment and your feedback, and certainly are being very mindful of caregiver support and services in terms of thinking about how to engage families more. One of the big things that we´ve focused on that Jim touched upon is that the provider network for provider education so that your physicians can inform the members more about the products available to them so they can understand how to crosswalk those services. We have I think been working very collaboratively with CMS to improve that knowledge and to continue to think creatively about how we can include... because the caregiver support is such a huge component of this population, right? It´s a large portion that´s unaccounted for in terms of compensation and in terms of documentation, and so to better understand what the crosswalk is, I think the department is \inaudible\ to working with stakeholders and to thinking again as we move forward how to work more collaboratively, and looking to see what other states have done with the demonstrations to ensure... because as you´ve seen from \armarel\ when compared to other states, other states have been more receptive to the alignment demonstration, so I think as we move forward that´s one thing we´re going to be very mindful of.

[11:55:36] Sure, and I will just say in terms of the CMS perspective, I think it´s \we´re engaging\ stakeholders of all types, that´s something that we´ve always placed an emphasis on ever since the very beginning of our financial alignment as we were seeking state proposals to participate in, stakeholder engagement and involvement is something that has been emphasized along the way. I think certainly through kind of the early implementation we see just how critical it is to make sure that we are trying to provide information about what´s happening, potentially, in a way that makes sense. I think that Jim´s point about \inaudible\ integration as a very abstract concept is a very important one, and I know that there´s a lot more that we can do on the CMS side and the partnership with the states to try to make some of the information more understandable and accessible. It´s part of our ongoing efforts around financial climate initiative more broadly, and we´ve really been trying to take an effort to look at \inaudible\ materials, and do testing with actual consumers and their caregivers to try to figure out are there ways that we can simplify and streamline some of these... Many times, on the Medicare side, we´ve required information, but making sure that the information that is getting out there actually resonates with people in a way that they can understand. I think we´ve made some progress, but certainly there is a lot more that can be done from engaging individuals and making sure that they are aware of and understand what this is, so they can make informed choices about whether or not it is right for them.

[11:57:23] I´d like to also just follow up and say when we´re finished with the questions and answers here, and we have plenty of time for it, I want to move into just a few minutes at the end to get a stakeholder process together. We´d like to get the input of everyone here and everybody on the phone on how frequently and where and all of that stuff. So, stick around. Thank you.

[Sonya] Hi. I´m Sonya Rodriguez, and I work \with the Department of the Aging\, and I´m actually boots on the ground. I go out there to speak to anyone and everyone who will listen to us about FIDA and what a good program FIDA is, but speaking to the importance of the providers. I think that´s absolutely \changed\. I speak who people who´ve said I spoke to my doctor, he doesn´t know anything about FIDA, and the trust level... we speak to them, we could be just another provider or some health plan that is looking to engage them. They´re really wary when we speak to them, and they were wary about making any decisions about that \important\ program. I would like to really see some kind of engagement with the provider, real engagement with the provider community, for your local doctors or your IPAs who are actually working with Medicaid people \inaudible right off the boat. I shouldn´t have to go to go to the FIDA. I´m on \inaudible\ plan. Those are the ones that we think we can actually carry over to FIDA and have the care that they really need and should have. Those are numbers that I think working with Alyssa and those that... Brooklyn has a large number of those potentially eligible, we hear about potentially eligible, we´d like to know where they are in some real way through the provider community, having some interaction with the providers to say \inaudible\ Medicaid choice. Providers don´t have any clue. They don´t know anything about it. I think it´s really important to really start a campaign on a level where those patients actually have a trust level who´s giving them information.

[11:59:45] I know there´s been a rough spot from the webinar for a \inaudible\ very bad job of recapping what the lovely statement was. Basically, it was a really great point about the importance of engaging providers. There are a lot of providers out there who don´t know what FIDA is, and there needs to be a more concerted effort to really target providers and help them understand so that they are being on the front lines of communication and being trusted sources of information and communication with potential eligible individuals for FIDA to be able to either answer their questions and know what they´re talking about or direct them to places where they can get more information.

[Jeff] Hi. My name is Jeff Demeaner, and I just wanted to emphasize on Ralph´s point that he made. I happen to be a family member... I have a sister who´s been injured and been on New York State TVI waiver for a long time. Thank you, that´s \inaudible\ very happy with it, not opposed to going to \inaudible\. I just want to emphasize the point about getting the consumers and their families and their advocates involved. We don´t understand this stuff. Typically, our only vehicle into Albany or the Department of Health is through our providers. Sometimes our messages are twisted and they don´t get there. We really need to have a voice. As you guys develop these new systems, listen to us. We probably have a lot of good ideas for you on how to cut costs, make things more efficient, because we´re on the front lines every day. You´re only getting the reports. Please involve the consumers and family members.

