ESTADO DEL ARTE

39 _{Also called “Accelerating Integrated, Evidence-Based, and Sustainable Service Systems for Older Adults,}

State grantees recognize the importance of building a third-party billing capability for CDSMP services but have had very limited success in accomplishing this. Fee-for-service payment requires a business model that is vastly different from a delivery system that is funded through grants and/or state budget allocations. It will require a significant investment of resources as well as major cultural change in the way these grantees’ networks operate.

To bill for CDSMP services, a state must first determine the actual cost of providing a workshop or workshop session in order to price the service correctly and not operate at a loss. On the one hand, pricing should incorporate the costs of product development, marketing, service provision, quality assurance, and indirect expenses; on the other hand, the price of the service must be affordable for purchasers. States have experienced difficulty in striking this balance, particularly in serving low-income populations. In addition, many prospective purchasers are inquiring about the return on investment (ROI) for CDSMP, which will require outcome studies. Second, a state must have an accounting system to manage accounts receivable (i.e., to bill health plans, employers, consumers, and other purchasers) and accounts payable (i.e., to pay leaders, workshop sites, and other vendors for services provided).

States have been working with public and private insurers to explore different strategies for financing CDSMP. Fee-for-service reimbursement or capitated payment is the ultimate goal but, as an interim strategy, some states have negotiated lump sum payments (or grants) from health plans to help defray the state’s costs for providing CDSMP to individuals referred by the plans. Virtually all the states understand the advantages of moving to fee-for-service reimbursement by Medicaid, Medicare, and private health plans, but are experiencing difficulty in effecting what would be a major transformation in service provision within the aging network.

Below we discuss several approaches states are pursuing: Medicaid waivers, Medicare reimbursement, Medicaid reimbursement or allocations, coverage under Medicaid managed care, and coverage under integrated care programs for Medicare-Medicaid enrollees.

Medicaid home and community-based services (HCBS) waivers: Medicaid HCBS waivers are authorized under Section 1915(c) of the Social Security Act and enable states to provide Medicaid-financed long-term services and supports (LTSS) to eligible individuals. Individuals meeting a state’s Medicaid financial eligibility requirements and assessed to need a nursing facility level of care can participate in HCBS waiver programs. Each state establishes its own criteria for determining the need for a nursing facility level of care, but typically an individual must have deficits in two or three activities of daily living (ADLs). Older adult Medicaid waiver clients are typically very frail and often homebound.

States must obtain approval from CMS for their HCBS waiver programs. The approval process includes a review of services and supports that the state proposes to offer under the waiver. States seeking to offer CDSMP as a waiver service in a new or existing waiver program must first obtain approval from CMS.

Vermont and Washington are currently the only states approved by CMS to provide CDMSP as a service under a 1915(c) Medicaid HCBS waiver and can serve as models for other states. As an example, Washington offers CDSMP under its Community Options Program Entry System (COPES) waiver for older adults. As opposed to being a distinct waiver service, CDSMP is provided under a broader service category entitled “Caregiver/Recipient Training Services.” The definition for this service is:

“Recipient training needs are identified in the CARE assessment or in a professional evaluation. This service is provided in accordance with a therapeutic goal in the plan of care and includes for example, adjustment to serious impairment, maintenance or restoration of physical functioning, self

management of chronic disease [emphasis added], acquisition of skills to

address minor depression, management of personal care, and development of skills to work with care providers including behavior management …”40

The waiver application goes on to list “Chronic Disease Self-Management Trainer” as one of 14 approved providers for “Caregiver/Recipient Training Services.” The waiver application authorizes both “individual” trainers and “agency” trainers. In this way trainers (or the agencies they work for) can bill and be reimbursed for services by the State Medicaid agency. The State reports that about 100 individuals have taken advantage of CDSMP as a waiver service, with a per session reimbursement rate of $50.

California, working with the Partners in Care Foundation, conducted pilots in 2010 and 2011 in which care managers for the Multipurpose Senior Services Program (MSSP) Medicaid HCBS waiver referred waiver clients to CDSMP. Medicaid provided reimbursement of $60 per workshop session attended by the Medicaid client, as well as reimbursement for transportation ($24 per hour for each two-and-a-half-hour session). The State found that many waiver clients were too frail or encountered other barriers in completing the workshops and the pilots have been discontinued.

Medicaid reimbursement and FQHCs: Oregon, which has partnered with FQHCs to deliver CDSMP, reported that efforts to obtain reimbursement for Medicaid beneficiaries participating in CDSMP offered by FQHCs failed due to a billing technicality. Medicaid payment rates for FQHCs use a federally-defined methodology and are based on a per visit rate. FQHCs were required to bill each CDSMP session as a separate visit (at an estimated rate of $900 to $1,500 per patient), making the total cost of a six-week CDSMP workshop financially unfeasible. A single billing for the entire six-week workshop was not allowable under federal rules.

