TN_Duals_Alignment_SOWv4_FBO.docx

Study of Duals In Aligned Managed Care:

Measuring the Impact of Financial Alignment for Dual-Eligible Beneficiaries in Tennessee Statement of Work Purpose: The purpose of this project is to evaluate the impact of Medicare and Medicaid alignment for individuals eligible for both Medicare and Medicaid (dual eligible beneficiaries or duals) on beneficiary outcomes and utilization of acute care and long-term services and supports. This project will focus on one state (Tennessee) that has implemented Medicare and Medicaid financial alignment for duals through a combination of Medicare Advantage Dual-Eligible Special Needs Plans (D-SNP) contracting and Medicaid managed long-term services and supports.

Rationale: There are more than eleven million Medicare-Medicaid dually eligible beneficiaries in the US.[footnoteRef:1] These men and women are low-income seniors and persons with disabilities who rely on coverage under both Medicare and Medicaid to obtain critical medical and non-medical supports and services. For these individuals Medicare provides coverage of acute care medical services (including hospital, physician, prescription drugs, and post-acute care) and Medicaid provides financial assistance to cover Medicare premiums and cost sharing. Additionally, the majority of dually eligible beneficiaries also rely on Medicaid for coverage for services not included in Medicare, such as long-term services and supports.[footnoteRef:2] [1: Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office (MMCO). Medicare-Medicaid Enrollee Information, National 2011. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Analytics.html ] [2: Coughlin, T., Waldmann, T., Phaedra, L. 2012. The Diversity of Dual Eligible Beneficiaries: An Examination of Services and Spending for People Eligible for Both Medicaid and Medicare. Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, http://kff.org/medicaid/issue-brief/the-diversity-of-dual-eligible-beneficiaries-an/ ]

Dual eligible beneficiaries tend to have more chronic conditions, cognitive limitations, and functional limitations than other Medicare beneficiaries.[footnoteRef:3] As a result, duals account for a disproportionate share of Medicare and Medicaid spending. In 2011 duals represented 20 percent of all Medicare beneficiaries and 35 percent of Medicare spending. Furthermore, duals account for 14 percent of Medicaid enrollment and 33 percent of Medicaid spending.[footnoteRef:4] [3: Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office (MMCO). Accessed at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Analytics.html] [4: Ibid.]

By aligning Medicare and Medicaid benefits, policymakers aim to address the inefficient provision of services for dual-eligible beneficiaries. Despite this population’s complex care needs and high Medicare and Medicaid costs, measures to improve health care delivery face hurdles because neither program has a financial incentive to invest in initiatives that primarily produce savings for its counterpart program. These issues are magnified when Medicare’s coverage of acute services interacts with Medicaid’s coverage of long-term services and supports (LTSS).

Managed Care Approaches for Duals Because of their significant acute care and LTSS needs, there are numerous federal efforts underway to better integrate care for this uniquely vulnerable and expensive population. A key strategy to address these financial and operational challenges has been establishing managed care plans that provide both Medicare and Medicaid benefits. To date, evidence on the effectiveness of these approaches is limited.

The Program of All-Inclusive Care for the Elderly (PACE) The Program of All-Inclusive Care for the Elderly (PACE), established as a permanent Medicare and Medicaid benefit by the Balanced Budget Act of 1997, attempts to help nursing-home eligible seniors avoid institutional care by providing them with a rich mix of coordinated acute and long-term care services in the community. Individuals who are 55 or older, certified by their state of residence as being eligible for nursing home level of care, and live in the service area of a PACE program are eligible to enroll in PACE. Designed for the frail elderly, PACE programs are centered around—1) the adult day health center (ADHC) where participants receive medical and social services, and 2) an interdisciplinary team (IDT) composed of physicians, nurse practitioners, social workers, nutritionists, therapists, personal care attendant, and drivers. As of January, 2014, there were 103 PACE and pre-PACE sites operating across 31 states serving approximately 21,000 enrollees.[footnoteRef:5] [5: National PACE Association. 2014. http://www.npaonline.org/website/download.asp?id=1741&title=PACE_in_the_States ]

