August 23, 2016

The Minnesota Model: What Does Integrated Care Mean?

Care integration should bring together providers, facilities and patients to create the systems and pathways that join care not in sequential stages but, rather, as a web that supports the appropriate aspects of care will be delivered at the appropriate time, to promote optimized outcomes. Care integration relies on bringing together multiple factors:

  • Self-management
  • Peer Support
  • Care for chronic conditions (e.g. diabetes, heart disease, disabilities)
  • Provider engagement
  • Health system navigation services
  • Care coordination

Since the passage of the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) has focused on promoting better integration of Medicare and Medicaid services and developing new payment and service delivery models for dually eligible beneficiaries. A new report details a pilot care integration project by CMS and the state of Minnesota — and the evidence shows integrated care is improving outcomes. Here’s a look at the results and some key takeaways.

Project goals

The aim of the Minnesota project was to emphasize primary care physician (PCP) visits versus specialty physician visits, reduce preventable hospital stays and emergency department (ED) visits, and enable elderly patients with chronic conditions and disabilities to obtain services at home or in “assisted living” settings in preference to long-stay nursing home use.

Takeaway: Although the project began in 1997, CMS has been steadily moving towards these goals — as evidenced by rolling out accountable care organizations (ACOs) and bundled payments — and will continue to do so in future.

Pilot set-up

To test the outcomes associated with integrated care, CMS compared service delivery patterns among elderly dually eligible beneficiaries enrolled in two alternative managed care service delivery systems in Minnesota: Minnesota Senior Care Plus (MSC+) and the Minnesota Senior Health Option (MSHO). MSC+ is a Medicaid-only program, while MSHO is a fully integrated Medicare-Medicaid program. Because dual-eligibles in Minnesota can choose to enroll in MSHO rather than MSC+, and can switch between MSHO and MSC+, the report examines:

  • MSHO enrollment rates and changes in MSHO enrollment over time
  • Beneficiary characteristics and community factors are associated with MHSO enrollment
  • Service-use patterns across MSC+ and MSHO, controlled for differences in beneficiary characteristics and community factors
  • Potential impact of unmeasured differences in the characteristics of those making a choice between the MSHO and MSC+ on the estimated differences in MSHO and MSC+ service use
  • Characteristics that differentiate Medicare-only beneficiaries and dual-eligibles enrolled in MSC+ and MSHO and then examine differences in their service use patterns

Takeaway: The study resulted in an extensive dataset by which to measure beneficiary characteristics, enrollment status, service use and outcomes, meaning that the strength of the data.

Enrollment highlights

MSHO enrollees tended to be older, female, to have more medical conditions and disabilities, and slightly more likely to live in rural areas of Minnesota. Very few MSHO enrollees ever switched to MSC+ during a year, but 12.8% of MSC+ enrollees switched to MSHO after the beginning of a year.

Takeaway: As integrated care models are meant to be designed to manage multiple comorbid conditions, taking particular steps to bridge gaps in care (such as those caused by rural location) are important for success. In addition, patients appeared to have high satisfaction with their experience of integrated care.

Outcomes highlights

Compared to MSC+ enrollees, MSHO enrollees were:

  • 48% less likely to have a hospital stay, and those who were hospitalized had 26% less stays
  • 6% less likely to have an outpatient ED visit, and those who did visit an ED had 38% less visits
  • 2.7 times more likely to have a PCP visit, but 36% less actual PCP visits
  • 36% less specialist visits
  • 13% more likely to have home and community-based services
  • In urban areas, less likely to have inpatient hospital stays, and more likely to have PCP care over time

Takeaway: Lower hospital use among MSHO enrollees — despite their older ages and greater prevalence of chronic conditions and disabilities — is a particularly strong endorsement for creating more integrated care models. The Minnesota model is an example of how population health can be successfully implemented on a large scale, and demonstrates that providers, hospitals and ACOs should consider strategies for joining the push for population health to develop their own integrated care models.

What’s next for integrated health

CMS is partnering with 12 other states to implement and evaluate new models of integrated care similar to MSHO through the Financial Alignment Initiative. From 2011 to 2015, the number of dually eligible beneficiaries served in integrated care programs across the country rose from approximately 162,000 to more than 650,000.

“Integrated care is improving the lives of some of the most vulnerable Americans,” writes CMS. “These new findings from Minnesota affirm the promise of integrated care and reinforce the urgency with which we need to continue to develop, test, and scale successful models for better serving dually eligible individuals.”