The Future of Integrated Care In New York State

Transcript of webinar

Good morning everybody. Today we are starting in for the second time on continuing the conversation on the future of integrated care in New York. To begin visiting the last vehicle available to deliver the care necessary that it holds high quality product. I´d like to welcome everyone in our managed care plans, advocates, all the stakeholders, thank you again really for being here today and thank you to those on the webinar for your participation. I would also like to thank our partners in this integration from the Center for Medicare and Medicaid Services, **Julian Oliver, and then our esteemed \inaudible\ Erin Kate Calicchia, Kirk Dobson, Joseph Schunk, \inaudible\ Hunter, Deborah Conely Flora, Patrick Cucinelli, Mandalyn Royale, Jamal Johnson, \inaudible\. This past July on \inaudible\ the Division of Long Term Care, the other one is CMS, and a lot of stakeholders with the kickoff meeting to the broader stakeholder planning process \inaudible :08\ integrating Medicaid and Medicare services and the integrated care service center provided insight into how other states integrate Medicare and Medicaid outside of federal financial alignment initiative. From now through December, as you all know and that´s why you´re here today, DOH hosts a series of ongoing sessions, \two dollar\ additional meeting, and they will all be regarding the services and the discussion on how to plan best for states´ Medicare and Medicaid integrated programs after \cell\ 19. Through this process, DOH and CMS will gather input from the staff, all of you, and continue to do so. Various elements of policy programs \inaudible\ influence the future of integrated care in New York State. DOH began operating a fully integrated dual advantage program back in January 2015. It seems hard to believe that this year has gone by. As we began the demonstration of \who we´re targeting with\ the financial alignment initiative, and FIDA is just one of three other integrated products as you all know that exist and advantage long term care products under DOH. We also offer programs for \booster\ service for the elderly, PACE, Medicaid Advantage Plus, and of course FIDA, so all three of these products are geared towards really improving the care experience for low income \inaudible\, people with disabilities who are dually eligible where there was a lot of other little Medicare advocating.
In November 2016, DOH announced a big step to FIDA demonstrations, we average about 19, and we put it to CMS to \inaudible :02\ to allow New York to establish financial alignment initiative demonstrations beyond that time. DOH \inaudible\ committed to bringing stakeholders together to plan the future of integrated care. This opportunity really is great because it allows us to look at all three of our integrated programs and to really begin a vision into the potential of what integrated care can look like starting in 2020 after the pilot demonstration ends. The focus on shaping the care of the dual eligibles has really become more of focal points than priorities in our state health care reform efforts, and the Medicare and Medicaid enrollees, really some of our most vulnerable elders to probably go back \inaudible\, and health challenges, and we all know the benefits because you are all first line to that, that better coordination care services between Medicaid and Medicare hold significant problems in terms of being able to improve the lives and the health of New Yorkers, \inaudible\ greater efficiency in that \inaudible\. Both DOH and CMS together works for eligibles as you all know, the better care experience with operating really our full \ATS\ participant center coordinated integrated program, that is \inaudible :03\ Medicare and Medicaid services. We feel again, which is why we´re having these discussions, that opening it to discussion allows us to get to a place to successfully integrate Medicare and Medicaid will stand DOH´s opportunity to deliver the best coordination care for our dual eligible population. Again, I just want to thank all of you here for your participation and assistance in this late rate of joint pursuits. We have a very robust agenda today. We´re going to continue now, I´m going to hand over the microphone to Erin Kate Calicchia, who is our \inaudible :02\ Office of managed Care, the Division of Long Term Care. Erin Kate is going to go over a few more details today about \inaudible\ process, and then she will lead us into discussion of other topics. Sitting up front to help address any questions and provide feedback here at this time is all of our \inaudible\ experts from CMS and DOH, Joe Schunk, Deborah Conely Flora, Patrick Cucinelli, and the rest of the team will be \inaudible :06\. We all here will need to be really participatory today, and to write in on the webinar and submit your questions, we really want this to get a lot of good discussion. Without further ado, I will welcome Erin Kate. [Erin Kate] Thank you \inaudible\ for coming in person, and thank you to all of our others who are listening \inaudible\. Due to \inaudible :18\ 2019. The idea here is for us collaboratively and CMS to come up with what we like and what we don´t like, what we´d like the future of integrated care to look like, because in New York one of the lessons we have learned is that integrated care is \inaudible\. I know there were a few questions about \inaudible :05\ all products, all integrated care \inaudible\, everyone \inaudible :04\. After today, will be meeting number two \inaudible :05\. In October, we are going to be \inaudible\ should be showing them an invitation \inaudible :03\. In November, we are scheduled to be in Albany. We are trying to determine whether it would be valuable to move that one to Rochester or or the Western New York location other than weather. That will be announced as we get that sorted out. Finally, will be December 8th in New York. After that, we will be working proactively with CMS on all of the \inaudible\ and all of these meetings, and somehow pick some kind of mileage for the future of integrated care in the state. For today´s discussions, we have four topics that were listed on the agenda. We´re going to be handling one topic at a time, and we´re going to try to keep the comments to that particular topic even though sometimes we want to vary out into other areas, for the ease of putting everything together for us and for our notetaker to capture all the comments that are \inaudible\ we would like to try to keep it to those topics. We are not looking to drive to any conclusions today. We really want to go over all different points of view on everything, so we´re not going to try to provide any amount of \inaudible\ today. \inaudible :13\. We do have \inaudible :02\ we´re not able to get a microphone that we can send out into the audience, so when you have a comment, if you can, come up to the podium so that everyone on the webinar can hear it and everyone in the room can hear the comment. If that´s not really feasible, shout it on out and we will try to \inaudible.
Just to back up \inaudible :04\, today is the first of several in a series. There will be three more meetings after this. The meeting in November is being moved to Rochester and there will be more information out on that as soon as we get it locked down. We are going to try to get all of the topics in today in the meeting. All comments are welcome, and we´re trying to handle topics one at a time so that we are able to capture them in our notes and for us to give feedback. If you have questions on the webinar, send them in to \inaudible\. We will be pausing after every topic to see if there are questions. There will also be plenty of time at the end for any questions. If you decide that you don´t want to come forward and raise a question today, if you want to wait, you can send it in you do have an additional opportunity to share across \inaudible :02\ presentation, it is future of integrated care at We do ask that you send those comments in within ten days if possible of the end of each meeting so that we have time to absorb them. We only have about three to five weeks between each meeting. Still, after each meeting we will as a department, and CMS will individually, look over all the comments and we will piece together an after \inaudible\ of each one, and we will also be taking any written comments \inaudible :17\. So, we have already said who all our panelists are \inaudible :09\ which is the target population. So in a nutshell, we would like to hear from everyone today on your thoughts on which populations we should include in integrated Medicare and Medicaid programs. Up on the slide, here is our three prides that we have today. We have Joe Schunk \inaudible\, an image description of what the target population in FIDA looks like. We´ll turn it over to \Jeff Smath\ in \inaudible\.
[presenters] Thank you Erin Kate. We´ll go through some of these items that you have the target population for FIDA, and it has the curse FIDA has, full Medicare and Medicaid coverage, the age is 21 years or older, \inaudible :09\, and the service area that we have for FIDA is New York City, Long Island, and Westchester county that were in as of early this year.
>> Okay, so for Medicaid Advantage Plus, we have eligibility requirements on full Medicaid and Medicare, age 18 or older, community based long term care services are planned for greater than 120 days, there´s another level of care, and at this point in time living in the \inaudible\, Suffolk, or Westchester counties, then Albany, \inaudible\, Schenectady, and Montgomery. That of course is subject to change with any more service area expansion \inaudible\.
>> For PACE, a really fundamental program, the idea that this is a group of individuals that really want to be in the community and they want to \inaudible\. You can see in the combination of Medicare and/or Medicaid, 55 or older... One thing I would note on the age is that a lot of the coming under the \inaudible\ Act, there are a lot of proposals out there for changing that, for example: CMS has proposed a personal spender community care model which would actually lower the age to 21.
That´s something the state \can move on\. These folks were also needed in nursing home level care, scoring five or better on the \SUAS\. If they have the same requirement for over 120 days, and the PACE centers are very strict in terms of what service area \inaudible\.
>> It seems like we have a few things about \inaudible\ today, with eligibility, who should be included in the target population. I guess the elephant in the room is should it be able to be all new Yorkers in upstate where it is more rural or should we limit as FIDA with limit to issue a downstate only population where there´s more of a \skill\ population. [audience] Why would we limit it?