[12:01:48] Thank you for your comment. I just wanted to say that I think we are committed to continued provider education and really consumer advocacy, and we do have a lot of robust, especially for that group, the TVI folks, stakeholder work groups, to discuss that transition into managed care, but just on a higher level I think a lot of times we have so many DCMLs out there, but it´s an opportunity for folks really to write into the state, and we really do try to be as responsive as we can to questions, concerns, or comments coming in, so please know that even if you´re not hearing back from us, that we do collect all of those and we do think very carefully and thoughtfully about them. We appreciate that comment very much.

[Karen] I´m Karen Wilkelman. I´m with Leading Age New York. We´re an association of non–profit long–term care providers and we also include provider sponsored managed long–term care plans. Many of our members operate DESNPs, FIDA plans, PACE programs, etc. I want to build on what Ms. Rodriguez said and what \inaudible\ said. I think one of the biggest challenges that we all know with FIDA has been the enrollment challenge, and one of the ways that people get connected to these types of plans is through their providers. I think there´s an important role for not just physicians to play but also provider sponsored managed care plans. When an organization has a place in the community and a reputation in the community, and people are accustomed to getting their care from that organization, I think provider sponsored plans play an important role in being an attractive option. I also wanted to mention PACE programs. I appreciated what Melissa and Andrew said about the PACE programs, and I think the PACE center provides a safe and high touch hub for long–term care in the community, but it can also be a barrier to expansion geographically as Melissa or Andrew mentioned. We have some ideas for that, how you can expand geographically using other congregate settings like bringing medical services into social day centers and other settings, and we´d like to talk with you on that, because I think the program shows some promise. We also have seen some success with inaudible :04\ about building on this stuff is \inaudible\ programs, and I think we can create integrated programs that are no more burdensome than a DESNP program and build on that enrollment. I look forward to the work \inaudible\. Thank you very much everyone for \inaudible\.

[Kate] Hi, I´m Kate Wolfe. I´m the CEO of Enable Care Options. We´re a provider \inaudible\ managed long–term plan in Upstate New York. We operate in Upstate only. We have 40 counties and have about 5,000 members. A couple things that I noticed from the presentation that kind of resonated with me was some of the things that were very successful demos, Minnesota for example, their demographics and their population settings are much more similar to Upstate New York than New York City. New York City is unique in and of its own. However, one of the frustrations being an Upstate plan is FIDA, in that because then we´ve not been allowed to participate in any of the \inaudible\, so we are looking to be a part of FIDA, we´re looking to do some different things, and we´re looking at a timeline. As expansion happens, it´s just trying to take what happens in downstate and put it upstate, and it´s always a square peg into a round hole, and it seems to have a negative impact. In Upstate New York, we have a lot of great ideas, we´re very high touch and have a lot of different plans here from \lead engagement\ and our plan is one that´s looking into a \B–pile\ that maybe we could be more flexible. There´s places in the Adirondacks where you´re not going to get enough people for an adult day center, but there are other kinds of settings that we could try and develop something around it if it is not cost prohibitive. My question in all of that is, is there something we can do to include or start an opportunity for Upstate New York to engage, especially a provider based plan, with expansion and those provider based plans Upstate don´t have an opportunity to those bigger for–profit or larger plans are able to come in and take that.

[12:07:03] Thank you. We appreciate your comment. As you know. FIDA started downstate and now we are moving into region two. I think we have about three plans there. It is a time limited demonstration, and I think there have been various reasons why it started downstate and kind of migrated up due to networks and certainly the density of the population, but we certainly appreciate the fact that your provider sponsored plan and really bring a lot of knowledge and expertise. As we think about the next planning phase, I think incorporating areas with different geographic disparities, trying to think about how to bring DESNPs or integrated products up to date in a more expansive way, something we want to be very inclusive. I´ll leave it to others to talk about the opportunities that still exist or may exist, or conversations for FIDA upstate, but I think right now we´re on the path for region two and I think where we want this conversation to go is to really think about have your input and how others don´t have a FIDA plan, or some have exited the market, they started with a FIDA plan and kind of learned from that process to kind of buildup on what´s next. I appreciate you being here today and for your feedback.

