Examining Medicaid Managed Long-Term Service and Support Programs: Key Issues to Consider

Examines key considerations for states in shifting to Medicaid managed long-term services and support programs, including limited evidence of cost savings and issues for program design, the role of community-based organizations, and state oversight

N.C. Medicaid Reform: A Bipartisan Path Forward

The North Carolina Medicaid program currently constitutes 32% of the state budget and provides insurance coverage to 18% of the state’s population. At the same time, 13% of North Carolinians remain uninsured, and even among the insured, significant health disparities persist across income, geography, education, and race. The Duke University Bass Connections Medicaid Reform project gathered to consider how North Carolina could use its limited Medicaid dollars more effectively to reduce the incidence of poor health, improve access to healthcare, and reduce budgetary pressures on the state’s taxpayers. This report is submitted to North Carolina’s policymakers and citizens. It assesses the current Medicaid landscape in North Carolina, and it offers recommendations to North Carolina policymakers concerning: (1) the construction of Medicaid Managed Care markets, (2) the potential and dangers of instituting consumer-driven financial incentives in Medicaid benefits, (3) special hotspotting strategies to address the needs and escalating costs of Medicaid\u27s high-utilizers and dual-eligibles, (4) the emerging benefits of pursuing telemedicine and associated reforms to reimbursement, regulation, and Graduate Medical Education programs that could fuel telemedicine solutions to improve access and delivery. The NC Medicaid Reform Advisory Team includes: Deanna Befus, Duke School of Nursing, PhD ‘17Madhulika Vulimiri, Duke Sanford School of Public Policy, MPP ‘18Patrick O’Shea, UNC School of Medicine/Fuqua School of Business, MD/MBA \u2717Shanna Rifkin, Duke Law School, JD ‘17Trey Sinyard, Duke School of Medicine/Fuqua School of Business, MD/MBA \u2717Brandon Yan, Duke Public Policy, BA \u2718Brooke Bekoff, UNC Political Science, BA \u2719Graeme Peterson, Duke Public Policy, BA ‘17Haley Hedrick, Duke Psychology, BS ‘19Jackie Lin, Duke Biology, BS \u2718Kushal Kadakia, Duke Biology and Public Policy, BS ‘19Leah Yao, Duke Psychology, BS ‘19Shivani Shah, Duke Biology and Public Policy, BS ‘18Sonia Hernandez, Duke Economics, BS \u2719Riley Herrmann, Duke Public Policy, BA \u271

Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Planning a Better Future for Dual Eligible Elderly in Montgomery County

Older adults who are dual eligible (who qualify for both Medicare and Medicaid) face a daunting gauntlet of challenges in healthcare. Despite comprehensive coverage through Medicare and Medicaid, the lack of coordination between the two systems creates often insurmountable problems of access and delivery. Federally-funded Medicare lacks coordination and integration with federal-state funded Medicaid. Ironically, it is these dual eligible individuals who so desperately need healthcare since they have a higher incidence of cognitive impairment (including Alzheimer's Disease), mental disorders, diabetes, pulmonary disease and strokes. Further, they are more vulnerable and frail, have lower incomes, and are more isolated than are non-dual eligible elderly. These problems, in turn, contribute to significant challenges with housing, food and transportation. The challenges with access to care are tragic, expensive and avoidable.The high care needs of dual eligible individuals and the associated costs have driven states and the federalgovernment to seek ways to better integrate and coordinate their care. The Affordable Care Act (2010) is teemingwith initiatives, demonstrations, and new opportunities premised on finding a way to better meet dual eligibleindividuals' healthcare needs at a cost-effective rate. While little has yet been done at the state level, localproviders are starting to test innovative approaches to delivering better care to dual eligible individuals.This report summarizes state and federal initiatives and opportunities for delivering better care to dual eligible elderly. It also presents the efforts underway at the County level and by local providers. Following the informational section of the report, the Workgroup presents nine systems change recommendations to better improve the care provided to Montgomery County's dual eligible elderly. The recommendations may stand alone, each reflecting their own systems change, or may be combined in a more encompassing effort at service delivery system overhaul.There are numerous federal opportunities for delivering better care to frail populations. Some of them are specifically targeted towards the dual eligible population and others are targeted towards other populations, but include a considerable number of dual eligible individuals. In the report, we describe five different types ofapproaches and describe examples of each

Community Care of North Carolina: Putting Health Reform Ideas Into Practice in Medicaid

Summarizes assessments of how an enhanced medical home model of care that involves local nonprofit community networks and emphasizes care coordination, disease and care management, and quality improvement has affected cost savings and quality of care

Cost-Sharing: Effects on Spending and Outcomes

Reviews what is known and not known about the effects of consumer cost-sharing on distribution of and total spending, health outcomes, services, and prescription drugs and how responses to cost-sharing vary by socioeconomic factors and health status

Toward a Definition of Nurse-Managed Centers

The purpose of this study was to gain consensus on a definition of Nurse-Managed Centers. To accomplish this task, Delphi survey methods were used with the participants of the Second Biennial Conference on Nurse-Managed Centers. Delphi methods entail obtaining autonomous consensus from experts through rounds of questionnaires and feedback of results. A questionnaire was developed that included 22 items obtained from the literature, past conferences, and the expertise of the authors. An additional 6 items were suggested by the conferees. Of the 168 conferees, 148 participated in the first round, 147 in the second, and 133 in the third. Fifty-three percent of the respondents were educators, 22% administrators, and 11% clinicians. More than 75% of the respondents were masters prepared. After the third round, the highest-ranked items indicated that NMCs should provide direct access for clients to professional nursing, be part of a strong referral network, base services on client participation, and provide holistic treatment. A definition was formulated and associations between ranked items and selected demographic characteristics were analyzed