[presenters] We have heard from a lot of plans upstate who have really strong \inaudible\ population together in order to get availability and make services work including PACE... \inaudible :08\ sometimes it´s not that we can´t put the populations together, it´s just from under \inaudible\ downstate don´t necessarily work for upstate.
>> I don´t know that the issue is the population, that sometimes the regulation is challenging for people that are in the rural areas and that struggle with home care, so it´s not that the services aren´t necessary and that we wouldn´t \inaudible :05\ we´re very interested in, but we do have unique struggles. I think it´s more of an understanding that we do face different struggles than those downstate, not that the services aren´t needed, because they are very needed, especially in those rural areas, and the point is to provide access to care to people who currently don´t have it.
>> Downstate regulations don´t always work upstate. [audience] Today the state has been successful in getting managed long–term care as a state–wide initiative. It took some time, though we got there. The same for Medicare Advantage. Both sides of the equation exist state wide, so I don´t see why the integrated version shouldn´t be state wide. I would advocate for state wide.
[presenters] So we have a lot of advocacy for state wide. \inaudible :08\. There´s that we can take away. [audience] I have a question for the lady who was speaking about PACE. What exactly do you see as a challenge from a regulatory perspective between downstate and upstate?
[presenters] I was for, really, for upstate programs as a managed long–term care plan. Some of the \inaudible\ things is a bit of a challenge sometimes meeting the requirements in some of the areas, as well as travel distance can sometimes be a bit of a challenge, so it´s not that... \inaudible\ travel in Wyoming county, it´s not that I don´t think the need is there, it´s just the need of requirement is a bit of a challenge, so to then look at FIDA, a program like that, I think it´s necessary, it just needs regulation. ... The rural aspect, yes.
[presenters] Take a look at the Medicare and Medicaid populations. Are there any subsets that we should exclude as we go forward?
>> I think you´re looking for whatever people think anyone who has Medicare and Medicaid should be included, or whether certain populations should have a different program, and who those populations would be... the future that DOH should be looking at is the whole population, all in one program that would be Albany.
>> Do people think that what we´re looking for is one integrated care product that services everyone, or do you think the future should be more in the way of how we have things today where we have the FIDA population, keeping things separate, and you have different requirements for \inaudible\.
[audience] I did want to make a special point about the IDT population. We do have an initiative under way already that \launched\ a plan of others to follow, because that population... so many people are dually eligible, it´s probably 50% of the IDT population, but FIDA \inaudible\ is really the only one that will work effectively for that population. Right now, the demonstration for that IDT population is going a little slowly but it´s going very successfully. The early data is showing it producing significantly better outcomes in some areas \inaudible :02\ for those people who do enroll. I would certainly encourage \inaudible\, the IDT population, because obviously that population has special \inaudible\ issues, care coordination, \inaudible :02\ that a regular IDT population \inaudible\, so there probably is an argument to not just apply all the same standards consistently, and frankly even on assessments... it´s a different group of people and professionals who have been working with that population and doing \inaudible\. It probably does not make sense for that, but rather than exclude them I want to make a special \formula to balance equally\. On the others, these programs all do some different things. I think it´s useful to have them all and see them all sort of running, \AMAT\, and PACE, and FIDA, because there are reasons why a consumer stays at a \Kroger\, and there are reasons why some programs in terms of provider interaction and who the plan entity is in those, are different, everybody on the plan side for now sticking on the non–IDT \inaudible\, doesn´t necessarily have the scale or the great ability or frankly \inaudible\ not that both \inaudible\ but they certainly \will be in half\. There´s a whole different set of considerations for PACE and programs that are in that or want to be in that, it works better for them, but again a \inaudible\ thing to do to FIDA. I would argue not to, generally speaking, be excluding populations–I´m not sure who you would exclude, but \inaudible\ suggestions... our program typically has been \inaudible :04\ can´t mandate Medicare choices here, but you don´t mandate anybody, so in some ways having options for people and letting the system to evolve, I would probably \inaudible\.
[presenters] That is a good point for keeping in all of the populations that are in, but keeping them in separate programs, so not excluding but keeping them separate, and at the same time keeping things the way they are today which is to pick criteria and \inaudible :02\. Is there anyone who thinks that we should not have so much going toward \inaudible :08\?
