Washington State Health Reform

Washington State Health Reform
Quarterly Meeting Northwest Portland Area Indian Health Board January 20, 2015

Agenda Integrated Purchasing of Medicaid Physical and Behavioral Health Care Background Coming Changes Planning Calendar Possible System Models Possible Service Models Other Questions Comments – January 5, 2014 Accountable Communities of Health Governor’s Health Innovation Leadership Network Seeking recommendations for Tribal Representative and Urban Indian Organization Representative

Integrated Purchasing of Medicaid Physical and Behavioral Health Care
Background

Apple Health (Medicaid) Managed Care
Since early 1990s, Medicaid transitioning beneficiaries to health plans with CMS approval Today, over 90% of full-benefit Medicaid eligibles covered through Apple Health Managed Care Plans State pays PMPM (per-member, per-month) to Plans with defined set of benefits for defined groups —each Plan is fully “at risk”* for care of assigned population Currently, Apple Health Managed Care Plans cover physical health care services and mental health care services below the access to care standard *”at risk” means that the MCO is paid a per member per month (PMPM) rate to provide the full array of services they are under contract for. If the MCO spends more than it receives from HCA, the MCO loses money. If the MCO spends less than it receives, the MCO can keep a portion of this money. CMS requires the PMPM to be an actuarial rate and HCA to monitor and incentivize MCOs to ensure appropriate care is provided to clients.

Managed Care Today: Not Integrated
State contracts with entities to provide Medicaid services by county Entity Physical health care MCOs Mental health care Below “access to care” standard Above “access to care” standard RSNs MCO = Medicaid Managed Care Organization RSN = Regional Support Network Other Medicaid services (such as chemical dependency treatment and dental services) are provided outside of managed care (on a fee-for-service basis)

Legislative Directives (Senate Bill 6312)
Purchasing Reforms Clinical Integration Regional purchasing - DSHS & HCA jointly establish common regional service areas for behavioral health and medical care purchasing County authorities elect fully integrated purchasing (Early Adopter RSAs) by April 2016, with opportunity for shared savings incentive payment (up to 10% of state savings in region) Other RSAs – separate managed care contracts for physical health (MCOs) and integrated behavioral health care (newly created Behavioral Health Organizations) Primary care services available in mental health and chemical dependency treatment settings and vice versa Access to recovery support services Opportunity for dually-licensed CD professionals to provide services outside CD-licensed facility

Goals: Integrated Purchasing of Managed Care
Provide more holistic, better managed care for people with co- occurring disorders. Support seamless access to services with standards and medical necessity guidelines in one system, without “access to care” standard. Improve ability to monitor quality across all providers Quality metrics in managed care contracts Sanctions for specific performance measures. Align financial incentives for expanded prevention and treatment and improved outcomes across physical and behavioral health systems. Create system for interdisciplinary care teams that are accountable for full range of physical and behavioral health services. Improve information and administrative data sharing, making relevant information more available to multidisciplinary care team.

Coming Changes

Regional Service Areas (RSAs)
Parallel Paths to Integrated Purchasing 2014 Legislative Action: 2SSB 6312 By January 1, 2020, the community behavioral health program must be fully integrated in a managed care health system that provides mental health services, chemical dependency services, and medical care services to Medicaid clients 2020: Full Integration of Behavioral Health and Medical Care Across the State Transition Period Apple Health Managed Care Plans Behavioral Health Organizations Fully Integrated Purchasing in “Early Adopter” RSAs, with shared savings incentives 2016 Regional Service Areas (RSAs)

Medicaid Managed Care Purchasing in 2016
State will contract with entities to provide Medicaid services by RSA Today Beginning April 1, 2016 By County All Other RSAs Early Adopter RSAs Physical health care MCOs Mental health care Below “access to care” standard Above “access to care” standard RSNs BHOs MCOs* Chemical dependency treatment FFS *There will be no “access to care” standard in Early Adopter RSAs “Access to care” standard is a threshold for intensity of mental health services that are needed for a client. BHO = Behavioral Health Organization FFS = Fee-For-Service (not managed care) MCO = Medicaid Managed Care Organization RSA = Regional Service Area RSN = Regional Support Network

Regional Service Area Designations
By April 1, 2016, HCA and DSHS will regionalize purchasing of health care services.