[12:03:54] It looks like a question came in about the comment around increases in care coordination and how that´s defined through what we expect about that in terms of what´s categorized \inaudible :03\. I will say, assuming I´m interpreting the point in the questions correctly, when I talked about on my second to last slide was more about the increase in the coordination infrastructure that has been put into place but certainly prior to the demonstrations, we do have these plans, as many plans nationally, that we´re focused on because full integration on the Medicare and Medicaid side as for a secure coordination aspect can be part of that, and I spent a lot of infrastructure \inaudible :03\ that together. That is certainly in place. I think we do have a sense from folks that kind of preliminary, qualitative findings from RTI and others, I´ve been looking at demonstrations in the field, as Jim pointed out in the non–demonstration role, when individuals are connected to a human being, a care coordinator, then that care coordination works really well for them. I think one of our goals obviously at CMS is \inaudible :02\. Many people could need that interaction and care coordination and are able to access it as \inaudible\ experience that type of success themselves. In terms of what is categorized \interpretation\, each of the demonstrations have pretty structured parameters as part of the demonstration in the three–way contracts I mentioned with the MMPs about what care coordination environment \inaudible\. There are certainly opportunities for the plans to be flexible and innovate around those different requirements that, broadly speaking, all demonstrations have some pretty specific instructions and requirements around assessments and carefully \inaudible\ seems to be part of the IDT and how all of that process works. Generally, all that wrapped up is what we think about and talk about \inaudible :03\.

[Harold] Harold with [inaudible\, and we represent the New York Health Plan Association. Thank you for convening to sort of take stock of where we´ve been with this program. I wanted to make several comments. First, I think the consumer engagement point is a very good one, but I will say to both DOH and CMS, there were substantial efforts in consumer outreach all along the way. The things to be thinking about now is was it effective consumer outreach? What might we be able to do differently? Sometimes the usual efforts, especially for this kind of program and even the usual "consumer organization" may not be the right one, and communications which I think we´ve all felt have that sort of governmental feel to them often because of Medicare roles and things like that, and that´s not really being the most effective way to communicate the special aspects of this program. Of course, peer to peer endorsements are always going to be way more effective than governmental, and it is communication. I think that´s also very true with the provider engagement, and I completely agree with your comment as a physician. We´ve heard consistently that there is a lot of physician resistance, not because they don´t like the idea, in some cases frankly it is not financially advantageous for them to have their patients be in FIDA as opposed to other programs. Doing a webinar for \MSNY\ is really not the way to break through that. We need to find fewer, better ways to engage with providers and especially with the physician community to get them to think about this differently and recognize what some of the real barriers are. Again, in some instances they are financial, but they are going to be reimbursed better outside of FIDA plans. This sort of brings us to the elephant in the room which is the financial fee for this, and there was a lot of reporting but not a whole lot of how this looks financially both to the government and to the different stakeholders. We understand that´s sort of mandated statutory savings \feat\, put stuff in \strengths\, but I think that throughout this we kept bumping into an actual disconnect as to the different programs where plans and setups may be out of line but the same with physicians, same with IPAs, it just for all the effort doesn´t really align perfectly in any case. Going back and thinking about it, especially for CMS, for how you might deal with some of those things would be helpful at really getting the pieces aligned a little bit better on the financial side. I will say as sort of a closing observation, that´s incredibly important with the VBP initiative, because as the state pushes forward on that, if you think about that and the FIDA program there is the potential for real alignment, but again to make that work well you can´t do a good VBP arrangement for a FIDA population with a couple hundred in your plan. We´re going to need more scale. There are going to be risk issues and all these other things, but I would say that is a piece that connects all of this, but it´s going to obviously be a challenge \inaudible\ program. So, a lot of observations there, thank you for convening.

[12:15:50] That was a lot of feedback, Harold. Thank you. Just quickly to touch on a few things you said... I think we´re committed to find better ways to engage the provider community and there has been some comments about how we can think about consumer engagement as well, and education materials... Yeah, the first time is not always the charm, so I think this is an opportunity, and I think this is kind of illustrative of all of our effort that this panel and this day and this continued series of kind of thinking about what are the next steps moving forward, so this is the kind of feedback that´s very helpful for us and I think having CMS here today, Jim, and all the DOH folks, really is an opportunity for us to get the feedback, to digest some of it, and then think about next steps going forward possibly for the next period or chapter. We appreciate \inaudible\.

[12:17:00] We received a very similar question from an educational aspect, asking about educational campaigns that capture and share stories of people who are actually in integrated plans, and generally it seems like there is a lot of focus on finance and the administrative sides of things, and some focus on solutions but not much for the general public. Is there anything that you all are planning that can be focused on more of the real stories out there?