[audience] I have a question related to the \inaudible :03\ these three programs, we noticed that the eligibility criteria is very similar in terms of having a certain level of long term support services fee. It would be great to get some thoughts on if we should look at the so called community well pool, individuals who are eligible for full Medicare and Medicaid benefits but don´t need the level of care that we \inaudible\.
>> I´m with a hospital. One of the things that we´ve been sort of looking at is how this will all \inaudible\ with the DSRIP initiatives that we´re looking at, and working obviously with the Medicaid population, these two really transform how health care is delivered today. We struggled with how those plans are. If we´re really going to \inaudible\ on integrating care and we´re going to be transformative and we´re going to hold people accountable for care navigation and all of the wonderful aspects that I think are coming about as [inaudible\, then I don´t understand why we wouldn´t have a full pass to available to everyone; that is easier for everyone to navigate. You are in different programs, following the rules of those programs, whether you´re a hospital, whether you´re an outpatient center, doing whatever, it´s really difficult, but I look at the consumer and how hard it is for them to figure out how to navigate the program that they might be in, and even understanding the program. One of the things we struggle with is patients not really understanding is what their program is and how their care is supposed to be delivered and what kind of tool they have at their disposal, because we´re really probably not doing a great job at care managing the way we say we are, and we´re probably all talking about it at our levels and what we do in our roles. We´re never actually pulling it down to the patient level the staff is supposed to work with. I´m not sure they get this. My case management department chronically is telling me how they can´t get through to the care managers or the social workers who are supposed to be delivering a Medicare or Medicaid plan. I have been thinking about the end user, the patient who I still waiting for someone to get back to them.
Then you have to bring in the social determinents of health and how it applies to this entire population and are we doing a good enough job of screening. I think DSRIP is doing a really good job at starting the integration \inaudible\, we have to tie this all in to how it colors \inaudible\.
>> Do you have any thoughts on education on choice of what we´re doing? Did you mention that it´s difficult sometimes for the consumer to really understand the different programs? Certainly we saw early on in the program the difficulty with even some of the providers being educated or really understanding the difference of the programs or what FIDA was for instance. What are folks thoughts on what we´re doing with education in consumer choice, it´s great to have choice, but the flip side of that is that too much choice can confuse someone who is frail and elderly and has six or seven chronic conditions, and they don´t have a patient navigator or a case manager, the care management team isn´t specifying the differences or can´t really delineate one from another, that it creates confusion, and while it´s inclusive it can be fragmented.
>> One of the things that we´re mandated to do as hospitals is to make sure our patients have a safe discharge. One way to do that is the chronic education on what a patient can do, and what that actually means for that discharge. For me, it´s when you have a patient in your care for such a short period of time in a hospital, and you have x amount of things that you have to deliver to that patient, that are regulatory, that are mandated, that the patient walk out with this in mind... it´s too overwhelming for a person to get that. Then you´re told that well, their plan offers a care navigator, someone to offer that education, then when you go to reach out to that educator there´s no return phone call, or we´ll be back to you in a number of days, or I´m sorry we work Mondays through Fridays and somehow people got their health care on Sunday or Saturday. People don´t get sick Monday through Friday from nine to five.
They get sick all the time. They get discharged from the hospital all the time. They get discharged \inaudible\ from home health all the time. Yet, our system hasn´t caught up with that, so I don´t know whether the DSRIP initiative really cares, it´s working toward realizing that we are \inaudible :03\, people are going to get sick all the time, we haven´t really done a good job at education. There are so many things... When you come in as a chronic diabetic, you can´t get \inaudible\, I have so much to do to just get you in there, to take your insulin, take a medication the right way, that all the other pieces of the regulatory things are going to be an underscale of what \inaudible\, but it´s all about their plan. No one here has \state plan\. I´m not necessarily saying I have answers to that, but I know that a few people \that are job\, but we can´t do it when we have so many programs that you´re trying to educate people on. If we could just give them... here´s the program, and we talk about \inaudible\ and self manage as far as \inaudible :02\, you can do that only have the social determinants of health, so their lives are so chaotic that trying to manage the process is just one other thing that they can´t communicate, they can´t do the thing they need to do, it´s an impossibility unless we start working together to do it. I think the problem is we´re so silent, and the programs we have are so silent. We have to integrate. So I´m excited about it, and I think I speak for more than just my hospital, hospitals are excited, that´s why we´re excited about DSRIP, that´s why we´re working with smaller programs. We´ve got a lot of work to do \inaudible :03\.