North Central RSA in Transition
Transitional two-RSA approach for counties presently served by the Chelan-Douglas and Spokane RSNs: Apple Health Managed Care: New North Central RSA separate from Spokane RSA BHO: Single BHO will serve new North Central and Spokane RSAs during the transition 2020 Full Integration: Fully integrated managed care is required in 2020 by Senate Bill North Central and Spokane RSAs will be separate regions for purposes of integrated physical and behavioral health managed care systems in 2020.

Special Cases − Potential Early Adopter RSAs
Counties in 3 RSAs have expressed interest in early adoption of fully integrated physical and behavioral health care purchasing in Non- binding letters of intent are due in January 2015.

Medicaid Purchasing in “Early Adopter” RSAs
Standards being developed jointly by HCA and DSHS County authorities in an RSA must agree to become Early Adopter RSAs Procurement process will be necessary to select MCOs Compliance with Medicaid and State managed care contracting requirements Shared savings incentives Payments to Early Adopter counties targeted at 10% of savings realized by the State, based on outcome and performance measures Available for up to 6 years or until fully integrated purchasing occurs statewide Models continue to be discussed broadly

Some Criteria for MCO Early Adopter Participation
Managed care organizations must: Meet network adequacy standards established by HCA and pass readiness review Provide full continuum of comprehensive services, including critical provider categories (e.g., primary care, pharmacy, and behavioral health) Ensure no disruption to ongoing treatment regimens Be licensed as an insurance carrier by the Office of the Insurance Commissioner Meet quality, grievance and utilization management and care coordination standards and achieve NCQA accreditation by December 2015

Currently Proposed Roles
HCA Final accountability for contracts in all RSAs Oversee MCO performance Collect data from MCOs and share data with County/ACH Analyze data or contracts Impose sanctions for nonperformance Incentives for exceeding minimum performance Establish “early warning system” for problems Inform/engage ACH/County where appropriate to amend contracts to improve regional responsiveness County Determine whether to become Early Adopter In Early Adopter RSAs, designate Implementation Team members to work with HCA/DSHS in AH contracting activities: Develop contract language for the fully-integrated managed care program Review draft contracts Participate in procurement review and selection process for the RSA they represent Review data and information gathered through health plan readiness assessment process Designate one member of HCA/DSHS Monitoring Team to participate in ongoing quality and performance monitoring Alert HCA as to health system issues at local level and make recommendations for improvements ACH Create mechanism for receiving performance data Share information with State and MCO partners on findings based on regional health needs inventory/planning. Partner with HCA to develop contract requirements for health plans to participate in health transformation planning Partner with MCOs in at least one local health transformation project Designate participants for HCA/DSHS Monitoring Team to do ongoing quality and performance monitoring MCO Determine which RSAs to bid on Supply network information in all RSAs Supply response to RFP in Early Adopter RSAs Pass readiness review Partner with ACH in at least one local health transformation project Participate in ongoing meetings of ACH

PLANNING CALENDAR

Medicaid Integration Timeline
2014 2015 2016 Early Adopter Regions JUN Prelim. models JUL Model Vetting OCT-DEC Regional data; purchasing input JAN-MAR Full integ. Draft contract MCO/Stakeholder Feedback MAR Full integ. RFP Draft managed care contracts/ Preliminary Rates JUN MCO Responses Due AUG Vendors selected NOV Final managed care contracts JAN Signed contracts Common Elements JUL Prelim. County RSAs SEP Final Task Force RSAs NOV DSHS/HCA RSAs Joint purchasing policy development MAY-AUG Submit 2016 federal authority requests Provider network review P1 correspondence DEC- JAN Federal authority approval; Readiness review begins MAR CMS approval complete MAR SB 6312; HB 2572 enacted APR Integrated coverage begins in RSAs BHO/ AH Regions DEC-FEB Review and alignment of WACs for behavioral health MAR-MAY Development of draft contracts and detailed plan JUL BHO detailed plan requirements Draft BHO managed care contracts 2016 AH MCOs confirmed AH RFN (network) OCT BHO detailed plan response AH network due NOV JAN AH BHO contract detailed signed plans reviewed Revised AH MC contract APR Final BHO and rev. AH contracts OCT-DEC BHO Stakeholder work on rates; benefit planning for behavioral health RSA – Regional service areas MCO – Managed Care Organization BHO – Behavioral Health Organization AH – Apple Health (medical managed care) SPA – Medicaid State Plan amendment CMS – Centers for Medicare and Medicaid Services Early Adopter Regions: Fully integrated purchasing BHO/AH Regions: Separate managed care arrangements for physical and behavioral health care November 4, 2014 Key Opportunities for Tribal Feedback and Consultation