[12:17:44] \inaudible] focus with a story of a consumer experience. The website for FIDA has at least a dozen consumer experience stories of how they enjoy the integrated product that they provide. It is definitely out there in the public domain. I don´t know if there are other ways that information can–

[12:18:06] I think what they´re asking about is if we do another campaign \inaudible\

[12:18:15] Thank you for that that question from the webinar. I´ve said this for about a year now, but from the start coming from the provider community or from a plan, I think there is an opportunity we often talk about the financial alignment \inaudible\, but this is a program that while we don´t have all the \heedists\ and we don´t have all the consumer measures at this time, because it is so early on in the demonstration, I think we do get a lot of stories there about how the program really helps to navigate and touch people´s lives and how the person centered model really is working and is successful, so we can think creatively about how to highlight that either on our website or other ways of sharing those stories, so that we do think there is an opportunity for an individual to share some of the success stories there, so we appreciate that and we´ll definitely take that into consideration.

[12:19:22] I just want to say a comment quickly on a couple of things that Harold mentioned. One, I think we totally agree with you that a lot of the \probably very bureaucratic\ information that comes out of CMS is probably not the most meaningful way to engage individuals, and as I mentioned we are trying to figure out ways to do better but there´s always going to be some layer of "that" that is part of that, so we currently are happy to continue to work with states and plans and others at the local level on what are the more kind of local messaging that would better reach actual individuals participating in the program. On the provider engagement piece, again, I totally agree. I´d be curious, though, I said that I didn´t think a webinar would necessarily be the most effective way to reach providers, but I´m curious if people have suggestions of a better way to do that, because this is an issue that we´ve often seen to various degrees of \inaudible\ subsets of providers in other demonstrations as well. If there are better ways to actually outreach to providers of different types to help them understand sort of what we´re doing and why it may be good for their patients \inaudible :02\, I think we´d be very interested in that not only for FIDA but also more broadly as well.

[Valerie] Hi, Valerie Bogart with the New York \inaudible :03\ today. I think if when DOH first put in \the protocol\ for FIDA there was a second clause that got left off, that was primary care case management, and it was not for a long–term care population, it was for \inaudible :03\ illnesses. I would urge that consideration be made here, engaging with MO or expanding it through non–long–term care beneficiaries. There might be more receptivity of people who are not receiving long–term care \inaudible\ support who are going to be very wedded to their primary care practitioners. They have by definition a severe chronic condition that they´ve been treated for a long time, and their \face pulse\ is their doctor. Also, I´m really surprised that the Medicaid advantage enrollment is still so low in New York, because I would think with the Medicaid expansion people aging into Medicare at 65 who are already in Medicaid managed care plans, that they are going to be more in touch with their doctors. They are in managed care plans, and many of those companies offer Medicaid advantage plans. I would think that if you´re \inaudible :02\ for both consumer education and for the provider education, to be bringing them in. There´s still savings to be achieved in these populations. They are still aging. They might not already be at the point where they´re using those services, but they will be, and if you look at it more as a long–term shift I think it would be beneficial if some of the folks \inaudible :03\.

[Don] Hi, my name is Don Perdillo, and I´m from the State Home Care Association. We have plans and all levels of providers in the association. I just want to follow up on the content of alignment, and I know it´s been talked about for various aspects with the clinical alignment, financial alignment... I just want to talk for a minute about procedural and regulatory alignment and the extent to which there is a consideration within CMS about looking at the regulations and the procedures that you require when providers are responding in people´s \silos\, to see whether those really need to be adjusted to make a system really work more fluidly when it´s in an integrated system. For example, CMS has just adopted and has delayed the implementation of a whole new set of conditions of participation procedurally on the home health system. That´s not only going to be a very expensive proposition, and many of those things are good, I´m not debating their merit, but in the context of an integrated system it may not all be necessary the way you were told \inaudible\. There are certain rules that create boundaries in the \siloed\ environment on the use of Medicare services with a certain benefit, so it would really encourage consideration of whether those can be more flexible. I´d just like to hear your thoughts on that. The second piece, and you mentioned this in terms of technology and integration of information technology because we totally agree, you can´t really integrate unless you integrate the information of operation. One of the big problems is most of the system is currently struggling to develop the capacity on its own within each provider level for information development and exchange, but then it´s then magnified in all systems, especially when you have hospitals, nursing homes, home care, health plans, all on different systems. The one thing is, what might be being contemplated to sort of help that integration process and to perhaps provide an ability for investment either through the rate that you pay in integrated plans or otherwise to enable people to really integrate [inaudible :02\. Thank you.