>> So it seems like from your perspective there is a lot of plans to introduce to the discharge planning process really educating folks right as they´re leaving the hospital...
>> Well, it´s the idea that when folks used to leave a hospital they left the hospital in a well state. People don´t leave a hospital in a well state. They go in \inaudible :02\ skilled nursing facilities. \inaudible :04\ locations don´t need a hospital \inaudible\ less, they just need it better than when they came in, because that´s what we wanted to know. Care should be delivered in the right setting at the right time. We believe that. In order to do that, we have that infrastructure, and I don´t think that infrastructure is there yet, but I do believe it´s on the way, through programs like DSRIP. Again, I think that \inaudible :03\ health home mandate put us \inaudible :07\ we´re spinning on a wheel, so when we find out the \inaudible :05\ they have to go back to the patient and if they just had asked us up front, we would have known, we would have been able to put a patient right into the health home that they were at and start working with their case managers there.
[Judy] My experience is not only \inaudible :03\ New York State and health discharge planning, but it was a number of years ago. I do know right as your hospital association participated at one of those, and the education of discharge planners was a priority. I don´t know what the outcome was. It was training on the different programs available in New York State. I do know at that time I also... \inaudible\ speak to critical hospitals about options within long term care, and I think time´s really good for the hospitals that have organized those educational railroads or that discharge planners that are whole \inaudible\ social work department to know about the options that are available so maybe that part of this integrated care planning, we can integrate a component that provides that training, because it is a partnership between discharge planners and the health plan and all of the providers in the continuum of care, so I think it´s really important. It´s not just on the plans to do this. The Department of health, CMS, all of the providers, and the consumers of course have to be involved.
[presenters] It seems like maybe training and education is an area that people want to focus on in future meetings. Maybe we can add that as another bucket here.
[audience] I just wanted to respond to this question about whether it should be multiple spurs into the rail... I am a little bit concerned about this. I do think it should be for all duals, but I´m concerned about making all the populations together into one group. Today, New York State has two models that wrap around Medicare Advantage plan, one called Medicaid Advantage for the healthier duals and \ATMATH\ for the frail duals, and this may be reaching over into another topic so I apologize. Today the way financing in Medicare Advantage is structured, a plan can only get a Medicare frailty adjustment if they´re serving exclusively the frail duals, and if we fix populations together, it could have financing implications. I think there´s been a lot of research that shows that Medicare Advantage \inaudible :02\ doesn´t adequately pay for the cost of care for the frail duals, so it´s important to have that frailty adjustment. Yes, I thin it should serve all duals, but maybe not all in one catch–all pot or program. Maybe there needs to be some different models for different \cut offs\.
>> So, just to be clear, are you advocating for a frailty adjustment like with the new integrated program, or rather really a separate program altogether, like carving out that population?
>> Well, I think that´s an interesting question. There has been discussion about a frailty adjustment \inaudible\ years, and we´ve all made the case that like the risk adjustment, a frailty adjustment should be assigned to the person not to the program side, but today it is assigned to a program. If we were able to make that change and have the frailty adjustment follow a person the same as the risk adjustment follows the person, then I think that issue comes flat.
[presenters] Thank you. In the interest of time, if there are any more comments on this particular topic please submit them to \inaudible\. We are going to move on to the next model which is covered services under the Medicaid program. For this topic, we ask that you think about the covered services included included in \inaudible\ program, in FIDA, in FIDA IDT, in \MAT\, and in \inaudible\. Also, Medicaid services that are included in other Medicaid programs, like the HCBS waivers part and fee for services. So, our discussion here will focus on which Medicaid services we should include, and we will count the option to select from Medicare \inaudible :03\. Here we have sets for covered services, or a little bit about our services in each type of plan, and I will ask Joe and Deb and Patrick if they want to \inaudible :03\.
