People who are dually eligible for Medicare and Medicaid often have complex needs that are not met in fragmented, uncoordinated systems of care. Ohio’s solution to this problem has been to work with the Centers for Medicare & Medicaid Services and health plan partners to implement a capitated model demonstration, MyCare Ohio, through the Financial Alignment Initiative. With more than 80,000 enrollees, MyCare Ohio is the second-largest of 10 Medicare-Medicaid capitated demonstrations in the nation. By comparison, California’s demonstration has 115,697 enrollees, and other demonstrations enrolled between 1,000 and 54,000 beneficiaries. Through the support of the West Health Policy Center, the Center for Health Care Strategies looks at unique features of the demonstration and lessons to help inform other states.
Impetus for Pursuing a Financial Alignment Initiative Demonstration
Ohio pursued a capitated financial alignment model because it offered the highest potential for comprehensive Medicare and Medicaid integration. This program alignment was key to achieving the state’s goal of providing seamless access to Medicare and Medicaid services in an integrated, person-centered delivery system that was easy for both providers and beneficiaries to navigate. Blended financing also provided incentives for participating plans to transition individuals from institutions into the community.
Key elements of MyCare Ohio include:
- Eligibility and enrollment. Dually eligible individuals age 18 and older who live in seven regions of the state can choose whether or not to enroll in the demonstration to receive their Medicare-covered services. However, a major design element — and possibly a factor in MyCare Ohio’s success — is that the state requires eligible people who receive Medicaid-covered long-term services and supports (LTSS) to enroll in a MyCare Ohio health plan to receive these services. In addition to the 80,000 dually eligible beneficiaries in the demonstration who receive Medicare and Medicaid services from MyCare Ohio plans, approximately 33,000 dually eligible beneficiaries, who chose not to enroll in the demonstration, receive Medicaid-covered LTSS benefits through MyCare Ohio.
- Care management. The demonstration’s care management model is based on a population health approach. A MyCare Ohio care manager provides a single point of contact for both the enrollee and a care team that may include primary care providers, behavioral health providers, a waiver service coordinator for individuals using home- and community-based services (HCBS), and other members chosen by the enrollee, including family members, caregivers, and other specialists.
- Community-based partnerships. Ohio required MyCare Ohio plans to work with Area Agencies on Aging (AAAs) on HCBS care management. AAAs in the state are responsible for coordinating all HCBS waiver services for beneficiaries 60 and older. Ohio wanted to maintain the AAAs’ solid, long-standing relationships with beneficiaries and providers; their required inclusion in the demonstration is seen as a positive by plans and other stakeholders.
Last June, Ohio released its MyCare Ohio 2018 Evaluation Report. The state identified several achievements since the demonstration’s launch, including:
- Robust beneficiary participation. Ohio reports that about 70 percent of those who were eligible chose to enroll into MyCare Ohio, which is the highest “opt-in” rate of all financial alignment demonstrations nationally.
- Innovative practices from MyCare Ohio plans. All plans offer value-added services in addition to required benefits, such as incentives for flu shots and wellness visits, and other social supports. The state has also collected numerous anecdotal success stories from beneficiaries that reflect high satisfaction with the plans’ willingness to support members in their homes and the value they find in having care managers coordinate all their benefits and services.
- Positive performance measure results. Results on more than half of reported Health Effectiveness Data and Information Sets (HEDIS) measures exceeded the 90th percentile national Medicaid benchmark. MyCare Ohio plans also saw improvements in Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) results between 2016 and 2017.
- Shift in services to the community from institutional settings. From 2015 to 2017, MyCare Ohio achieved a two percent increase in the number of enrollees transitioning from nursing facilities to the community as compared to the traditional fee-for-service Medicaid program. Ohio estimates that it will save $30 million annually by shifting individuals from high-cost settings to more cost-effective, person-centered, and community-based settings.
Challenges and Lessons
While MyCare Ohio has achieved several successes, the state acknowledges that it learned from the challenges it faced in launching the demonstration related to: timing, stakeholder engagement, and contract requirements. The state’s work to mitigate these issues provides lessons for other states.
First, the three-month timeline the state set to transition individuals into MyCare Ohio from its fee-for-service Medicaid program was fast. Additional time for transition could have been allowed for troubleshooting service issues for beneficiaries, addressing systems improvements, and ensuring plan readiness, but did not disrupt the ultimate success of the program.
Take-away: Other states might consider a transition period of no less than six months and a phased-in approach by region or population when switching from a fee-for-service to a managed care delivery system.
Ohio prioritized robust stakeholder engagement as critically important to launching a managed, integrated model, and conducted outreach to a broad array of stakeholders, including MyCare Ohio plans, providers, and beneficiaries in design and implementation activities. The state refined its engagement approach on an ongoing basis as it learned about new ways to educate and work with different stakeholder groups. State staff reported that it is particularly important to ensure that beneficiaries understand how programs work and that participating providers understand their obligations. Ohio worked with plans to provide additional training for smaller LTSS providers to get them up-to-speed on managed care business and billing practices. This was crucial to ensure that they were submitting the right information to get paid in a timely fashion.
Take-away: The more stakeholder engagement, the better.
Over time Ohio made changes to contract requirements, refining its approach after learning what worked well and what changes were needed to improve the demonstration. For example, in response to plan and beneficiary feedback, the state provided MyCare Ohio plans with more flexibility on certain care management requirements, giving plans more latitude to: (a) determine how frequently to contact some members; and (b) use clinical judgement in designing more individualized care approaches for each beneficiary. Additionally, to address concerns that providers were not being paid in a timely manner, Ohio made changes to prompt pay requirements, requiring plans to report out payments by provider type (e.g., nursing facility; behavioral health; hospice; and waiver services). This new reporting approach allowed the state to identify and address specific payment issues.
Take-away: States need to be willing to continuously refine integrated programs to best meet beneficiary and provider needs.
The MyCare demonstration in Ohio is successfully attracting and retaining enrollees at a rate surpassing all comparable programs across the country and providing high-quality integrated care to dually eligible beneficiaries. Elements of the demonstration’s design and Ohio’s experiences in its implementation provide valuable lessons for other states integrating the care of their dually eligible populations.