Acute, long-term care providers team up to manage Minnesotas dual eligibles
Minnesota Long Term Care
December 31, 1997
Minnesota's waiver program to integrate and capitate acute and long-term care for Medicare/Medicaid dual eligibles has already succeeded in at least one important respect— creating incentives for acute and long-term care providers to work together to manage patients across settings of care.
While there are no hard data yet on cost-savings or improved care management, each of the three participating plans, Medica, Metropolitan Health Plan (MHP), and UCare Minnesota have forged separate arrangements with provider networks and community-based service providers.
"There used to be little interest among providers in working together across the continuum, or in serving the institutionalized population," said Steve Heil, manager of dual eligible programs for Medica, a division of Allina Health System in Minneapolis.
"Long-term care has been at the bottom of the food chain all along, but now is on an equal level with other provider types." It is refreshing, he said, "to have providers work together and make decisions based on what's best for members and not make those decisions based on who's paying them,"
Community-based service providers such as Hennepin County Coordinated Home Services, say the collaborative effort required under the Minnesota Senior Health Options (MSHO) program is working in part because the plans have shown respect for the local groups. "They haven't run roughshod over us," said Todd Munson, division manager for Hennepin County Coordinated Home Services. The group works both with MHP and UCare to coordinate a range of services, including housing, Meals on Wheels and adult day care.
There have been some early disappointments, however, most notably the relatively low enrollment numbers. One of the plans, Medica, accounts for 1,500 of the 2,000 enrollees in MSHO. In contrast, UCare, which made a large investment in reconfiguring its MIS systems, has only 279 enrollees.
"MSHO sounds marvelous," said Jennifer Clelland, UCare’s director of government programs. "We can do the right thing and be creative, but we still really need to follow Medicare and Medicaid rules for some things, such as doing Medicare charting for enrollees in nursing homes. It "has been a heck of an investment for a small number of people,"
Hard to reach responsible party
The plans say part of the difficulty in enrolling dual eligibles is due to the large number of dual-eligibles with cognitive impairment. "We didn't anticipate the large number of institutionalized enrollees," said Mr. Heil of Medica. "A large number of those have some level of incompetence. It's difficult to track down the responsible party."
The plans say dealing with cultural diversity among the MSHO population has been a challenge as well since the plans must ensure access to interpreters who can help assess health status and confirm eligibility.
A UCare spokesman noted one other challenge: patients in nursing homes may not see the need to switch to MSHO, given that they often have a nurse in charge of their care, and don’t need to to deal with paperwork themselves.
Pamela Parker, manager of the MSHO program for the state, acknowledges concern about the low numbers in the program, but said she hopes to boost enrollment in the five-year program to 4,000 dual eligibles. The potential universe of enrollees in the seven-county Twin Cities region covered by the program is about 48,000.
One significant change in the program's initial design is that enrollees are not allowed to go out of network for Medicare services, a concession that pleased the plans.
Each of the participating plans has taken a somewhat different approach to coordinating services with provider networks and community-based service providers.
MHP, an HMO operating under the auspices of Hennepin County for those on public assistance, has always had elderly Medicaid enrollees. To meet the different levels of need of its dual-eligible enrollees, MHP decided to case-manage low-risk patients internally, and contract out case- management responsibilities for higher risk patients.
Hennepin County Coordinated Home Services, an offshoot of the county's public health and social services departments, case-manages those who are at risk for nursing home admission, but who can stay in the community with proper support services. Optage, a consortium of nursing home providers, case-manages enrollees in nursing homes. Under the MSHO program, plans are at risk for the first 180 days of nursing home care, so there is a strong incentive to keep patients in the community or move them out of nursing homes quickly, if feasible.
So far, "the payoffs for us have been multiple," said Joan Delich who helped to negotiate the contract for MHP. "Even if the program were to go away tomorrow, we have forged working relationships with other arms of the county to serve the senior population."
Medica had head start
Medica already had risk contracts with both Medicare and Medicaid and, according to Mr. Heil, in partial response to Medica's efforts, "care systems" began to develop that would eventually become partners with Medica when it began to enroll dual eligibles into MSHO. Medica contracts with three care systems, Evercare, Optage, and Fairview Partners, to coordinate or provide all services to MSHO enrollees on a capitated basis.
Optage, in turn, contracts with other providers for acute and community-based services. Fairview Partners is a joint venture of 14 nursing homes, three hospitals and a large physician group. Evercare is primary care clinic "without walls" that takes primary care to patients primarily in long-term care and assisted living settings. MSHO enrollees in Medica choose one of these three care systems.
UCare is an affiliation of hospitals and primary care clinics that contracts with nursing homes and community-based providers. MSHO enrollees can sign up with one of two clinic systems, Health East or the Wilder Foundation. Both have contractual relationships with nursing homes. Every party is at equal risk in the partnerships, said Ms. Clelland. Each enrollee has a care coordinator and is categorized according to his or her level of need—low, medium, or high.
Capitation on a small scale
In addition to the benefits of collaboration, community-based service providers say there have been other pluses as well, such as the opportunity to experiment with capitation on a small scale. Mr. Munson of Hennepin County Coordinated Home Services, which is paid on a capitated basis by UCare, said it has been an important learning experience. "Capitation is new to us but, because it is a small bit of our business, it can be a small learning laboratory," he said.
Overall, said Ms. Parker, she is encouraged with the way the marketplace has evolved to serve this population. MSHO was not the entire impetus behind the change, she said. "These care systems evolved anyway, and positioned the market way better than it had been. There have been some very out-front provider groups. It takes time for the market to come to this point."
Iris Freeman, executive director of the Advocacy Center for Long Term Care, takes an even more cautious stance. She said she knows of no consumer complaints and that anecdotal evidence suggests consumers are receiving the personal attention critical to making the program work. But, "it’s hard to be excited or disappointed about anything at this point," she said.
"One of the things I’m curious about is that it’s human nature at the start-up to pay extra special attention to new enrollees. As enrollment increases, everyone might not have the benefit of the same individual attention and care."
—Jana Sansbury
Contact Mr. Heil at 612-992-3546, Ms. Delich at 612-347-5050, Mr. Munson at 612-348-4464, Ms. Clelland, at 612-603-5379, Ms. Parker at 612- 296-2140.
Acute, long-term care providers team up to manage Minnesotas dual eligibles
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