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Medicare/Medicaid Integration Program

Wisconsin Partnership Program

Project Overview

Introduction
The Wisconsin Partnership Program is an integrated program of health and long term care designed to improve access and quality while achieving cost savings. Acute and long term support services are coordinated across care settings using a inter-disciplinary team comprised of a physician, nurse practitioner and social worker or independent living coordinator.

Combining the benefits of the Medicaid/Medicare systems into one program theough an 1115/222 dual waiver, helps to avoid fragmentation and duplication of services -- challenges inherent in the dual fee-for-service system. Combining the benefits of both systems reduces costs related to duplication of services, and permits better coordination and improved quality of services to participants.

By choosing a system of capitation over fee-for-service, the Partnership Program proposes to achieve the cost savings and flexibility traditionally achieved in managed care programs, while ensuring that quality is not sacrificed for cost. Research conducted will ensure that consumer-defined indicators of quality care and service delivery are carefully incorporated into Wisconsin Partnership Program.

Two Innovative Models of Care
The Wisconsin Partnership Program consists of two innovative models of care, one for the elderly, and one for people with disabilities. Service delivery in the Partnership Program model is home-based and involves the consumer in care planning and decision-making. Community-based organizations are facilitated in developing the capacity to integrate the provision of acute care services with the long term support services CBOs traditionally provide.

Consumer Choice
Consumer choice is a cornerstone for the Wisconsin Partnership Program and has been shown to be a critical factor in the degree of satisfaction which elderly or younger persons with disabilities experience with their health and long term care. Individuals enrolled in the Partnership Program are offered a choice of care, choice of setting, and choice of the manner in which service is delivered. Participants are supported in their choice to receive community-based care in their homes. Participants are also able to choose their primary care physician within very broad parameters. Competent and trained participants have the option of selecting and directing the work of personal care workers.

Eligiblity
Participants in the Partnership Program must be Medicaid-eligible, or dually eligible for Medicaid and Medicare. Both Partnership models (elderly and physically disabled) serve individuals who meet nursing home level of care requirements. Participation in the Partnership Program is voluntary, and participants may disenroll at any time. Contractors may not disenroll participants except under stringent protocols approved by the Wisconsin Department of Health and Family Services.

Cost Containment
The Wisconsin Partnership Program uses cost containment features of a managed care system to integrate Medicare and Medicaid funding streams and service delivery systems for acute and long term services. Managed care systems offer the opportunity to provide flexible service plans and benefits to meet individual needs.

