Amendment #719 to H3400

MassHealth Chronic Care Management

[Sponsors] Representatives Sanchez of Boston, Mr. Mahoney of Worcester, Devers of Lawrence, Smizik of Brookline, and Cantwell of Marshfield move to amend the bill by adding the following 2 sections: -

“Section XX.  (a)Notwithstanding any general or special law to the contrary, the office of Medicaid, subject to appropriation and the availability of federal financial participation, and in consultation with the MassHealth payment policy advisory board, shall establish a chronic care improvement demonstration project focused on improving care for high-cost, high utilization beneficiaries.  Within the chronic care improvement demonstration, the office shall solicit the participation of physician group practices, hospitals, or integrated delivery systems which meet the terms, conditions, and eligibility standards for participations in subsection (c) and (d) to provide practice-based care management to high-cost beneficiaries with multiple chronic illnesses through the utilization of nurse case managers integrated into physician-based primary care practices.

(b) The office shall establish a method for identifying eligible beneficiaries who may benefit from participation in a chronic care improvement program, provided, that beneficiaries shall have a high level of disease severity as indicated by Hierarchical Condition Categories scores and high health care costs and utilization of services based on claims data from the calendar year prior to enrollment in the project.  The office shall utilize a population-based intent-to-treat model to enroll eligible beneficiaries into control and treatment populations. Beneficiary participation will be voluntary, and may terminate participation at any time.  Beneficiary participation will not change the amount, duration or scope of a participating beneficiary’s traditional benefits.  Eligible beneficiaries shall not be charged an additional fee for participation in chronic care improvement program.

(c) The office shall enter into three-year contracts with selected physician group practices, hospitals, or integrated delivery systems (participants) that provide for the payment of care to eligible beneficiaries utilizing a fee-at-risk payment methodology that includes a negotiated per-beneficiary-per-month management fee and pay-for-performance payments based on quality measures as determined by the office.  In addition to terms and conditions deemed necessary by the office, all contracts shall require selected participants to (i) achieve a minimum 2 percent net savings in MassHealth costs for the treatment population as compared to the MassHealth costs for the control group plus the sum total of beneficiary-per-month management fees and pay-for-performance payments (ii) provide for adjustments in payment rates to a participant insofar as the office determines that the participant failed to meet the performance standards specified in the contract (iii) monitor and report to the office, in a manner specified by the office, on health care quality, cost, utilization of services, and outcomes (iv) meet the eligibility standards for participations in subsection (d).

(d)  (1) To be eligible to submit a request for participation in the chronic care improvement demonstration project, a physician group practice, hospital, or integrated delivery system must demonstrate to the office that it possesses sufficient resources to (i) provide an enhanced level of care to eligible beneficiaries to reduce cost as well as improve quality of care and quality of life for those beneficiaries (ii) execute a process to screen each eligible beneficiary for conditions other than those required for inclusion in the demonstration such as impaired cognitive ability and co-morbidities, for the purposes of developing an individualized, goal oriented care management plan (iii) incorporate decision-support tools such as evidence-based practice guidelines or other criteria as determined by the office (iv) incorporate health information and clinical monitoring technologies that enable beneficiary guidance through the exchange of pertinent clinical information, such as vital signs, symptomatic information, and health self-assessment and permit the participant to track and monitor each eligible beneficiaries across settings and to evaluate outcomes (v) designate a nurse case manager as the primary point of contact responsible for communications with the eligible beneficiary and for facilitating communication with other health care providers under the projects (vi) meet any other standard for participation as determined by the office.

(2) To be eligible to submit a request for participation in the chronic care improvement demonstration project, a physician group practice, hospital, or integrated delivery system must employ a delivery practice model that encourages the development of a one-on-one relationship between patients and their practice-based nurse case managers, supplemented by support received from dedicated mental health, pharmacist, and end-of-life components mental health, pharmacy, community resource, end-of-life and financial service components, data analytics care team members.  Each nurse case manager shall be located in a physician practice case managers, conduct comprehensive assessments to evaluate the unique needs of each patient, collaborate with physicians and the practice’s clinical team to develop treatment plans, facilitate the coordination of patient care across the continuum of health care services, educate patients about options for medical treatment and support services, facilitate patient access to services, support patient self-management of medical conditions, conduct visits to patient homes on an as-needed basis, and perform other functions deemed necessary to achieve successful health outcomes under the program.  The panel of beneficiaries assigned to a nurse case manager shall not exceed 200.

(e) The office shall conduct an annual project evaluation including documentation of (i) cost savings achieved through implementation (ii) improved clinical and quality outcomes, including reductions of preventable hospitalizations, emergency department visits, and by reducing mortality rates, and (iii) beneficiary and provider satisfaction.  The office shall submit a report of the evaluation to the senate and house chairs of the joint committee on health care financing and the chairs of the senate and house committees on ways and means.

