Minnesota Disability Health Options: A Voluntary Managed Care Program for Persons with Physical Disabilities

Sue Bulger, RN, MA; Director of Health Coordination, AXIS Healthcare

About AXIS Healthcare

A joint venture ofCourage Center and Sister Kenny Institute,bringing the knowledge of disability to managed care.

Our Vision:

• AXIS envisions a time when all people, regardless of ability, will have the health care service and support needed for lives they find meaningful and productive.

Our Strategy:

• To work in partnership with persons with physical disabilities, as well as their key providers and payors, to address their needs by coordinating a high-quality, cost effective network of specialized services, spanning the continuum of care and support.

About AXIS Healthcare

AXIS was created by physical disability providers as a response to traditional managed care strategies to limit utilization

• Sister Kenny Rehabilitation Services
  • Acute rehabilitation institute, founded in 1952
  • Operates inpatient units at 2 Acute Care Hospitals
  • Physiatry practice of 10+ Physiatrists
  • Inpatient programs and outpatient clinics serving 8,000 annually
• Courage Center
  • Comprehensive rehabilitation agency, founded in 1928
  • Operates 64-bed transitional facility; with multiple outpatient sites
  • Vocational, educational, recreational, camping and independent living programs
  • Serves over 18,000 annually

The Mission of AXIS Healthcare is to provide the best care at the right time in the least restrictive setting in the most cost-effective manner so that people with disabilities live healthy lives

Four Key Objectives:

1. Improve consumer quality of care
2. Promote consumer direction and autonomy
3. Increase consumer satisfaction with the health care delivery system
4. Contain escalating health care costs

Development of the AXIS Model

What Consumers say they need:

• “Someone knowledgeable and experienced to help me navigate the health care system”
• “One person who will coordinate all the rest of my doctors”
• “Access to the best providers”
• “Competent services provided in my home and local community”
• “Access to what I need without having to justify every single service”
• “Respect for me in knowing what I need”

What Payors say they need:

• “Health care costs must be controlled – the public is no longer willing to accept double-digit inflation”
• “New and flexible service delivery models, developed by experienced, quality providers”
• “This population must be carved out of the general population, with a rate setting methodology sensitive to individual needs”
• “Intensive care management by highly experienced nurses and social workers with practical knowledge of home and community-based resources”

What Providers say they need:

• “One person to call for all authorizations”
• “Help in addressing systemic issues facing our consumers”
• “Integrated funding streams to minimize conflicts and cost shifting”
• “Freedom from the rules and regulations of the fee-for-service system, to reduce administrative costs and other inefficiencies”
• “Payor case managers who know and understand the health care needs of persons with disabilities”

The Current Health Care Delivery System (D-link)

The Current Healthcare System....

...there must be a better way

Learning from Other Projects: Wisconsin Partnership

Model:

• 6 individual projects scattered throughout WI, operating collaboratively under direction of WI HHS
• All sites serve elderly, 2 of the sites enroll <65 with physical disabilities
  Integrated MA and Medicare capitation with PACE adjuster

Lessons learned:

• Enrollment is slow and sporadic, requires multiple visits/calls with potential member
• Difficult for staff to learn to incorporate cost considerations into clinical decisions
• Difficult to consistently listen to member preferences, and ensure freedom to make informed decisions

Learning from Other Projects: Discontinued MN Demonstration Initiatives

In 1985, MN MA began mandatory enrollment of persons with disabilities in managed care. The initiative was discontinued within the first year due to withdrawal of contractors and a range of problems resulting from the complexity of serving this population

In the late 1990’s, MA planned for a mandatory, county-based managed care program. The demonstration was never implemented due to:

• Concerns about financial viability
• Conflicts between the multiple levels of government, and resistance from advocates and consumers
• Due to mandatory enrollment, the consumer expectations and protections were viewed by many stakeholders as onerous

The AXIS Model (D-link)

Consumer Involvement (D-link)

Uniqueness of the AXIS Model

• Specialty provider CMO (AXIS) – health plan (UCare) partnership
• Responsible for member needs across the entire continuum of health care services and supports
• Integrates Medicaid and Medicare benefits
• Extensive consumer and advocate involvement in project development and on-going evaluation/refinement
• Physical disability sensitive risk-adjustment methodology
• Limited PCP network

Project Partners

Minnesota Disability Health Options for people with physical disabilities

Minnesota Department of Human Services:

• State Medicaid Office
• Manages Waivers, including MnDHO
• Contracts with Health Plans for Managed Care Projects

UCare Minnesota:

• Medicaid and Medicare + Choice Plan
• 90,000+ members
• Sole MnDHO Plan
• Contracts with disability CMO, providers

AXIS Healthcare:

• Provider-sponsored CMO
• Created to demonstrate new model of Managed Care
• Primary link to disability community
• Experiences with H&CB services and key providers

Minnesota Disability Health Options (D-link)

Development of the Provider Network

Objective of the Network:

• To have a comprehensive network of preferred providers experienced in serving persons with physical disabilities, spanning the continuum from acute and primary care, home and community-based care and mental health services

