To Whom It May Concern: Please find attached Meridian ...

From: To: Subject: Date: Attachments:

Mike Cotton HFS.Webmaster Coordinated Care Program Key Policy Issues Friday, July 01, 2011 10:13:32 AM Meridian Health Plan Coordinated Care RFI Response 7.1.11 Final.pdf Care Coordination Measures Atlas.pdf

To Whom It May Concern:

Please find attached Meridian Health Plan's response to HFS' request for information regarding P.A. 96-1501. Also find a second attachment sent out by the AHRQ as we reference its usefulness in setting up the program in our response. It was our pleasure to respond to this important request and stand ready to be of any service HFS might need when contemplating how best to operationalize the Medicaid program. Have a great holiday and please do not hesitate to contact me with any comments, questions or concerns.

Best Regards,

____________________________ Michael D. Cotton President & COO Meridian Health Plan, Inc. 222 N. LaSalle Street, Suite 930 Chicago, IL 60601

Tel: (312) 980-2336 Fax: (313) 202-0076 Cell: (313) 407-4660 _____________________________

COORDINATED CARE REQUEST FOR INFORMATION JULY 1, 2011

Meridian Health Plan Inc. Coordinated Care RFI July 1, 2011

Table of Contents

The Coordinated Care Program Key Policy Issues ........................................................................................ 3 1. How comprehensive must coordinated care be? ..................................................................................... 5

Meridian Health Plan Response (#1) ...............................................................................................6 Table 1: Framework for Population Management (Adult)................................................................... 9 Table 1: Framework for Population Management (Adult) Continued............................................... 10 Table 2: Framework for Population Management (Children)............................................................ 11 Table 2: Framework for Population Management (Children) Continued .......................................... 12

2. What should be appropriate measures for health care outcomes and evidence-based practices? ...... 13 Meridian Health Plan Response (#2) .............................................................................................13

3. To what extent should electronic information capabilities be required? .............................................. 16 Meridian Health Plan Response (#3) .............................................................................................16

4. What are the risk-based payment arrangements that should be included in care coordination? ........ 18 Meridian Health Plan Response (#4) .............................................................................................18

5. What structural characteristics should be required for new models of coordinated care? .................. 20 Meridian Health Plan Response (#5) .............................................................................................20

6. What should be the requirements for client assignment? ..................................................................... 23 Meridian Health Plan Response (#6) .............................................................................................24

7. How should consumer rights and continuity of care be protected? ...................................................... 29 Meridian Health Plan Response (#7) .............................................................................................30

8. What is your organization's preliminary anticipation of how it might participate in coordinated care? .................................................................................................................................................................... 33

Meridian Health Plan Response (#8) .............................................................................................33 Additional Comments ................................................................................................................................. 35

Meridian Health Plan Response (Additional Comments) ................................................................35 Appendix A ? MHP Contact Information .................................................................................................... 37

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Meridian Health Plan Inc. Coordinated Care RFI July 1, 2011

The Coordinated Care Program Key Policy Issues

The Medicaid reform law adopted by the Illinois General Assembly in 2011, P.A. 96-1501, mandates that 50 percent of all Illinois Medicaid recipients be in coordinated care by January 1, 2015. (Relevant language from this law is attached to this document.) While outlining a general sense of direction for the Medicaid program, the legislation leaves key operational issues to be determined by the Department of Healthcare and Family Services. This paper helps identify some of the issues and seeks public and stakeholder advice on how to implement coordinated care in Illinois.

Initially we are inviting stakeholders to provide written comment in response to the following specific policy questions. Subsequently, we will hold public hearings to discuss the responses, focusing particularly on those areas where there is no consensus.

Please note that "Medicaid" is used in this document to apply to all State comprehensive medical health programs, including the Children's Health Insurance Program and certain related state-funded programs, as enumerated in the legislation.

Please submit your comments electronically to hfs.webmaster@ no later than close of business, July 1. All comments will be posted on the Coordinated Care tab on the HFS website. We will subsequently announce hearings during the summer.

Although the legislation requires at least 50% of all clients to be enrolled in coordinated care by January 1, 2015, there are two important realities that will shape implementation of this policy; and are useful to set the context for the issues in this paper:

About 45% of our current enrollees live in Chicago, another 14% live in Kane, DuPage, Lake and Will counties; and another 10% in a handful of downstate urban counties. The remaining 30% of our clients are scattered over 87 rural counties. While we believe everyone should have coordinated care, it will be difficult to offer the same delivery systems in the 87 rural counties that we offer in the more densely populated areas. Therefore, it will be practical to focus initially on the higher density areas - possibly enrolling materially more than 50% of the clients in these areas to meet the 50% statewide target. The Department will begin enrolling newly eligible Medicaid clients under the Affordable Care Act in the fall of 2013. This means we will have to establish coordinated delivery systems in place prior to the fall of 2013.

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Meridian Health Plan Inc. Coordinated Care RFI July 1, 2011 Below are the specific questions on which we are seeking comments. Comments do not need to address all questions, but as much as possible, all comments should respond to specific questions. Since many of the issues are interconnected, there may be multiple ways of arranging responses. Issues for comment are organized as follows: How comprehensive must coordinated care be? What should be appropriate measures for health care outcomes and evidence-based practices? To what extent should electronic information capabilities be required? What are the risk-based payment arrangements that should be included in care coordination? What structural characteristics should be required for new models of coordinated care? What should be the requirements for client assignment? How should consumer rights and continuity of care be protected? What is your organization's preliminary anticipation of how it might participate in coordinated care?