The Financial Alignment Initiative (FAI) The federal government launched the Financial Alignment Initiative in 2011 to test models with states to better align the financing of Medicare and Medicaid and integrate primary, acute, and behavioral health and long-term services and supports.[footnoteRef:6] Under the most common option, Medicare and 10 states have contracted with managed care plans for the provision of Medicare and Medicaid benefits.[footnoteRef:7] Plans must achieve financial savings while meeting quality standards. Early results are mixed.[footnoteRef:8] [6: Centers for Medicare and Medicaid Services. 2017. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.html ] [7: Centers for Medicare and Medicaid Services. 2017. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/CapitatedModel.html ] [8: Centers for Medicare and Medicaid Services. 2017. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.html ]

Dual Eligible Special Needs Plans (D-SNPs) Outside of the federal demonstration, several states are seeking alternative financial alignment strategies.[footnoteRef:9] One of the more scalable options for integrating care for dual eligible beneficiaries is dual eligible special needs plans (D-SNPs). D-SNPs, first authorized in 2003, are a type of Medicare Advantage (MA) managed care plan. D-SNPs enroll only dual eligible beneficiaries and are required to have an approved care management model describing how each plan will meet the needs of its enrollees with a coordinated Medicare and Medicaid benefit package.[footnoteRef:10] All D-SNPs are required to have a contract with the states in which they operate. At minimum D-SNPs must either include Medicaid benefits in their capitated benefit package or arrange for Medicaid benefits to be provided in some other way such as through a companion Medicaid managed long-term services and supports (MLTSS) program, a Medicaid managed care plan, or through Medicaid fee-for-service, depending on the state.[footnoteRef:11] [9: National Association of Medicaid Directors. 2017. http://medicaiddirectors.org/key-issues/duals/ ] [10: Medicare Prescription Drug, Improvement, and Modernization Act of 2003. http://www.gpo.gov/fdsys/pkg/BILLS-108hr1enr/pdf/BILLS-108hr1enr.pdf ] [11: Ibid.]

State Experiences with D-SNP/MLTSS approaches Because of the requirements for benefit coordination and a formalized relationship with the state, D-SNPs have the potential to deliver a coordinated Medicare and Medicaid benefit package that offers more integrated care than regular MA plans or traditional Medicare fee-for-service.

As of February 2017 there were 256 D-SNPs with 1.9 million enrollees, about 20 percent of the total dual eligible population. Although 43 states and territories (including the District of Columbia) have D-SNPs, enrollment is highly concentrated: 63 percent of enrollment is in 10 states (AL, AZ, CA, FL, GA, MA, NY, PA, TN and TX)(Exhibit 1)[footnoteRef:12] [12: Centers for Medicare and Medicaid Services. 2017. SNP Comprehensive Report. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/Special-Needs-Plan-SNP-Data-Items/SNP-Comprehensive-Report.html ]

D-SNP contracts can be used to align a state’s Medicaid managed care plans, including MLTSS plans, with D-SNPs operating in the state by requiring the entities offering Medicaid plans to also offer companion D-SNPs covering the same geographic area, or conversely, by requiring the entities offering D-SNPs to offer MLTSS plans. (Exhibit 2)

Impact of D-SNP/LTSS alignment There is limited evidence on impact of D-SNP alignment on utilization and spending. This is in part because many states have only recently begun to pursue this strategy. However, the data challenges inherent to studying dual eligible beneficiaries in managed care cannot be overstated. There is a dearth of publicly available reliable data on service use in managed care. Some researchers have been able to acquire data directly from managed care organizations, but this approach is especially time consuming and can result in a lack of comparability between data sources. What available data there is on managed care is often aggregated at the larger organizational level, which precludes direct comparison of beneficiaries.