Medicare reimbursement for DSMP: Section 4105 of the Balanced Budget Act of 1997 authorized Medicare coverage for diabetes self-management training services furnished by a certified provider who meets certain quality standards. Services are covered by Medicare only if the treating physician or a treating qualified non-physician practitioner who is managing the

beneficiary’s diabetic condition certifies that such services are needed. Medicare rules provide further specifications for eligible beneficiaries and training requirements. Training programs must be approved by a national accreditation organization.41 _{AoA has been working with the} American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE)—both approved accrediting organizations—to increase the availability of community- based training programs using Stanford University’s DSMP model. Up until now, most training programs have been offered in clinical settings. AoA has provided technical assistance to sites. Providers of DSMP must first be accredited by ADA or AADE and collaborate with a Medicare provider who is recognized by CMS as a diabetes self-management training provider. Providers must also have the infrastructure in place to bill Medicare.

A site in Massachusetts has been accredited to receive Medicare reimbursement for DSMP as a result of a collaborative effort by Hebrew Senior Life, a provider of elder housing, health care, and LTSS, and Elder Services of the Merrimack Valley, an AAA. To be accredited, a registered nurse, dietitian, or pharmacist must conduct a one-on-one assessment with the Medicare beneficiary, develop an individualized plan, and then refer the beneficiary to DSMP. Workshop leaders are supported by the nurse, dietitian, or pharmacist, and then each beneficiary is required to have a follow-up with a nurse, dietitian, or pharmacist at the conclusion of the six- week workshop. The State has convened its first DSMP workshop for which it will be claiming Medicare reimbursement for eligible participants (the workshop included a mix of eligible and non-eligible individuals). The partners believe that if they can build the infrastructure for program management and reimbursement, it could be a replicable model for helping older adults to manage chronic conditions. The “center for excellence” that the Massachusetts partners envision (see description above) would be the framework for this infrastructure. AgeOptions, the AAA for suburban Cook County in Illinois, was close to submitting their application for DSMP accreditation to AADE at the time the research team conducted the telephone discussion with Illinois. The State is exploring how to “brand” the program and whether to have workshops solely for Medicare beneficiaries or mixed workshops that include non-Medicare beneficiaries.

Allocations from Medicaid to support CDSMP: Colorado reported that the Medicaid agency made a grant to the Division of Aging and Adult Services to help support the provision of CDSMP to Medicaid clients. Some of the 14 local networks that comprise Community Care of North Carolina—which provides medical homes for Medicaid beneficiaries and others—make lump sum payments to local AAAs to help support CDSMP.

Coverage of CDSMP under Medicaid managed care: A majority of the states receiving ARRA funding have Medicaid managed care programs. The number and scope of Medicaid managed care programs continues to grow as states seek greater cost predictability, accountability, and

41 _{Department of Health and Human Services. CMS Manual System: Pub. 100-02 Medicare Benefit Policy,}

Transmittal 13, May 28, 2004. Accessed at www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/downloads/R13BP.pdf.

quality improvement. These programs aim to provide high quality, cost-effective care by assigning enrollees a medical home with a primary care provider, promoting care coordination, and investing in health promotion and disease prevention. Medicaid health plans—typically called managed care organizations or MCOs—receive capitated per-member-per-month payments from the Medicaid agency to provide care to members. The scope of benefits provided by MCOs varies by state and ranges from primary and acute care only to plans that cover primary and acute care as well as behavioral health, dental care, and/or LTSS.

Grantees reported exploring a variety of methods for covering CDSMP through Medicaid managed care but, to date, there are no reported community-based CDSMP providers (i.e., AAAs or other local providers) who are receiving reimbursement from Medicaid managed care plans. In northwest Missouri, CDSMP is being integrated into an Aetna Medicaid pilot program (as well as into an Aetna plan for employees of Heartland Health, an integrated delivery system, and Heartland Health’s new Accountable Care Organization), but arrangements for Medicaid reimbursement have not yet been developed. Oregon reported that one AAA has arranged for a lump sum payment from a health plan that comes from the plan’s community benefit program budget. WellCare of Texas pledged $100,000 to the East Texas Coalition to support expansion of CDSMP and DSMP in the Houston area. Maryland and several other states reported that MCOs and the Medicaid agency must first be convinced of the cost-benefit of CDSMP before they will agree to provide reimbursement for Medicaid members, so they are discussing outcome studies with health plans that would involve a comparison of health care expenditures for Medicaid members who participated in CDSMP versus a similar group of Medicaid members who did not. States reported major barriers to conducting outcome studies such as this (e.g., securing health plan participation and research partners, availability of claims data, developing a defensible study design, funding for the study).

Reimbursement under Medicare-Medicaid integrated care programs: A long-standing integrated care program for dual eligibles in Minnesota reimburses CDSMP providers. Under this program, members are enrolled in a Medicare Advantage D-SNP for their Medicare benefits and most receive their Medicaid benefits from the same plan that offers their Medicare benefits. This incentivizes plans to better manage the care of these dually-eligible beneficiaries across the two programs. Medica, one of the health plans that participates in Minnesota’s Senior Health Options program for dual eligibles, reimburses CDSMP providers $120 per workshop for each participating individual. Medica operates in 38 of Minnesota’s 87 counties. The State reports that because Senior Health Options members tend to be very frail, recruitment and retention can be challenging.