>> Okay, for the FIDA, the summary of the benefits that we have under care includes all Medicaid state plan benefits are covered by the FIDA plan, the home community based waiver service coming by the FIDA plan, TBI and XTD waiver services as well. The care team, or the IDT, has flexibility to cover additional items not otherwise covered by New York Medicaid, and the additional benefits not including state plan for the waivers must be covered as well, so that´s the summary of the way that services are aligned for the FIDA.
>> The Medicaid Advantage Plus plan covers most of the Medicaid state plan services, they \are respondants of\ fee for service. The Medicaid Advantage plan is also able to cover social environmental supports, so that does get plan flexibility on other services. The HCBS waiver services are not covered under that plan nor the pay plan at the time, but in 1–1–19 the \NSCDCDI\ waiver services are scheduled to come in to both that plan and \inaudible\, so that´ll be expanding in that. \inaudible :03\.
>> PACE... They are required to cover all of the Medicaid coverage services, all \inaudible :02\ part A D, \inaudible :04\ enrollees. As we mentioned, there´s no HCBS waiver services, but one of the big strengths about the PACE program is the IDT team \inaudible\ have a lot of flexibility to cover a lot of needs of the individual both geared toward what´s necessary without the \inaudible\.
>> One of the first things I think we wanted to get to talk on are whether an integrated care product going forward should include all of the Medicaid state plan services, and if they should not then establish which ones should be excluded or on the flip side which ones strongly should continue to be included \inaudible :02\.
>> \inaudible :52, not enough meaningful words discerned from speaker\
>> I just wanted to sort of build off what what she she said and on what I said earlier. State wide \inaudible :03\, exactly what she just said. It´s very challenging for people to understand that partially capitated plans, their services, and how it coordinates with their Medicare.
That´s really why we´re looking for the private products. That also makes us more responsible for rehospitalization. We do have a full time working care with those \ambulance or businesses\ that we do not provide under our partially capitated plan, so for us when we hit our target, it was always because there was \inaudible\ the FIDA model and \inaudible\ services.
\presenters\ Next are state plan services. It sounds like there´s a lot of agreement in the room that all state plan services should probably be rolled up into the \inaudible :03\. What about the \volunteer\ services, MLTSS, do you think that should be included, excluded, all together, excluded in meaning that they should be a physical \inaudible\ population but not \inaudible\. No responses? I guess we can move on from that topic then.
Waiver services is the last thing we wanted to do, the waiver services and the role that they might play in integrated care going forward.
>> Is it too soon to ask that since not all of them are in yet?
>> We have a lot of discussion about \rate and service\, and I think the concerns that we would have aren´t whether to continue to deliver x, but around some of the things we´ve talked about \inaudible :04\ for services seem to potentially overlap with other services that are already in the plan. If we were to cart them in, \inaudible\ idea for the same reasons that we´re all just that, the Department of Health people are confused about what´s in and what´s out. I think we have to take through and add a cart, because \inaudible\ code is very different I think when people get into a plan, and if one of our goals is to create a program that is affordable, I think we also have to be careful about services and what we´re actually putting out. >> All right, so do you want a little more time \to review that\?
>> Some of the waiver services include different modes of transportation \inaudible\ including social transportation that some of us have raised concerns about. I don´t know that I would advocate for social transportation. As a Medicaid benefit, it doesn´t feel like a health care \staple all the time\. The difference between care management and care coordination has been a big discussion \inaudible\ around TDI and some of the other waiver programs. I think we need to kind of hammer out how those interactions have been if we´re going to carve in, because there´s a little bit of tension on a service like that. You don´t need... FIDA \has\ multiple care managers... coordinated and one has to be responsible...
>> Help me understand... Are you advocating for service limits in general or on certain duplicative? What "services" or, how would you choose that out exactly? >> It´s a thing that we just struggle with in some of those departments. We have to make sure that we understand how they´re \worded in a way that is for\ all the stakeholders, members, \suppliers\, care managers, and I just worry about layering it off. It feels like we just kind of keep layering services on.
>> Thanks. I think that´s part of the stakeholder process we have going on simultaneous to this with a lot of... for the waivers.
>> The fact that I´m trying to make sure we solve this will be just \inaudible\.
>> It´s definitely another variable in the equation. Thank you.
>> I just wanted to say, I think before we look at that part of the population some of the issues that pertain to \inaudible...\ Are there issues that you find there with the different projects and the different ages, particularly around eligibility?
>> At this point, the