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) has conducted several qualitative studies examining the nature of care coordination and alignment in models such as D-SNPs and MLTSS. The ASPE studies along with the work of other researchers has shown that the most successful D-SNPs and MLTSS programs (those which manage to significantly reduce utilization and control or reduce spending) have several things in common: well-defined target populations, robust and intensive care management practices, and the routine exchange of useful and clinically relevant information between providers.[footnoteRef:13], [footnoteRef:14], [footnoteRef:15] [13: McGinn-Shapiro et al. 2015. Information Exchange in Integrated Care Models: Final Report. https://aspe.hhs.gov/basic-report/information-exchange-integrated-care-models-final-report ] [14: Grabowski, D.C. 2009. Special needs plans and the coordination of benefits and services for dual eligibles. Health Affairs (Millwood), Jan-Feb, 28(1), 136-14 ] [15: Wiener et al. 2017. Early Findings on Care Coordination in Capitated Medicare-Medicaid Plans Under the Financial Alignment Initiative. https://innovation.cms.gov/Files/reports/fai-carecoordination-issuebrief.pdf ]

A number of elements must be present to conduct a meaningful quantitative analysis of these programs. The state must either have a sizable and appropriate comparison group (duals who are not in the aligned program AND duals who are in the aligned program) or an aligned program that is mature enough to look at the population pre- and post- alignment. Furthermore, the state must have robust encounter data from the participating managed care organizations, data that will enable researchers to compile a comprehensive picture of beneficiaries’ use of key services during the time period of interest.

A handful of states meet the conditions for the aforementioned type of analysis. One such state is Minnesota. Minnesota’s aligned program has been in existence since 1997, and they have well-maintained data. ASPE was able to use the Minnesota’s encounter data to compare beneficiary outcomes for people in the state’s aligned (D-SNP + MLTSS) program to those who were not in an aligned product. The study found that those in the aligned product had significantly lower hospital and ED use and greater use of primary care; additionally, those in the aligned program were more likely to use HCBS and rarely opted out of the program.[footnoteRef:16] [16: Anderson, W., Feng Z. 2016. Minnesota Managed Care Longitudinal Data Analysis. https://aspe.hhs.gov/report/minnesota-managed-care-longitudinal-data-analysis ]

Tennessee is another state with a mature aligned program and good quality encounter data. Since the mid-1990s, the Tennessee Medicaid program (TennCare) has been a leader in implementing managed care coverage. In 2010, TennCare created the CHOICES program to shift LTSS benefits to Medicaid MCOs. After applying to participate in the federal Financial Alignment Initiative, TennCare withdrew due to concerns about the adequacy of plan payment rates.[footnoteRef:17] Instead, Tennessee chose to advance benefit alignment by requiring its Medicaid MCOs to expand their geographic coverage areas and to offer D-SNP plans. Many other states are interested in advancing D-SNP based alignment for duals, similar to Minnesota and Tennessee, but the lack of evidence on beneficiary outcomes and utilization is a barrier. [17: Gordon DJ. Letter to Melanie Bella, Director, Medicare-Medicaid Coordination Office - request to withdraw from Financial Alignment Demonstration: TennCare; 2012 December 21. https://www.thearctn.org/Assets/Docs/TennCare-Memo-Stakeholders-0113.pdf.

ASPE is interested in expanding the evidence base to support federal and state policy development around D-SNP based alignment of Medicare and Medicaid for dual eligible beneficiaries. This project will test the hypothesis that the aligned delivery of Medicare and Medicaid funded services to full-benefit duals is associated with improved health status and increased efficiency of health care utilization (decreased ED utilization, decreased nursing facility utilization, and increased use of home and community based services) among full benefit duals in Tennessee, by evaluating the impact that Tennessee’s financial alignment strategy (pairing D-SNPs with MLTSS) has had on beneficiary outcomes and utilization.

Data Landscape ASPE anticipates that the following data will be necessary to conduct this analysis:

Exhibit 3. Data Sources

Medicare FFS claims

Inpatient, skilled nursing facility, home health care

Hospice, prescription drugs

Quality measures (e.g. readmissions)

Functional indicators

Research Questions:

1. How did increased availability of aligned benefits (D-SNPs with MLTSS) impact health care use and quality of care across all dual-eligible beneficiaries?

2. How did participation in aligned plans (D-SNPs paired with MLTSS) impact participants’ health care use and quality of care?

Specification of Tasks:

The contractor shall provide the necessary personnel, materials, equipment, support and supplies (unless explicitly indicated in this statement of work to be provided by the government) to complete the tasks listed below over a time period of 18 months, and in accordance with the information provided in the overview information provided above.