Planned Composition

• Small Primary Care Clinic network
• Acute care hospitals, based on the utilization pattern of the specialty physicians
• Transitional, short-term stay, and Long Term Care settings
• Multiple choices for Home & Community-based Services
• Mental Health providers experienced with the relationship between physical disability and mental health, including behavior management

Identification Process:

• Interviews with staff from owner organizations
• Identification of referral preferences of primary care physicians
• Consumer experiences and preferences obtained through focus groups, individual interviews and Consumer Workgroup
• Tracking provider utilization by participants in the pilot health coordination projects
• Review of existing county-based waiver provider contracts
• Providers who have expressed interest in the AXIS model, and have come forward with creative service delivery ideas

Current Network Composition:

• 5 primary care clinics; 1 with extensive experience with the population; 3 joining due to mission focus
• Access to any UCare-contracted specialist, making a very broad network
• County-based hospital and providers not participating due to perception of competition
• Numerous Home & Community-Based providers, many contracted based upon request of individual member
• Carved-out network for dental, chiropractic, and mental health; existing dental and mental health network expanded specifically for the population

AXIS Model: Pilot Project

Purpose

• To develop, apply and refine the AXIS model
• To build stakeholder understanding and involvement in the project
• To build relationships with potential members and participating providers
• Develop and test internal communications and management policies and procedures

Key Learnings:

• The system is more dysfunctional than originally perceived
• Roles and responsibilities need to be developed and defined
• All stakeholders are fearful and resistant to change

Demonstrating the Model: Joe

Situation: 45 year old man with SCI since his teens; Living independently

Presenting situation:

• Recently diagnosed with cancer
• Skin breakdown subsequent to bedrest during treatment
• Conflicting recommendations between oncology & plastic surgery
• Subsequently readmitted, demonstrated disorientation

AXIS intervention:

• Facilitated communication between specialists
• Established interim plan, with supports and equipment
• Evaluated cognitive status and medication effects with SCI
• Arranged referral to hospice and discharge home

Demonstrating the Model: Keith

Situation: 50 yr. old man with quadriplegia; living independently

Presenting situation:

• Currently receiving only PCA services
• History of 2 flap surgeries for pressure ulcers
• Broke leg, resulting in lengthy ER wait with subsequent skin breakdown with hlebitis a few days later

AXIS intervention:

• Assessment of skin, temporarily increased PCA time
• Assessed ER wait times and arranged for same-day PCP appointment

Experience to Date

• 54 members, (out of 24,000 eligibles)
• 59% dual eligible (38% of eligibles)
• Age distribution:
  • 13% age under 30
  • 22% age 30-39
  • 41% age 40-49
  • 17% age 50-59
  • 4% age 60+
• 22% residing in nursing facilities (4.3% of eligibles)
• 74% Nursing Home Certifiable (10.7% of eligibles)
• 39% functionally-quadriplegic; 28% paraplegic
• Primary Diagnoses include:
  • 28% Spinal Cord Injury
  • 20 Cerebral Palsy
  • 11% Traumatic Brain Injury
  • 13% Multiple Sclerosis
  • 6% CVA
  • 4% each of Spina Bifida, Blindness, Diabetes
• Secondary Diagnoses include:
  • 48% depression
  • 22% current skin breakdown or pressure ulcer
  • 33% history of skin ulcers
  • 33% constipation
  • 20% hypertension
  • 15% Baclofen pump
  • 17% chronic pain
  • 13% sleep disorder

MnDHO Evaluation

Evaluation goals:

1. To assess the satisfaction of members, the health plan, providers and purchasers
2. To assess the overall health and well being of members
3. To assess the financial viability of the rate setting methodology

Evaluation tools:

1. CAHPS-based longitudinal pre & post survey
2. Self-determination longitudinal pre & post survey
3. Structured focus groups for qualitative information
4. Comparable surveys with control group of MA recipients on FFS
5. Clinical and encounter data

Evaluation Consortium:

• Center for Health & Disability Research, National Rehabilitation Hospital, Washington, D.C.
• Institute for Community Integration, University of Minnesota
• Department of Human Services (State Medicaid Agency)
• UCare Minnesota
• AXIS Healthcare
• Courage Center

Key Challenges: Partnering with Health Plan

• Identifying a health plan willing and able to partner in serving a population largely unknown to managed care
• Clarifying roles, responsibilities and communication channels, both internally and with other stakeholders
• Learning to understand and trust the competencies of each other

Key Challenges: Enrollment

• Extensive consumer education and problem solving systemic issues
• Lengthy assessment
• Establishing potential member confidence in the managed care model – though frustrated by the existing FFS, the unknown of managed care is even more frightening for many
• Limited avenues and slow process for marketing

Key Challenges: PCP Interest and Commitment

• “I see enough of those people”
• Initially engaged individual doctors in the model – using them to obtain clinic commitment
• Identifying lead physician within each PCC
• Create centers of expertise within PCC provider community, instead of further burdening the few existing PCPs with experience

Key Challenges: Adequacy of rate-setting methodology

• DHS created highly sensitive rate setting methodology
• Need to tie flexibility with accountability, both within this project and in the existing waiver programs
• Are the rate cell definitions adequately identifying and assigning rates to the subpopulation of the eligible individuals who choose to enroll?

Go to: Final Summary | Disability Conference | Provider Reimbursement | HRSA | HHS