HCA Calendar for Early Adopter Planning & Implementation
Key Purchasing Milestones January 2015 Early Adopter Model Options completed for discussion Draft MCO Contract available for review Non-binding letters of intent due from potential Early Adopter RSA counties Late March 2015 RFP to be issued for MCO vendor selection, using MCO Contract June – August 2015 MCO vendor selection process (Note: County decisions on Early Adopter RSAs to be made prior to final vendor selection) December 2015 – March 2016 Early Adopter RSA implementation readiness review process April 2016 Performance monitoring begins Tribal consultation/ comments on: Draft MCO Contract, Early Adopter Model Options, and Criteria for MCO vendor selection (part of RFP process).

POSSIBLE SYSTEM MODELS
Integrated Purchasing of Medicaid Physical and Behavioral Health Care POSSIBLE SYSTEM MODELS

Chemical Dependency Providers
Potential BHO RSA Model: Physical & Behavioral Health Purchasing with Separate Managed Care Arrangements State Mental Health & Chemical Dependency Providers Individual Client DRAFT Collaboration Counties Accountable Communities of Health Business Community/Faith-Based Organizations Consumers Criminal Justice Education Health Care Providers Housing Jails Local Governments Long-Term Supports & Services Managed Care Organizations Philanthropic Organizations Public Health Transportation Tribes Etc. Behavioral Health Organizations Mental health (Access to Care Standard (ACS)) Substance use disorders Apple Health Managed Care Plans Physical health Mental health (non-ACS) DRAFT Carved-Out Services & Tribal Programs Physical Health, & limited Mental Health (non-ACS) providers

Early Adopter Agreement
Potential Early Adopter RSA Model: Fully Integrated Physical & Behavioral Health Purchasing with Standard Managed Care Arrangements Early Adopter Agreement State Physical Health, Mental Health and Chemical Dependency Providers Accountable Communities of Health Business Community/Faith-Based Organizations Consumers Criminal Justice Education Health Care Providers Housing Jails Local Governments Long-Term Supports & Services Managed Care Organizations Philanthropic Organizations Public Health Transportation Tribes Etc. Individual Client Licensed Risk-Bearing Managed Care Plans Counties in RSA DRAFT Collaboration DRAFT Carved-Out Services & Tribal Health Programs

Early Adopter Agreement
Potential Early Adopter RSA Model : Fully Integrated Physical & Behavioral Health Purchasing with Single Shared Regional Behavioral Health Network Early Adopter Agreement State Physical Health, Mental Health and Chemical Dependency Providers Accountable Communities of Health Business Community/Faith-Based Organizations Consumers Criminal Justice Education Health Care Providers Housing Jails Local Governments Long-Term Supports & Services Managed Care Organizations Philanthropic Organizations Public Health Transportation Tribes Etc. Individual Client Licensed Risk-Bearing Managed Care Organizations Counties in RSA DRAFT Collaboration DRAFT Single shared regional network of essential behavioral health providers Carved-Out Services & Tribal Programs

POSSIBLE SERVICE MODELS
Integrated Purchasing of Medicaid Physical and Behavioral Health Care POSSIBLE SERVICE MODELS

Current Medicaid + Non-Medicaid Service Administration
AI/AN Population MC Plan? Medicaid Funded Services Entity State/Local Funded Services Medicaid Clients Yes Physical + some mental health MCO Examples: Involuntary Treatment Act Therapeutic Courts Transitional Care Coordination from Prison or IMDs Inpatient chemical dependency treatment IMD/State Mental Health Hospital inpatient care RSN County RSN/ County State Mental health Chemical dependency County FFS No FFS RSN + FFS Non-Medicaid Clients