[12:25:47] There was a question about the procedural regulatory side of things, whether there´s any ability or flexibility to take a fresh look at those things from provider perspective in particular, and then also a comment about recognition of the difficulties associated with the information exchange that has been discussed in Jim´s presentation, especially when you´re talking about a whole bunch of providers who have different \inaudible\ and may not really be able to talk to each other. Starting with the second one first, I totally... yes, it is definitely a challenge. I agree with that. I think that certainly in an ideal situation all \providers\ can talk to each other and the information exchange would flow and everything would be wonderful, and we know that isn´t really reality. I think our hope is that we can work with the plans, especially in the capitated model demonstration environment, to look at ways to try to make for the best information flow even if it is not in the automated technology kind of way. \inaudible\, I agree with you that there´s a lot more than can be done there. On the procedural and regulatory side of things, I think that we have some flexibility through the demonstration construct and can kind of look at things a little bit differently. We have probably less so in some ways on the provider side because of the nature of the demonstration and for us to focus on the plan as opposed to kind of going down to the providers, but it´s a point well taken and certainly something that we´ve been thinking about for future opportunities.

[12:27:34] Just to follow up on that last point... I think just \inaudible :02\ difficulties is that rightfully so in each sort of category of service, each participant is addressing the needs of a consumer or location, as care management, case management, responsibilities. How many case managers are involved in the same patient? Is any of that really coordinated? All of the participants that have access to a medical record... The answer to all of those questions is really no. If we really want something to work in the same way you want an orchestra to play music, you have to tune the instruments.

[12:28:11] I totally agree with that.

[Jim] I have a couple points on information exchange. One is... It is a major investment of dollars and resources to get these kinds of systems to talk to each other, and if you´re like \Kaiser Permeant\ for example, you´ve been doing this for seven or eight years and it´s a totally integrated system and you´ve got it all figured out. If you´re not in that category, and if you´re not sort of United Health Care that can spread those investment costs over multiple states and billions of people, then it is a challenge. There are some states, Arizona comes to mind, where the state itself has taken a major set of steps towards setting up a state–wide information resource that is available to all of the health plans in the state including the Medicaid plans and the commercial plans and others. It´s still in a relatively early stage, but it´s pretty ambitious, and they´ve got some good stuff on their website, and they´ve got some CMS support for doing that, but it for sure is a heavy lift. If you´re a state like Arizona where you´ve got sort of wall to wall managed care and Medicaid and you have had them since like 1985, then you´ve got a starting point for that sort of thing, and the Medicare managed care is pretty prevalent in Arizona as well as is commercial. So, you´ve got a number of pretty sophisticated managed care plans in the state that are essentially national organizations as well, so you´ve got something to really build on in making that very, very substantial investment in information technology that lets people actually exchange information in ways they couldn´t otherwise.

[12:30:32] We have heard a lot today about the challenges which we´ve heard a lot about too at the department about getting providers on board with managed care, and I particularly hear it in FIDA. I was talking to a FIDA plan earlier this week. They said when they reach out to providers and they´re trying to enroll them in their network so they can get the membership, they don´t say the word FIDA and they don´t say the words managed care. I´m wondering whether in your work with others states whether you have examples of ways to successfully get the providers engaged and more on board with a concept of managed care or on the flip side of it whether you have stories to share on unsuccessful efforts that we would like to avoid.

[12:31:19] I think probably the biggest point I would make is that once you´ve got managed care implemented and you have plans in place, and they are enrolling people and they have gone through the effort of setting up networks and are at the point where they´ve got to deliver for the enrollees and they´ve got to deliver for the state and for their shareholders if they are publicly held, they have all the incentives and all the resources that are necessary to work with individual providers in a way that will engage those providers. First of all, they´ve got to pay them at least a little bit more than they get in fee– for– service, and most managed care organizations will do that. You´ve got to demonstrate to them that there is a benefit not only for their patients but for the providers themselves in managed care. Again, if you´ve got a care coordinator or a care manager who can work with the individual physician to make sure that the person actually shows up for their appointment and they have some kind of an understanding of the information they need and the help they need from the providers so that the 10 or 15 minute visit goes more efficiently than it would otherwise, you´ve done as much as you can to minimize administrative hassle for the provider, but you just need to demonstrate to these providers, because you have to have them in your network and they are the ones that are going to make the actual care that is provided to your enrollees, a better care than they can get in fee– for– service or worse care. I would say, that´s the crucial interaction or interface or whatever you want to call it. It´s between the plans and the providers in their network, and there´s only so much that the state or CMS can do by sending out mailings and holding webinars and having radio ads and stuff like that. It´s really got to be, again, for the human being interactions, between the human beings and the health plans, and the physicians and other providers in their networks that over time makes this work. It does take time. You can´t persuade people that a new way of doing business is better for them just by saying it up front. You got to prove.

