Stakeholders Meet on the Future of Integrated Care
The Department of Health (DOH), in partnership with the Centers for Medicare and Medicaid Services (CMS), convened the fourth in a series of meetings on the future of Medicaid/Medicare integrated managed care last week in Albany. The agenda included rates, participant and provider engagement, plan operator qualifications, and enrollment.
DOH began the meeting by recapping some of the common themes struck by submitted comments as well as those expressed at the most recent meeting held in New York City on Oct. 16th. Some of these included:
- support for a streamlined review process for marketing materials;
- a preference for Fully Integrated Duals Advantage (FIDA) translation requirements;
- recommendations that quality measurement be aligned with Value Based Payment (VBP);
- suggestions that DOH and CMS not duplicate quality measures and that there not be too many of them to preclude focused improvement;
- support for flexibility in network requirements based on population served, geography, and provider availability;
- a call for streamlined network submission and directory requirements;
- cautions that overly burdensome provider training requirements may threaten provider participation/support; and
- recommendations that providers be more involved in the final development of the model.
The discussion first focused on Medicare rate setting structures with staff from the CMS Medicare-Medicaid Coordination Office contrasting FIDA rate setting, where CMS sets the Medicare rate, to the Medicaid Advantage Plus (MAP) process, in which plans bid against benchmarks (as is the standard in most Medicare products). Some participants expressed support for the bidding process, pointing out that it facilitates products with additional benefits and may allow plans greater control of their bottom line. A key question will be whether a bid process, if used, would require separate bids for each product an organization offered. Some requested additional information on bid versus non-bid rate setting options, while others asked whether the state envisioned separate contracts between the plan and CMS/DOH or a single three-way contract, noting that separate contracts may be more appropriate if a bidding system were used. Several participants recommended using simplicity as a guiding principle throughout the process.
There was unanimous agreement that a frailty adjustment should be part of integrated products, and some recommended that the frailty factor should not be attached to a product, but follow the individual to whatever plan they were enrolled in. Participants pointed out that current Medicare rates do not adequately reimburse for the vulnerable populations being served, and the factor provides an important and necessary boost. CMS noted that they may not have legal authority to apply them for some products and that a threshold of frailty was required for factors to be used with potential implications if the well elderly were included with the current MLTC population. Frailty factors are used in Programs of All-Inclusive Care for the Elderly (PACE) and MAP, but not in Special Needs Plans or FIDA. One participant suggested that risk adjustment reflect the presence or absence of an informal caregiver.
Consumer representatives expressed concerns about care management and inadequate reimbursement for some FIDA services such as transportation. DOH asked whether the addition of care managers in an integrated plan would not result in savings from avoided hospitalizations. Plan representatives pointed out that the high cost of care management would require significant medical savings to offset, but agreed that integrating services may make care management somewhat more efficient than in non-integrated models. Some noted that care manager documentation requirements take time and might benefit from streamlining where possible.
Some upstate plan representatives suggested a streamlined process for upstate plans to move into whatever integrated product is developed to allow existing plans to serve areas and populations that they know well. Participants expressed support for a separate Medicaid funding stream such as a separate rate cell if well duals were to be included in the product.
During a discussion of plan qualification requirements, there was widespread agreement that there should be no solicitation for new entrants given that DOH is encouraging plan consolidation. Participants suggested that preference for operating FIDA successor products be given to those organizations that continue with FIDA even as the sunset of the model becomes more likely. Several people recommended experience with Medicare-Medicaid models as a requirement while some stressed familiarity with the frail population. When asked, DOH said that there was no intention of seeking new entrants such as large out-of-state plans.
Some participants spotlighted concerns that training requirements may result in inefficient double-training of providers if each plan is required to train their network. Several suggested that the state should take on some of that training responsibility and that gathering provider perspective on what is most effective training is important. VBP training was offered as an example of where plentiful theoretical education is available, yet practical, hands-on training may still be lacking. Additionally, it is critical to ensure that providers, specifically individual physicians who may not have tolerance of additional administrative burden, are willing to participate. An issue that should be addressed to help smoother enrollment into integrated products is inconsistent enrollment dates, as is the case currently with MAP. Overall, MAP was identified as a good product with some administrative challenges.
The discussion concluded with an invitation for additional written comments to be submitted to DOH at email@example.com. The final meeting is scheduled for Dec. 8th in New York City and will cover the following topics:
- Geographic Scope;
- Consolidation of Existing Programs;
- Platform for Integrating with Medicare; and
- Considerations for Transition.
Contact: Darius Kirstein, firstname.lastname@example.org, 518-867-8841