Medicaid-Funded Services – Early Adopter RSAs & Behavioral Health
AI/AN Population MC Plan? Medicaid Funded Services Entity Medicaid Enrollees Yes Physical health, mental health, and chemical dependency services MCO No FFS* Not Eligible for Medicaid Questions: There may be transition period for MCOs to build in-house behavioral health expertise. HCA is considering allowing subcontracting of certain essential behavioral health functions (but not financial risk) for 18 months. Are the proposed “essential behavioral health functions” the right functions to allow subcontracting for? Is 18 months the right timeframe? Are there other limits on subcontracting to consider? “Essential Behavioral Health Functions” would include utilization management, network development, provider relations, quality management, data management and reporting. *In Early Adopter RSAs, there may not be a county-based entity responsible for mental health or chemical dependency treatment.

Medicaid-Funded Services – Early Adopter RSAs & AI/AN Clients
AI/AN Population MC Plan? Medicaid Funded Services Entity Medicaid Enrollees Yes Physical health, mental health, and chemical dependency services MCO No FFS* Not Eligible for Medicaid Questions: How can HCA facilitate better care for Medicaid clients who opt out of Managed Care? What can HCA do to keep AI/ANs in Managed Care?? How can HCA best support Tribal clinics? Would Tribal clinics consider becoming in- network providers? How can HCA facilitate better care coordination between BHOs and MCOs across RSAs? *In Early Adopter RSAs, there may not be a county-based entity responsible for mental health or chemical dependency treatment.

State/Local-Funded Services – Early Adopter RSAs & Non-Medicaid Funds
Potential Entities in Early Adopter RSAs to Perform Service Examples: Involuntary Treatment Act Therapeutic Courts Transitional Care Coordination from Prison or IMDs Inpatient chemical dependency treatment IMD/State Mental Health Hospital inpatient care MCO With services carved-in or carved-out of MCO contract ASO (administrative service organization) For services carved- out of MCO contract) County Alternative to ASO Question: Who should administer these funds and services? Each MCO administers portion of non-Medicaid funds Single MCO or Administrative Service Organization (ASO) administers all non-Medicaid funds in coordination with MCOs Split design Each MCO administers funds for Medicaid clients Single MCO or ASO administers funds for non-Medicaid clients

State/Local-Funded Services – Early Adopter RSAs & State Hospital Beds
Potential Entities in Early Adopter RSAs to Perform Service Examples: Involuntary Treatment Act Therapeutic Courts Transitional Care Coordination from Prison or IMDs Inpatient chemical dependency treatment IMD/State Mental Health Hospital inpatient care MCO With services carved-in or carved-out of MCO contract ASO (administrative service organization) For services carved- out of MCO contract) County Alternative to ASO Question: How will state hospital beds be allocated and how will MCOs reimburse the State if the hospital bed allocation in their region is exceeded?

State/Local-Funded Services – Early Adopter RSAs & Crisis Services
Question: Should the State contract with an ASO on a regional basis for the provision of crisis services? Are there other models that make more sense? Model 1 – ASO holds non-Medicaid contract and bills MCOs for Medicaid-allowable services Model 2 - ASO holds Medicaid and non-Medicaid contract with the State Which “crisis services” should be part of the regional crisis system managed by the ASO? What should go into the contract for the MCOs (E&T services)? If MCOs are not at financial risk for their clients’ use of the crisis system (Model 2), how do we ensure that MCOs use the crisis system appropriately? State/Local Funded Services Potential Entities in Early Adopter RSAs to Perform Service Examples: Involuntary Treatment Act Crisis Services Therapeutic Courts Transitional Care Coordination from Prison or IMDs Inpatient chemical dependency treatment IMD/State Mental Health Hospital inpatient care MCO With services carved-in or carved-out of MCO contract ASO (administrative service organization) For services carved- out of MCO contract) County Alternative to ASO