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Meridian Health Plan Inc. Coordinated Care RFI July 1, 2011

1. How comprehensive must coordinated care be?

The legislation is clear that to meet the definition of coordinated care, an entity must provide or arrange for the "majority of care", including a patient-centered medical home with a primary care physician, referrals from the primary care physician, diagnostic and treatment services, behavioral health services, inpatient and outpatient hospital services, and when appropriate, rehabilitation and long-term care services. The law also requires arrangements where the State pays for performance related to health care outcomes, the use of evidence-based practices, the use of electronic medical records, and the appropriate exchange of health information electronically.

This comprehensive definition does not contemplate coordinated care coverage for specific diseases, such as management of asthma or diabetes. It does not preclude, however, organizations that offer comprehensive services or care management tailored to people with specific diseases or conditions working with other entities serving a broader population. In addition, medical homes will be required components of coordinated care, but by themselves will not be sufficient to meet the requirement for accepting responsibility over all services.

Coordinated care in Illinois is contemplated to include a wider range of potential arrangements than traditional, fully capitated managed care. Coordinated care entities could be organized by hospitals, physician groups, FQHCs or social service organizations. While the Department would like to test these new models, we need to determine the current level of interest and capacity to offer these comprehensive, risk-based services through the Medicaid Program.

Questions for Comment

a) Do you think that coordinated care should require contracts with specific entities that arrange care for the entire range of services available to a client via Medicaid, across multiple settings and providers? Are there any alternatives you would recommend for consideration?

b) Must all of these elements be required in any entity accepting a contract, or just some elements? Might these change over time, i.e. start with a base set of requirements and gradually increase over time?

c) Medical homes are generally considered the hub for coordinated care. How should the existence of a "medical home" be operationalized? Would existence of a medical home require NCQA certification? Would all primary care physicians be required to be in practices that meet these requirements? What requirements are essential for every practice? Presumably it would be possible to increase requirements over time. What progression would make most sense?

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Meridian Health Plan Inc. Coordinated Care RFI July 1, 2011

d) How explicit should requirements be about how an entity achieves coordinated care? For instance, should the care coordination entity be required to assign an integrator or care coordinator to each enrollee?

e) Where, if at all, should HFS provide some kind of umbrella coverage for entities, e.g. negotiate a master pharmaceutical contract that would be available to all coordinated care entities?

f) What incentives could be offered to enlist a wide range of providers, in key service areas, to join coordinated care networks?

Meridian Health Plan Response (#1) For the best outcomes in care and quality, all health care providers should be engaged contractually. If the Department plans to contract with Coordinated Care Entities (CCEs), those entities should have the ability to meet financial risk and quality expectations. Contracted CCEs should also have networks in place to arrange services across the entire spectrum of care covering all Medicaid benefits. The CCE would serve as a hub, overseeing the coordination of care across a range of services and providers.

The goal of Coordinated Care Programs is to derive a client-centered service plan that meets all the needs of the enrolled population. Full coordination of care should encompass the services of facilities and healthcare providers across multiple settings. This inclusive effort provides consistency and reliability, assists in the establishment of a medical home, reduces confusion as to who covers what services, and allows for the continuous monitoring of healthcare services to meet enrollee needs. Specific programs could be included within a CCE for the aged, blind and disabled, children with special health care needs, adults that are developmentally disabled, or chronically mentally ill.

To be clear, CCE contracts should not be offered to individual practices, clinics, or entities that directly provide a service and do not coordinate/arrange services outside of their scope for the recipient. This type of fragmentation would lead to waste in the system and less than optimal health outcomes.

At a minimum, the CCE should provide certain basic elements in order to deliver the best, most efficient care possible: primary care physician, referrals from the primary care physician, diagnostic and treatment services, behavioral health services, inpatient and outpatient hospital services. Specifically, the CCE should offer:

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Meridian Health Plan Inc. Coordinated Care RFI July 1, 2011

Self-management support ? Providing information to patients, teaching disease-specific skills, training patients in problem solving, assisting in emotional impact of chronic disease, providing regular follow up and encouraging patient participation. Care management ? Implementing a registry or predictive model for population identification and patient management, as well as collaborative practice models. Community linkages ? Identifying local resources, collaborating with ISD, AAA, housing and transportation agencies. Information systems ? Developing integrated electronic information systems for patient information, labs, imaging, referrals, meds, social and community services, patient registries, etc. Secure transitions of care ? Providing all pertinent communication, including follow-up tests, changes in the plan of care, medication reconciliation, etc.

With these elements in place, enrollee care can be coordinated in a comprehensive and meaningful way.

All of these elements should be required in order to fully coordinate enrollee care in a comprehensive and meaningful way. As Coordinated Care Programs continue to progress, participating providers would be expected to meet standards and requirements as they are updated. Certain elements may be added over time, such as long-term care or pharmacy.

Restricting the benefits that are offered or not supporting the collaboration of access across all paths of care would be counterproductive to the goal of coordinated care. An effective CCE will offer enrollees with complex medical concerns the necessary tools to move from high risk categories of care to moderate or even low risk categories.

Entities can achieve care coordination a variety of ways, however, the benchmarks to measure coordination and health outcomes should be clearly defined for all participants.

The CCE network should have the ability to provide comprehensive services, as well as the ability to provide outreach to all enrollees, and case management or coordinators for all enrollees who request them. There should be a requirement for making a certain amount of calls to recipients when they first enroll, and then regular, ongoing contact to keep in touch and provide health education.

Enrollees in the Coordinated Care Program should be assigned to a "Patient Centered Medical Home" (PCMH) where their Primary Care Providers (PCPs) can guide them through the healthcare system. PCPs will help coordinate and implement the individualized care plans that enrollees may need. This will provide ongoing, systematic efforts to monitor the

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