The Family Care 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 an 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 through 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 consumer-defined indicators of quality care and service delivery are carefully incorporated into the Partnership Program.
Two Innovative Models of Care
The Partnership Program consists of two innovative models of care, one for the elderly, and one for people with developmental or physical disabilities. Service delivery in the Partnership Program model is home-based and involves the consumer in care planning and decision-making. Managed Care Organizations (MCOs) are facilitated in developing the capacity to integrate the provision of acute care services with the long-term support services MCOs traditionally provide.
Consumer choice is a cornerstone of the Partnership Program. Consumer choice 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.
Participants in the Partnership Program must be Medicaid-eligible, or dually eligible for Medicaid and Medicare, and meet nursing home level of care criteria. Participation in the Partnership Program is voluntary, and participants may disenroll at any time. MCOs may not disenroll participants except under stringent protocols approved by the Wisconsin Department of Health Services.
The Partnership Program uses the 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 of the Partnership Program are to:
- Control health care costs among elderly and physically disabled people who meet nursing home admission criteria. By capitating (pre-paying the set Medicare and Medicaid funding for all services, regardless of actual cost) and integrating 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. Capitation of Medicare and Medicaid funds helps prevent cost shifting and increases the incentive to provide preventive care.
- The comprehensive range of services available under the Partnership Program further reduces the 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.
- The Partnership Program's 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 weakest point-the point of intersection-where the health care system most often breaks down. The team coordinates transitions between service providers. The inter-disciplinary team is knowledgeable about all aspects of the participant's care plan and can prevent two or more different systems from prescribing duplicative or contradictory treatments. The consumer's involvement in the team and participation in decision-making supports a high degree of consumer satisfaction.
- Improve health outcomes through the delivery of integrated preventive care. Many elderly and people with disabilities suffer from secondary illnesses brought on by their disability or chronic condition that can be prevented and/or minimized by coordinated care. Capitating the Medicare and Medicaid funding streams increases the incentive for the inter-disciplinary team to make cost-effective decisions. The incentive to shift costs is eliminated. Unnecessary hospitalizations and institutional care can be reduced by greater focus on preventive services and consumer education and support of chronic conditions. Participants experience improved health outcomes.
- Increase the role of the participant in decision-making. The Partnership Program creates visible and important roles for participants in planning their care and services. 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 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 Managed Care Organizations (MCOs) 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 Partnership Program will assist MCOs 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 and Organization to Accomplish Objectives
The Department of Health Services contracts with MCOs 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). The funds were capitated and a graduated risk-sharing plan was in effect. Wisconsin received a Medicaid/Medicare waiver from the Federal Health Care Financing Administration (Centers for Medicare and Medicaid Services) and began full Medicaid/Medicare capitation in January 1999.
The Wisconsin Department of Health Services is the State Medicaid Agency. The Managed Care Section in the Office of Family Care Expansion is responsible for the design and development of the Partnership Program. Staff at the Department 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), Partnership Program (1994), and Family Care (1998). On September 27, 2001, the Partnership Program received a grant from the Robert Wood Johnson Foundation to support Partnership's participation in the Foundation's Medicare/Medicaid Integration Program.
Partnership Managed Care Organizations
The first site of the Partnership Program for Elderly People was Elder Care of Dane County, a community-based, not-for-profit organization that provides services to elderly people in Dane County, Wisconsin. The Community Care Organization in Milwaukee, a full risk comprehensive PACE site, was the second Partnership site serving the elderly.
The Community Living Alliance in Madison, Wisconsin became the first site of the Partnership Program for persons with physical disabilities. An additional site was selected at the end of 1995, the Community Health Partnership, Inc. in Eau Claire.
Pooling the Resources of Managed Care Organizations
The managed care 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 jointly developed.
For additional information regarding the Partnership Program, contact:
Wisconsin Department of Health Services
Division of Long Term Care
Bureau of Managed Care
One West Wilson Street
PO Box 7851
Madison, WI 53707-7851
Bureau of Managed Care
Division of Long-Term Care
Department of Health Services
State of Wisconsin
In Partnership with:
U.S. Centers for Medicare & Medicaid Services
Care Wisconsin Health Plan, Inc., Madison, WI
Community Care Health Plan, Inc., Milwaukee, WI
Independent Care Health Plan, Milwaukee, WI
Dane County Department of Human Services
Eau Claire County Department of Human Services
Milwaukee County Department of Aging
University of Wisconsin-Madison
Office of the Commissioner of Insurance
Made possible by a grant from:
The Robert Wood Johnson Foundation