Medicaid Managed Care Organizations
Early Adopter RSAs & Crisis Services – Model 1 DRAFT DRAFT State Individual Client Medicaid Managed Care Organizations Medicaid Contract Non-Medicaid Contract for Non-Medicaid Crisis Services Medicaid Contract Non-Medicaid Regional Crisis System Managed by ASO Medicaid Managed Care Organization Medicaid billing Medicaid billing Required sub-contract Required sub-contract Data reporting Examples of Behavioral health including: E&T providers DMHPs/CDPs – 24/7 Crisis hot line Crisis stabilization Continuum of Integrated Clinical Services

Early Adopter RSAs & Crisis Services – Model 2
DRAFT DRAFT State Individual Client Medicaid Managed Care Organizations (Penalties when members access crisis) Medicaid Contract Non-Medicaid PMPM for Medicaid Crisis Non-Medicaid Crisis Contract Medicaid Contract Non-Medicaid Regional Crisis System Managed by ASO Medicaid Managed Care Organization (Penalties when members access crisis) Required Coordination Required Coordination Data reporting Examples of Behavioral health including: E&T providers DMHPs/CDPs – 24/7 Crisis hot line Crisis stabilization Continuum of Integrated Clinical Services

Potential Crisis System Models: Descriptions
Single regional behavioral health crisis system, managed by an Administrative Service Organization, (ASO) subcontracts with an established regional behavioral health crisis provider system, for the delivery of Medicaid and non-Medicaid crisis services to Medicaid and non-Medicaid individuals on a cost-reimbursement basis. The ASO holds a contract with the State for all non-Medicaid services, provided to both Medicaid and non-Medicaid enrollees. MCOs in the region are required to subcontract with the ASO for the provision of Medicaid/non-Medicaid crisis services to their enrollees. In this model, the ASO would bill the MCO for Medicaid-allowable services provided to their enrollees, which would be included in the MCO’s Medicaid PMPM. The ASO’s contract with the State would fund the non-Medicaid services provided to the Medicaid enrollees and non-Medicaid individuals. The State-ASO contract would also include funding (as in the case of RSNs today) for the ASO to reimburse the county for court costs. Single regional behavioral health crisis system, managed by an Administrative Service Organization (ASO), subcontracts with an established regional behavioral health crisis provider system, for the delivery of Medicaid and non-Medicaid crisis services to Medicaid and non-Medicaid individuals on a cost-reimbursement basis. ASO holds a contract with the State for all non-Medicaid services, provided to both Medicaid and non-Medicaid enrollees. The ASO also receives a PMPM for all Medicaid crisis services provided to Medicaid enrollees. The cost for Medicaid crisis services is not included in the PMPM for Medicaid managed care organizations (MCOs). MCOs are required, in contract, to coordinate with the crisis system and are penalized when their members access the crisis system or held at performance risk for their members use of crisis services.

OTHER QUESTIONS

Behavioral Health Provider Network
What behavioral health provider types should be included in the Essential Community Provider Network? CMHAs, state-owned and operated hospitals, crisis providers, inpatient and outpatient SUD providers Opioid treatment programs Mobile crisis, crisis residential, respite beds

Model of Care Draft Model of Care available for review
Draft Model of Care will be background for procurement Questions: What needs to be strengthened? Is any section overly prescriptive? Has anything been left out? Does the framework (4 quadrant adaptation) help with understanding of program goals?

COMMENTS - january 5

Medicaid Integrated Purchasing – Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns HCA’s Response Mobile clients: What protections will MCO clients have when they travel outside an RSA? MCO clients will have access to urgent care when traveling outside an RSA (like today). Access to specialty care: What happens if MCO client needs access to a provider type not in an RSA? MCO clients who need specialty care not available in RSA will be referred to provider outside the RSA (like today). Medicaid incentives for providers: Are there plans to improve incentives for providers to accept Medicaid? MCOs ensure access to sufficient providers in their networks, but this is a challenge for fee-for-service. IHS encounter rate: Will Tribes receive the encounter rate in Medicaid managed care? The encounter rate is paid as a wraparound payment for care to AI/ANs enrolled as MCO clients. Federal grant opportunity: There is currently a federal grant opportunity for tribal care integration. HCA would be happy to work with Tribes on this. Please share more on this.

Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015
HCA’s Response County oversight of MCOs/BHOs: Tribes are not subordinate to the counties, but counties appear to be the primary governance authorities. AI/ANs continue to be exempt from Medicaid managed care, but this raises the following questions. Tribes and counties have roles to play in MCO oversight. HCA Question: How do we make sure Tribes still have access to behavioral health services in Early Adopter RSAs? HCA Question: How do we best serve AI/ANs and Tribes in this changing Medicaid purchasing environment? MCO contracts with Tribes: It has been difficult even for Tribes that want to contract with MCOs to finalize these contracts. What will be done? HCA would appreciate Tribal input on how to make contracting with MCOs more streamlined and effective. Culturally competent care: Tribes do not want interference from MCOs. HCA agrees.

HCA’s Response MCOs and Tribes: Why isn’t there a requirement for MCOs to collaborate with Tribes? Until recently, Tribes have been mostly outside the MCO system. HCA is now seeking input from Tribes to bring better collaboration/coordination with MCOs. PCCM and Health Homes: What’s happening with the PCCM and Tribal Health Home programs? HCA is currently in discussions with CMS on the PCCM program. The Tribal Health Home program is for higher need clients. Health equity goals in MCO contract: For the Early Adopter regions, would HCA include RFP criteria for MCOs to target health equity goals, such as reducing uninsurance among urban AI/ANs? North Sound RSN is working with Tribes on how they will meet AI/AN needs. Great suggestion.

HCA’s Response Tribal comments to MCO contract: It is important for Tribes to comment on the HCA-MCO contract. The comment window will be short, but we want Tribal comments. We will also share the set of clinical criteria HCA is working on; this is still a few weeks out. Tribes in Early Adopter RSAs: Which RSAs will be Early Adopters? The counties have until January 16, 2015 to give non-binding letters of intent to be Early Adopters. We have received indications of interest from King County, Pierce County, and Clark County. Tribes and MCO RFP review: Can Tribes be part of the RFP review? We would appreciate input from the Tribes. Tribes can also participate in developing the MCO selection criteria that will drive the RFP review. List of Non-Medicaid Services: Can Tribes get the full list of non-Medicaid services? HCA will provide the full list when it is completed.

HCA’s Response Burden to Tribes: Creating new relationships in a new system is an added burden for Tribes. This is a huge job. HCA will do what it can to reduce this burden. Lack of trust with MCOs: Tribes still do not trust MCOs and RSNs (to be BHOs). HCA would like to hear what has been problematic in the past and how HCA could facilitate better relations. IHS encounter rate: Washington needs to protect the IHS encounter rate. HCA has no intention to eliminate the IHS encounter rate. MCO standards for Tribes: What MCO standards will Tribes have to adhere to if they contract with MCOs? HCA is hosting a meeting with the MCOs and Tribes in Olympia on February 13, 2015 to discuss these issues. Specialty networks and Tribes: Tribes need guarantee that MCOs will work with Tribes in effective way for AI/ANs to access MCO specialty networks.

HCA’s Response MCO pass-through of encounter rate: Why doesn’t the State allow MCOs to pay Tribes the encounter rate? The Tribes would prefer this. HCA and MCOs are in the middle of implementing this for FQHCs. HCA will look into extending this to Tribes after the kinks are worked out. MCO interest in/support to Tribes: Tribes have excellent programs. MCOs should be knocking on our doors to learn and support our programs, instead of telling us to follow their rules. How do MCOs see themselves helping Tribes to become better primary care providers? HCA is hosting a meeting with the MCOs and Tribes in Olympia on February 13, 2015 to discuss these issues. MCOs and encounter rate: If Tribes contract with MCOs, how will that affect the encounter rate? Tribes will still be able to receive the encounter rate for services to MCO-enrolled AI/ANs. MCOs pay providers in many ways, in attempts to reward keeping clients healthy rather than encounters.

HCA’s Response MCOs and Tribal network adequacy: What incentives will MCOs have to contract with Tribes? It has been difficult. MCOs have network adequacy requirements. Tribes may be very attractive in some parts of the State. Tribal members and MCOs: Tribal members do not trust outside entities. This is not going to be easy. HCA would like to work with Tribes to identify the benefits and the concerns from contracting with MCOs. MCO contract and non-Natives: If a Tribe contracts with an MCO, will the Tribe be forced to see non-Native patients? If a Tribe sees non-Native patients for medical care but not for behavioral health care due to lack of capacity, will contracting with an MCO interfere with the Tribe’s decision on whom to treat? HCA and the MCOs have certain legal requirements regarding access, waiting periods, urgent care, etc. However, Tribes have the right to determine whom their clinics treat. HCA would like to hear more about these concerns and work through these issues with Tribes.