[12:34:02] I think folks mentioned earlier today the value of having peer to peer dialog, and for a provider I think one thing we learned from working with other states... we worked with \MNTL\ on this as well, California experienced higher than expected opt out rates particularly in LA County, and one of the things they did was convene about 400 providers, bringing in primary care physicians in the room and really spotlighting physician champions, provider champions who vouched for what the value of the program was not only for their patients and their beneficiaries but also for their provider agency and provider group. I think, and Lindsay can most likely back me up, I think they just need value in terms of actual increase in numbers from that convening that at least from the conversations we´ve had with the state they see a lot of value in spotlighting those provider champions. I think there´s a lot of value in bringing them together here.

[12:35:07] I agree, yes, the type of provider \summit\ Anne Mary talked about was helpful, and another thing that I would just mention, we have seen that a couple of demonstration scenarios, especially at the beginning, we had a couple of states where they had a lot of experience with Medicaid managed care and providers sort of understood especially from the acute care side of managed care less forcefully already there, but the long–term service side was brand new as the demonstration was rolled out from a managed care perspective for providers... In those places, we saw a lot more hesitancy and skepticism and concern about what this means. I think in a couple of places we saw fairly effectively where very early on, the state established in some places weekly meetings that were at the same time every week, they required that the plans participate in them, and providers came and sort of asked technical questions, maybe aired some concerns, but there was plans there that the state fully expected would either answer the questions on the spot during that meeting or provide that human being interaction to be able to address those concerns, and I think over time that ability to kind of build that trust between the providers and the plans in some ways helped. Certainly, it is probably not going to work in every situation, but I think there were some things that a few of the states tried to help \force\ in some ways in those conversation and engagement that did go some way in terms of kind of building the trust and rapport between some of \inaudible\ some other things that I would throw out there.

[David] David Socola of the \ICAN\ program, the FIDA participant \inaudible\ in New York State. Thank you for the really helpful presentation. I think it was some consumer advocates were concerned that in New York State we have all these different kinds of plans. There were some plans I didn´t even know about today. I didn´t know what a FIDESNP was. I´m pretty sure the consumers don´t know either. There are different models out there that are essentially competing against each other for consumers. I was surprised to see actually how many consumers are enrolled in integrated products in New York State. It´s just a lot of them are \inaudible\. It seems like now we would have a lot of data to work on kind of comparing those different \inaudible\, what´s working and what isn´t, what are sort of which models are delivering on in different objectives about having their care management or their integration and things like that. I think a lot of people might be concerned about the... we´re sort of by default choosing the model that has the best sustainability with the plan rather than saying let´s take them all in what we think is the right balance of features we want to see and then make that the most financially sustainable for clients, make that the best deal so that in essence there isn´t a divestment from the model you like and to models that might not fulfill the objectives. In addition to that, I would hope that there is a public recent data comparing... you´ve got apparently 200,000 people enrolled in DESNPs... what´s happening with them? Is there actual coordination with Medicaid for those folks? Is there any outcome data? Things like that, so we have a basis for comparison along with different models.

[12:39:34] Thank you for your question, David. I think a lot of this data may not be publicly known. \inaudible\ a lot of the data that is available sometimes grabs the experience of being able to access that data isn´t as robust as we think it could be. One of the things we´re looking at now in the program is how to make long–term care programs for the consumer experience more friendly, and this is a new initiative that we´re going to be rolling out, and I think part of that is looking at how people get into this system, how people become aware of what educational materials we can expect for education, and engagement, and opportunities for folks, not just stakeholders but actual consumers to interact with the state and to navigate, because I think being a member and trying to navigate this stuff can be very, very complicated. You hear about \FIDEs\, MMPs, DSNPs, and it´s hard for even us to keep it straight sometimes, right? So I think the consumer experience must be very convoluted in some ways. I think you kind of resonate a lot of things that we at the state we hear a lot of times, and I think the idea behind looking at the consumer experience, that includes things as simple as informational brochures and maybe their best in class practices that we can promote from a state level, and also just looking at our website which I know we´ve had a lot of feedback on how folks can read about the programs and products on there. I think it´s something we´re acutely aware of, and we have all these products now but as we look to the future and think about how are we going to tout the ones that we have that benefit the one, I think the idea of touting all those in New York State, we really pride ourselves on consumer choice. Choice can be a good thing and choice can be a confusing thing at the same time. I think the goal is to provide choice and also provide direction on what those benefits are so that folks can make \inaudible\ and be empowered from the consumer standpoint.

