It's Not Your Mother's Case Management Anymore

Presented by Renee Miskimmin, MD, MBA at the Executive Leadership Summit on March 24 - 26, 2015.

In April 2014, Virginia Premier Health Plan welcomed their first dually eligible member under the ACA Financial Alignment Demonstration Project whereby individuals with fully eligible Medicare benefits and Medicaid benefits would be covered by the same entity. While the health plan had 18 years of experience working with complicated Medicaid members, there were a number of new challenges that accompanied these new beneficiaries. Discussion points include:
1. What does a health plan do when there is minimal historical data on a population
2. What were the early lessons learned and how has that changed throughout the past year
3. How has working with this population changed how case management is structured at the health plan

Transcript

1. It’s Not Your Mother’s Case Management Anymore Renee Miskimmin, MD, MBA Chief Medical Officer Virginia Premier Health Plan
2. Background • Virginia Premier (VP) is a non-profit, single state Medicaid HMO • From April - December 2014, 6,000 dual demo members were added • These members have full Medicare and full Medicaid benefits through VP • Membership was assigned to the plan and categorized by the state • Care management stratification has traditionally been done using claims driven software • Plan provides its own non-emergent transportation 2
3. What Did VP Know? • All members are ages 21+ • 20% of members are in a nursing home or are receiving long term support services (LTSS) • “Demographic” information • Data from Medicaid for which members were receiving Targeted Case Management (TCM) for mental health issues • Data from Medicaid for long term supports and nursing home information in the form of authorization data 3
4. What Didn’t We Know? • No data related to inpatient or outpatient care • No pharmacy data • Breakdown of the 80% community well into true well and the vulnerable subpopulation 4
5. Challenges Presented? • Same demographic challenges present in Medicaid are present in duals, even for members receiving services • High expectation that all members will have an assessment done within 30-90 days depending on their complexity • All members must have a CM and that CM follows the member for the life of the demonstration • Learning curve for LTSS providers and plan as this is carved out under straight Medicaid • No PCP information (attribution and contact info) • Claims lag 5
6. How Did CM Change? • Establishing contact • Longitudinal thinking vs episodes • Team coordination vs case log – Vendors – Pharmacy – PCP – Community Agencies • Volume 6
7. Lessons Learned • Try to get Medicare data early • Think about how to leverage your pharmacy data out of the gate • Identify your bad numbers and address early • Build relationships with LTSS and DME providers to obtain better demographic data • Just because someone has Medicare experience does not mean they know duals (people and vendors) • Many unmet needs seen in members receiving services 7
8. Where Are We Now? • Approximately 30% of the community well are in the vulnerable subpopulation • Internal data clean up • External data clean up • Reassessments • HCC coding • Movement of special populations under FFS Medicaid into plans 8
9. Closing • Many unmet needs seen in members receiving services • Members are very thankful and relieved to have someone they can call • Very rewarding to know you are making a difference • Excellent experience as special populations are moving to Medicaid 9
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