HCA’s Response Tribes are different: Different Tribes have different issues. These issues are more complex than Medicaid expansion. HCA will a list of issues and ask Tribal Health Directors to identify which issues apply to their Tribe. Tribal MCO: For Tribes that serve only AI/AN clients, can they be an MCO for natives? HCA can explore this with the Tribes. Facility-based payment: Tribal clinic may have multiple primary care providers who serve clients as a team. MCOs seem to expect one PCP to see the client. If this does not happen, the MCO holds up payment. More and more patients are being assigned to a clinic rather than a provider. This is pretty easily negotiated in a contract. MCO support for case management: We don’t get paid for case management, but it is very effective so we do it. More and more MCOs are paying for community health workers, nurses, social workers. Many more options than before.

HCA’s Response Tribes that opt out: MCOs and Tribes are of two different cultures. MCOs focus on money; Tribes focus on sustainable care. How can Tribes not be pressured to contract with MCOs (opt out of the managed care system)? AI/ANs will continue to have the federal exemption from managed care, and Tribes will continue to receive the encounter rate for services provided at the Tribal clinic.

Accountable Communities of Health
Background

Healthier Washington Improving how we pay for services …so people and their providers can choose the best treatment options Ensuring health care focuses on the whole person …people’s physical and mental health care are integrated to better meet their needs Building healthier communities through a regional approach …local organizations work together to build strategies that work for their community

Healthier Washington Strategies include:
Accountable Communities of Health to support locally-driven goals, approaches, and processes Redesign of provider payments* to improve the quality and value of care Creation of a regional extension service to share information about best practices *Tribes are not participating in provider payment redesign effort.

What is an Accountable Community of Health (ACH)? A group of public and private organizations and individuals working together to integrate health care and improve health in their region Participants include: public health, housing, and social service providers; MCOs; insurers; county and local government; Tribes; and consumers Clinical Community ACHs

ACHs are intended to regionally align with Regional Service Areas (RSAs) in order to enable ACH input on Medicaid purchasing priorities to ensure they are responsive to regional health needs. ACH input will be informed by data on population health produced by HCA and DSHS and its partners and provided to the ACH for development of a health action plan. The State proposes phased engagement of ACHs based on the evolution of the ACH Initiative and the maturation of ACHs as follows: Statewide procurement objectives that address regional needs and perspectives; Assessment of MCO RFP responses for the ACH’s specific region; On-going oversight of MCO and BHO effectiveness; Sharing of public health and managed care data to inform priorities for improving health within the ACH in partnership with public and private entities within the ACH boundary.

An Accountable Community of Health is not intended to: Add approval layers Replace government entities Divert state funds Bear financial risk

Two ACH Pilot Grants have been awarded to: CHOICE Network (Cascade Pacific Action Alliance) Counties: Mason, Thurston, Lewis, Grays Harbor, Cowlitz, Pacific, Wahkiakum North Sound Counties: Snohomish, Skagit, Whatcom, San Juan, Island ACH Design Grants to be awarded

How are ACHs different from Oregon’s Coordinated Care Organizations (CCOs)?
What are they? Local health entities that will deliver health care and coverage for people eligible for the Oregon Health Plan (Medicaid), including those also covered by Medicare. “To-be created” regionally governed, public-private collaborative or structure, built using a collective impact/health in all policies approach. (ACHs do not exist yet) Governance Structure Governed by a partnership among health care providers, community members, and stakeholders in the health systems. Majority must be risk bearing members. The precise organizational and governance structure will not be dictated at the State level. No one single entity or group of entities will control the direction. What is their focus? Deliver integrated, preventive, patient-centered care for physical, behavioral and dental health. Be a forum and organizational support structure for a region to achieve transformative health results through collaboration across sectors. Are they risk-bearing? Yes No