(f) The office shall, in consult with the Massachusetts General Physicians Organization Care Management Program at Massachusetts General Hospital, promulgate regulations for the phase-in and implementation and evaluation of this demonstration project.

Section XX.  (a) Notwithstanding any general or special law to the contrary, the office of Medicaid, subject to appropriation and the availability of federal financial participation, and in consultation with the MassHealth payment policy advisory board, shall establish a disability care management demonstration project for dual eligible beneficiaries with involved physical disabilities.  Within the disability care management demonstration, the office shall solicit the participation of provider organizations and entities that meet the terms, conditions, and eligibility standards for participation in subsection (c) and (d) to provide integrated primary, acute, behavioral health, and long-term care services and supports through disability-competent, multidisciplinary primary care team models consisting of physicians, nurse practitioners, nurses, social workers, physical therapists and durable medical equipment coordinators.

(b) The office shall establish a method for identifying eligible beneficiaries who may benefit from participation in a disability care management program, including (i) beneficiaries with significant physical disabilities due to (A) cerebral palsy, (B) spinal cord injuries, (C ) degenerative neurological illnesses, (D) developmental disabilities, and  (E) cerebrovascular accidents and  traumatic brain injuries; (ii) meet Medicaid “Nursing Home Certifiable” standards, and; (iii) incur predictable and continuous high costs for medical and long term care.

Beneficiary participation will be voluntary, and beneficiaries may terminate participation at any time.  Beneficiary participation will not change the amount, duration or scope of a participating beneficiary’s traditional benefits.  Eligible beneficiaries shall not be charged an additional fee for participation in chronic care improvement program.

(c) The office shall enter into three-year contracts with selected eligible entities and providers (participants) that provide for the payment of care to eligible beneficiaries utilizing a prepaid global payment methodology that includes a prospective patient-centered DxCG risk adjusted payment for all medical services and a consolidated payment for community based and institutional long-term care services based on the cost of such services to a similar beneficiaries in Medicaid fee for service and primary care clinician programs.  The office shall design a shared savings provision within the global payment that provides incentives to participants that meet performance standards related to quality, efficiency, and care coordination. The office shall ensure that the global payments account for appropriate risk-adjustments for the beneficiary population. In addition to terms and conditions deemed necessary by the office, all contracts shall (i) provide for adjustments in payment rates to a participant insofar as the office determines that the participant failed to meet the performance standards specified in the contract (ii) require selected participants monitor and report to the office, in a manner specified by the office, on health care quality, cost, utilization of services, and outcomes (iii) require selected participants to meet the eligibility standards for participations in subsection(d).

(d)  To be eligible to submit a request for participation in the disability care management demonstration project, a provider organization or entity must demonstrate to the office that it possesses sufficient resources to (i) provide an enhanced level of care to eligible beneficiaries that promotes improved health outcomes and living with dignity and independence to the greatest extent possible for those beneficiaries (ii) to deliver care through a goal-oriented, culturally competent, multi-disciplinary team approach based on a collaborative relationship among the beneficiary, the beneficiary’s family members or other caregivers at the beneficiary’s discretion, primary care providers, and care coordinators (iii) develop, execute, and monitor individualized and disability-specific comprehensive care assessments, care planning, self-management coaching or other criteria as determined by the office (iv) incorporate health information and clinical monitoring technologies that (A) enable beneficiary guidance through the exchange of pertinent clinical information (B)  permit the participant to track and monitor each eligible beneficiaries across settings (C) evaluate clinical outcomes, and (D) rapidly respond to immediate clinical needs in home and community-based care settings  (v) demonstrate sufficient clinical, administrative, and financial integration to (A) deliver or manage all covered health and support services for each beneficiary (B) simplify and streamline both administrative procedures for both providers and beneficiaries (C) manage risk-adjusted global payments, and (D) bear financial risks associated with the complete operational responsibility for the care of enrolled beneficiaries (vi) meet any other standard for participation as determined by the office.

(e) The office shall conduct an annual project evaluation including documentation of (i) cost savings achieved through implementation (ii) improved clinical and quality outcomes, including reductions of preventable hospitalizations, readmissions, emergency department visits, and disability specific quality measures such as pressure sore incidence and functional measures, and (iii) beneficiary and provider satisfaction.  The office shall submit a report of the evaluation to the senate and house chairs of the joint committee on health care financing and the chairs of the senate and house committees on ways and means.

(f) The office shall, in consult with the Commonwealth Care Alliance, Inc., promulgate regulations for the phase-in and implementation and evaluation of this demonstration project.