Task 1: Post-Award meeting Within two (2) weeks of the contract award the contractor, a representative of the state of Tennessee (someone from the state who is familiar with the state’s duals population and alignment strategy)and other relevant staff shall meet with the Contracting Officer’s Representative (COR) and other relevant federal staff to discuss the objectives of the contract and any related project issues. This meeting may take place in person or via telephone. Specific topics to be discussed (at a minimum) include the project purpose and objectives, project timetable and deliverables, and preliminary framework for case study site selection. No less than one week prior to the meeting the contractor shall submit a draft agenda for the meeting, this agenda is subject to the review and approval of the COR. No more than two (2) weeks after the post award meeting the contractor shall submit for review and approval by the COR a draft, 1-2 page memorandum summarizing the discussion at the kick-off meeting including any decisions made during the meeting.

Task 2: Monthly Progress Reports and Interim Meetings The contractor shall submit monthly administrative progress reports (not to exceed two pages) outlining all work accomplished during the previous month. At a minimum, such reports shall cover the following items:

· Discussion of the progress in accomplishing the tasks specified in this task order.

· Difficulties encountered and remedial action(s) taken.

· Activities anticipated during the upcoming reporting period.

· Personnel and other management changes.

Monthly reports are due no later than the second week of every month following the post-award meeting (Task 1) and shall be sent by the Principal Investigator directly to the COR via electronic mail. The contractor and the COR shall also have interim meetings (mostly via teleconference) as deemed necessary to discuss issues that need the COR’s input or approval.

Task 3: Analysis Plan The offeror’s technical proposal will provide the starting point for the development of the analysis plan. The contractor shall work with the COR to develop an initial framework for the analytical approach, and upon agreement with the COR, the contractor shall then develop this into the analysis plan.

The analysis plan will go beyond the offeror’s technical proposal. The analysis plan will present options for the analysis, and their advantages and disadvantages.

The contractor shall prepare a memo containing a draft analysis plan for the review and approval of the COR. This draft plan shall include, but is not limited to:

· specification of the research questions to be studied;

· a discussion of which data sources will be used to address the research questions, a list of the necessary data that the contractor currently has access to, and the data that will need to be procured from CMS, including the procedures employed and likely sample sizes for the various populations of interest;

· a discussion of the statistical methods that will be used in the analyses; and

· a discussion of data limitations.

The draft memo is due within 8 weeks following contract award. The contractor shall revise the draft memo in accordance with comments provided by the COR. The revised memo is due 2 weeks after comments from COR are received by the contractor, and will be considered final upon approval by the COR.

Task 4: Negotiate Data Use Agreements and Obtain Data The contractor shall prepare a data use agreement to obtain the necessary data from CMS and the state of Tennessee. The contractor shall consult with the COR regarding whether the data will be purchased or accessed via the CMS Virtual Resource Data Center. (VRDC) If the contractor requires use of the VRDC ASPE will provide a CMS VRDC seat. The data use agreements shall be submitted to the COR for review and approval no later than 16 weeks after contract award. ASPE will submit DUA documents that are to be submitted through ResDAC. All other DUA documents submitted to other entities (i.e. the state of TN, etc.) are to be submitted by the contractor after receiving approval from the COR. ASPE recognizes that there is some variability in how long each DUA application takes from time of submission to DUA approval.

Task 5: Data Analysis Using the approach outlined in the analysis plan developed in Task 3, the contractor shall conduct the necessary data analyses. The contractor shall notify the COR if any significant problems arise in analyzing the data that could affect their ability to address the purpose of this task order or significantly impact the timeline for completion of the project. This task includes both data preparation as well as conducting the appropriate analyses to achieve the purpose of this task order. The contractor shall start the data analyses upon the approval of the final analysis plan (Task 3) and DUA approval (Task 4). The data analysis shall be completed no later than 64 weeks after contract award.

Task 6: Interim Briefing The contractor shall conduct an interim briefing for the COR, a representative from the state of Tennessee, and other federal government officials whom the COR selects. The briefing shall include a discussion of the project findings to date, a discussion of project challenges and to-date. For the briefing the contractor shall prepare a technical memo (e.g. summary tables, table shells, bulleted narrative, etc.) which will guide the discussion during the meeting. The briefing shall be conducted via telephone or a web-based platform. The briefing shall take place no later than 40 weeks after contract award.