[12:41:57] I would just make a couple points on the performance measurement front. One of them is a wonky point and another one is a simple–minded point. The wonky point is that there are not actually, in most states, really good data on what kinds of services are actually provided and not provided inside managed care organizations. A lot of states are required to report what´s called encounter data which is essentially fee– for– service data on what goes in in managed care, and states like Arizona, Tennessee, and Minnesota have been requiring that for years of their Medicaid plans. Medicare advantage just started requiring that back in 2012, and the data has been submitted to CMS but so far it has not seen the light of day. So, there really is that missing measurement piece on especially the Medicare side but in the Medicaid side in many states as well. So that´s the wonky point. The simple–minded point is that if you´re operating in a voluntary environment and people can enroll and disenroll in a managed care plan anytime they want for any reason, the plans that systematically enroll and keep enrolled and grow their enrollment are probably the better plans, and the ones that don´t get enrollment and keep losing the enrollment that they get are probably not such good plans. There is in the Medicare advantage star measure system a standardized measure of voluntary disenrollment. You can look it up and see what percentage of people voluntarily disenroll. In the plans in states like Minnesota, it´s like one percent of voluntarily disenroll. You look at some other plans that for other reasons are probably not such good plans, and it´s up around 30–40%. That´s telling you something very useful, and it´s simple.

[Dan] I guess maybe it is just part of the transition... I´m Dan Lowens with \DNSNY Choice\. To the point about choice and the multiple several products that we have here, I guess I´m trying to... these are the goals to get us to a single platform at the end of this process, that does contain time and is the best of both worlds and gets the efficiencies from \NAFTA and FIDA\. At the end we do have something, one thing, and we can compete as plans on one platform or are we going to have multiple?

[12:45:20] Thank you for your question, Dan. I don´t think there is any one real answer to that. I think that´s the point of the stakeholder process. I think we´ve heard from folks, from the stakeholder community about with FIDA, with some of the things they like about FIDA, things they like about \SMATH\, thinking about things like frailty factors that some of the products have and have enrolled in... I think trying to think of what are the good components, what are the things that folks really care about? I think you´ve heard today from the panel that every state is doing this in a different way, and New York is obviously very unique. I don´t overemphasize that in many ways in terms of what we offer. So, I think it´s an opportunity here and amongst this group and the stakeholders and I don´t think you´re going to hear the states telling folks what we should have. I think that´s the opportunity here is really to engage everyone, to hear from you. I think we´ll be talking about next steps in terms of follow–ups to this meeting, but I think that´s an opportunity you´ve heard from really the experts in the field nationally and at CMS, and I think it´s an opportunity for us again to learn from what we´ve done well, some of the things that haven´t gone so well with FIDA, and to think about next stage planning. I think we´re doing it now because we know it´s time limited and we don´t want to do this two years down the road or in a year and a half and be rushing toward something. It´s something certainly that folks have made outreach to the department time and time again, and they want to be involved with the process. This is really to allow for a smooth transition if there is a sort of transition, but I think the opportunity here is for all of you to provide further feedback here and look at things like upstate/downstate, look at it including not–LTC beneficiaries–thank you for that comment Valerie–and think about all the different component parts here. I know we´re almost out of time. Again, I just wanted to thank all of you, and everyone on the webinar, and Lindsay and Melissa and Jim and Anne Mary for being here today, and to all the DOH folks. We really appreciate the time you took today out of your work schedule to spend a couple hours discussing this and we hope it is illustrative of our commitment here to next steps and the commitment that CMS has with working with the state to be flexible in the approach year. Thank you everyone.