The Primary Objectives

Control health care costs among elderly and physically disabled people who meet nursing home admission criteria. By capitating Medicare and Medicaid funding streams and providing integrated long-term support and acute care through a managed care system, the Partnership Program will demonstrate that health care costs for a high cost population can be controlled. Capitating Medicare and Medicaid funds will prevent cost shifting and will provide an incentive to provide preventive care. The comprehensive range of services provided under the Partnership Program further reduces any incentive to shift costs. The managed care delivery system will result in an integrated plan for individuals enrolled in the Partnership Program that will limit the use of high cost institutions and specialty services, as well as reduce administrative costs. Data collected during the demonstration will be used to develop improved risk adjusters for special populations, enabling more valid and reliable cost estimates.
Increase quality through integration of preventive, primary and chronic care via the inter-disciplinary team model. The Partnership Program inter-disciplinary team model ensures that care is coordinated across systems that currently operate in parallel. The team coordinates all aspects of care and focuses at the points of intersection where the health care system traditionally breaks down to coordinate transitions between service providers. The inter-disciplinary team is knowledgeable about all aspects of the participant's care plan, preventing two or more different systems prescribing duplicative or contradictory treatments. The consumer=s involvement in the team and decision-making ensures a high degree of consumer satisfaction.
Improve health outcomes through the delivery of integrated preventive care. Many elderly and disabled people suffer from secondary illnesses brought on by their disability or chronic condition that can be prevented by coordinated care. Capitating the Medicare and Medicaid funding streams provides an incentive for the inter-disciplinary team to make cost-effective decisions. The incentive to shift costs is eliminated. Switching the focus to preventive services reduces unnecessary hospital and institutional care and results in improved health outcomes among participants. To emphasize the long-term benefits of preventive activities, the Partnership Program protocols severely constrain contractors from disenrolling participants involuntarily.
Increase the role of the participant in decision-making. The Partnership Program creates visible, important roles for participants in care planning and in service delivery. Consumer involvement in care planning shifts the responsibility for making cost-effective decisions from an impersonal administrative organization that primarily controls costs, to a team that is simultaneously responsible for ensuring quality and managing costs. Beneficiaries are educated as to their role, not only in the development of their own plan of care, but in the development of that care plan in relation to other beneficiaries. Participant education includes not only health education, but education regarding choices in the context of a managed care system.
Increase quality through the development and use of consumer-defined measures of quality. The financial incentives are realized only to the extent that individuals enrolled in the Partnership Program continue to participate in the program over time. However, participants in the Wisconsin Partnership Program are volunteers and can disenroll from the program with relative ease. Thus, the Partnership Program must continue to provide a high quality service package that fosters the consumer satisfaction necessary to retain enrolled individuals over time. The Partnership Program will demonstrate that consumers who participate in defining measures used to determine the quality of their care, will be more satisfied with their quality of care and will be less likely to disenroll.
Demonstrate that community-based organizations can provide a comprehensive range of long-term support and acute health care to a nursing home level of care population of elderly and people with disabilities. The infrastructure developed by the Wisconsin Partnership Program will assist community-based organizations in developing their capacity to meet the financial and organizational requirements to provide acute health care as well as community-based long-term support in a managed care, risk-based environment.

Implementation
The Department of Health and Family Services contracts with community-based organizations (CBOs) to implement the Partnership Program. These organizations in turn subcontract with hospitals, clinics, HMOs and other providers to ensure a comprehensive network of acute and long-term care. The Program began serving individuals in January 1996 as a Medicaid Pre-Paid Health Plan (PHP). Funds are capitated and a graduated risk-sharing plan is in effect. Wisconsin received a Medicaid/Medicare waiver from the Federal Health Care Financing Administration and began full Medicaid/Medicare capitation in January 1999. The demonstration is fully implemented in Dane, Milwaukee, Eau Claire, Dunn and Chippewa counties.

Organization
The Wisconsin Department of Health and Family Services is the State Medicaid Agency. The Center for Delivery Systems Development in the Office of Strategic Finance is responsible for the design and development of the Partnership Program. Staff at the Center are experienced in administering community-based programs, and have designed and administered many nationally acclaimed human service programs. The Department has a history of collaborating with internal and external partners to develop and study new managed care models in Wisconsin, including PACE (1989), Independent Care (1994), and the Partnership Program (1994).

Partnership Provider Organization
The first site of the Partnership Program for Elderly People is Elder Care of Dane County, a community-based, not-for-profit organization that provides services to elderly people in Dane County, Wisconsin. The second elderly site is the Community Care Organization in Milwaukee, a full risk comprehensive PACE site.

The first site of the Partnership Program for Persons with Physical Disabilities is Community Living Alliance in Madison, Wisconsin. An additional site was selected at the end of 1995, the Community Health Partnership, Inc. in Eau Claire.

Pooling the Resources of Community-Based Organizations
The community-based organizations involved in the Partnership Program are collaborating on functions that are common to each organization. Risk management is one example. The member organizations have pooled their resources to provide stop-loss protection. A management information system, claims processing system and clinical protocols are also being developed.

Updates
On September 27, 2001, the Wisconsin Partnership Program received a grant from the Robert Wood Johnson Foundation to support Partnership's participation in the Foundation's Medicare/Medicaid Integration Program.

Contact Information:

Wisconsin Department of Health and Family Services
Office of Strategic Finance
One South Pinkey Street, Suite 340
P.O. Box 1379
Madison, WI 53701-1379
FAX: (608) 267-0358