Task 7: Draft Final Report The contractor shall prepare a draft report presenting the results of the analyses performed in Task 5. The report shall include:

· an Executive Summary (no more than 4 pages) that presents an overview of the study, the methodology employed, major findings, and policy implications;

· a description of the data and methodology used in the analyses;

· a discussion of limitations in data and/or methodology;

· major findings, conclusions, policy implications and directions for future research, including the research questions and how they were answered by the research performed; and

· Technical Appendix, Supplementary Tables, and References.

Because the audience for this report is broad (including policymakers, program managers and researchers), the contractor shall ensure that the report is clearly written and includes appropriate examples, figures, and graphs. The report should be no longer than 30 pages, not inclusive of tables, figures, and appendices. The contractor shall submit the draft report for the COR’s review and approval no later than 72 weeks after contract award.

Task 8: Briefing for HHS Officials The contractor shall conduct a briefing for HHS and other federal government officials and other interested parties. The briefing shall take place at HHS headquarters in Washington, D.C., and present an overview of the study, summary of the data used in the analyses and methodology, major findings, and the implications of the findings for public policy. The contractor shall prepare a PowerPoint presentation and all necessary handouts for the briefing, and submit them to the COR for review and approval one week before the date of the briefing. The briefing shall occur no later than 76 weeks after contract award.

Task 9: Final Report Based on comments from the COR and other reviewers chosen by the COR, and discussion at the final briefing (task 8) the contractor shall revise the draft report. (Task 7) The final version of this document is intended for publication on the ASPE website and is thus subject to 508 compliance requirements. The final report is due 80 weeks after contract award, and shall conform to ASPE guidelines for the delivery of digital copies of reports. (see Appendix B) The report will be considered final upon review and approval of the COR.

Appendix A Schedule of Deliverables

(after contract award)

Post-Award Meeting Memorandum

Week 2 Week 4

2nd week of every month

Final analysis plan Week 8

2 weeks after receipt of comments

64 weeks

40 weeks

Appendix B Quality Assurance Surveillance Plan

Contacts the COR immediately with any issues or problems, and meets the time frames in the delivery schedule.

HHS Section 508 Accessibility Standards Notice (September 2009) This contract is subject to Section 508 of the Rehabilitation Act (the Act) of 1973 (29 U.S.C. 794d), as amended by the Workforce Investment Act of 1998, and the Architectural and Transportation Barriers Compliance Board (Access Board) Electronic and Information Accessibility Provisions (36 CFR Part 1194). Section 508 of the Act requires that, unless an exception applies, all communications products and services that require a contractor or consultant to produce content in any format that is specifically intended for publication on, or delivery via, a federally owned or federally funded website permit the following:

(1) Federal employees with disabilities to have access to and use information and data that is comparable to the access and use of information and data by federal employees who are not individuals with disabilities.

(2) Members of the public with disabilities seeking information or services from a federal agency to have access to and use of information and data that is comparable to the access and use of information and data by members of the public who are not individuals with disabilities.

(Note: Information about Section 508 of the Act is available at http://www.section508.gov/. The complete text of Section 508 can be accessed at http://www.access-board.gov/sec508/provisions.htm.)

Accordingly, regardless of format, all web content or communications materials specifically produced for publication on, or delivery via, HHS websites, including text, audio, or video, under this contract shall conform to applicable Section 508 accessibility standards. Remediation of any materials that do not comply with the applicable accessibility standards of 36 CFR Part 1194 as set forth herein shall be the responsibility of the Contractor.

The following Section 508 accessibility standards apply to the content or communications material identified in this SOW or PWS:

The following Section 508 provisions apply to the content or communications material identified in this SOW: Access Board Final Rule 36 CFR Part 1194.22(a)-(p).

Software Applications and Operating Systems (1194.21) Web-based Intranet and Internet Information and Applications (1194.22) Telecommunications Products (1194.23) Video or Multimedia Products (1194.24) Self Contained, Closed Products (1194.25) Desktop and Portable Computers (1194.26) image2.emf image1.emf