[12:47:57] A couple of quick questions on the stakeholder \inaudible\, because once we envisioned and started to highlight the stakeholder process to accept exactly those questions and questions like it. That will go through the end of the year. We´d like to get the input of people in the room and those on the webinar through the chat function. A couple of brief things, not to decide, but to get a sense of where the group lands on this. One of the first things that needs to be envisioned with convening somewhere, convening somewhere on a regular basis to talk about these exact things. We´re dealing with agendas based on the input that we get here and based on the comments that we´ve had today. I will have a series of meetings that will run through the end of the year. The first question we wanted to throw out there is... How frequently should we meet? Probably to get this done the Department of Health definitely wants to move this along in a timely fashion to stay on track. If we met monthly through the end of the year that might be too frequent for some especially \inaudible\ schedules. Every six weeks, maybe every eight weeks, although that would push this out a little. Any comments or questions on it? A lot of monthly If we schedule a monthly meeting, we still send out some dates with agendas that´ll be probably one for September, October, November, and December, and then we´ll look forward into January, hopefully. The next question is where; New York City, Albany, alternating between the two? Buffalo? One of the points about alternating is does... obviously we´re not just talking about just the eight side accounts here, we´re talking about the future of integrated care in New York, so if we did alternate \inaudible\. We could send out a survey so everyone can participate. We also wanted to seek the reaction of the room too. The next question has to do with focus. It sounds to me like we really have two things to decide. One is the program design element which we´ve talked a lot about, what we´ve liked, what we haven´t liked, hopefully more of what we´ve liked about the different programs and what we want to carry forward and what really hasn´t worked so much. The other is we heard Jim and Anne Mary talk a lot today about the platform on which other states have built their integrated care models. We´d like to do a lot of good discussion about platforms; the platforms we´ve been using, we want to try different ones, I was intrigued by the state that had the Medicare and Medicaid and had to have both in the same geographical area. We´d like to explore that a little more and see if that´s \inaudible :03\. Do we think that to explore those options we should have all our groups that then report up to a larger group, or should we have agendas for the larger group that touches areas \inaudible\? The benefit of having smaller groups is that it is a little bit easier to convene and maybe you get more participation. One of the downsides to having smaller groups that report up to a larger group is... two things. One is that it is more time and more resources and sometimes things get slowed down. The other downside is that sometimes when those smaller groups decisions get reported up to larger groups and some people feel as if their voices fell out of that.

[12:52:26] My suggestion \as far as that goes\ has two different tracks. One track is \finders\, the other track is \inaudible :03\.

[12:52:39] You think that we wouldn´t have the opportunity if we had all of the stakeholders in one room together to talk with each other?

[12:52:49] \That very fact\ is why I think \inaudible\.

[12:53:07] Just because it´s very helpful for you guys to hear \inaudible :04\ or for the providers to hear why consumers want something maybe they didn´t know before that it´s a very good opportunity for information sharing. I would also suggest that the meetings specifically start first with the design elements and then move into the model. I think we first have to figure out what it is that we like about each program before we can pick a model, so versus adding two \concurrent\ separate \consultation\, I think we should just flow from one into the other.

[12:53:50] Thank you. That makes a lot of sense. I tend to agree, but I want to get–Go ahead.

[Margaret] Hi, my name is Margaret Vicolog, I´m the other end of the spectrum usually on pediatrics, but I came here today because a lot of the problems, a lot of the concerns \inaudible\ two different populations. There is a design element that you´re doing here also \ruin\ our lives at the other end of the spectrum. I think you have to broaden your audience, too, and it´s not that all of us bring so much, it´s that the impact from what is decided or what is designed here has a huge impact across the state, across all programs, across all models, and it would be a lot less confusing if everyone knew about other stuff. I think it´s really important for providers, the advocacy, participants, the members, whatever they´re called today I can´t even remember, along with the elephants in the room, keeps meaning there´s more of an \interest\. They´re very \inaudible\ right now. A lot of what was said today has impact through the whole population. \inaudible broaden the network. How many physicians are here? How many representatives from the AMA? That´s one of the issues we´re–

[12:55:25] This is not a stakeholder work group. We´re–

[12:55:27] No, no, I understand that, but having someone reference that different populations is going to enrich...

[[12:55:36] We could not have led better into my last question, the only thing keeping you from that door, which is... Who is missing from this group today that we should be inviting and rolling into this stakeholder workgroup? So, thank you for that. You´ve given some good suggestions. Are there other suggestions of people we need to roll in?

[12:56:01] On Long Island \inaudible :02\, but there´s a lot of informal groups of various types, and we \sell\ services that need to be more informed though with things. I was at one meeting last night and basically people are not informed about the \inaudible :03\, and when they find out they feel like they need to be involved. Whatever happens, it needs to go out beyond the usual subset, beyond the organizations that are well established and do great work that are represented here today that represent consumers, but getting more directly various networks out to people that are using the service.

[12:56:58] Seeing no other hands, and if there´s no different types of comments, I think that we can call this a day. Thank you all for a really successful meeting. We´ll be sending out a series of agendas with dates and what will be discussed at each. Thank you.