How are ACHs different from Oregon’s Coordinated Care Organizations (CCOs)?
How does this change health care financing? CCOs receive global budgets for physical, behavioral and dental health to treat the population, with fixed rate of increase. Incentives are tied to achievement of benchmarks for pre-determined measures. To be determined. How does this change health care delivery? Coordinated care, with flexibility in CCO budgets to try new payment methodologies and interventions to address the whole person. To be determined. Each ACH will have a Practice Support agent connected to the Practice Support Hub (at the state level). Do they monitor population health? Yes, of enrollees in regions they serve. However, CCOs recognize the health of its enrollees is aligned with the health of the region as a whole. Of everyone in region, in partnership with many entities, specifically public health. How are they held accountable? Each CCO region has an oversight panel of community members, providers, and stakeholders. Each ACH region has a governance structure expected to include community members, providers, stakeholders, and Tribal members.

The ACH Timeline

Total Four-Year ACH Budget: $10.8 million ACH Design and Implementation (including personnel, travel, consultants, grants) Year 1 ~ 2 Pilot ACHs ~ 8 Design Regions Years 2 – 4 ~ 10 ACHs ACH-Tribal Coordination

Total Four-Year ACH-Tribal Coordination Budget: $300,000 Proposed Funding Structure for RFP: Year 1 (pre-implementation year): $75,000 Year 2: $150,000 Year 3: $50,000 Year 4: $25,000 Proposed Contract Deliverables to HCA: Protocols, templates, coordination plans for ACHs to engage with Tribes in their regions Data analytic recommendations for ACHs Recommendations for maintaining ACH-Tribal coordination process

ACH-Tribal Coordination Principles Health disparity reduction is a key goal of ACHs ACH participants are expected to understand and respect the Tribal-State government-to-government relationship Framework Tribal representation on local ACH governance/oversight board Tribe may invoke right to have State participate in any ACH meetings State must be cc’d on all written communication from ACH to Tribes

ACH-Tribal Coordination Financial Support Deliverables Principles Framework How can HCA facilitate productive relationships between ACHs and Tribes/Urban Indian Organizations in order to improve the health of American Indians/Alaska Natives?

Comments – January 5

Accountable Communities of Health – Tribal Thoughts/Concerns from January 5, 2015
HCA’s Response ACH Accountability: What is the mechanism for holding any of the participants accountable? RSNs have not worked for Tribes at all. ACH is accountable for priorities community has established to its partners/participants, its community, and the State for the pilot funding for the test grant. ACH is accountable through community’s sustainability plan for the ACH. ACH-Tribal Coordination: How is the ACH meant to interface with the Tribes? The budget described is intended to support the work needed to answer this question. These funds could enable Tribes to identify data analysis requirements and priorities (or protocols to identify priorities) specific to AI/ANs that all ACHs should use.

HCA’s Response ACH Organization: What is this ACH office going to look like? Is it a board? Is it social workers who come to the Tribes? Is it one office? Multiple offices in a region? The organization of ACHs will likely vary. HCA envisions boards of directors, including Tribal representation. If the organizational structure does not work, HCA will make adjustments. ACH Backbone Organizations: Who is HCA looking at to begin this process? Develop these boards? Each ACH is expected to have a backbone organization, such as non-profit community organizations or local health jurisdictions. HCA will provide link to list of backbone organizations. For example, Kitsap County Public Health will likely be the backbone organization for the ACH in Clallam, Jefferson, and Kitsap Counties. SPIPA: Please note that SPIPA decided it would not move forward as a backbone organization.

HCA’s Response ACH as Supplemental: Will ACHs compete with Tribes in providing services? No. ACHs will supplement Tribal services. Tribal Participation: So, a “to do” each Tribe could take care of is designating someone to link into these ACH efforts? Yes. HCA will be available to assist Tribal designees in linking with the ACH planning efforts. Government-to-Government Relations: RSNs have not always recognized the government-to-government relationships between the State and the Tribes. If these ACHs are non-profits, what is the take on the government-to-government relationship with the ACHs. This is why HCA is seeking Tribal input into how to facilitate Tribal participation in ACHs that will respect Tribal sovereignty while facilitating effective regional coordination of health care and support services. While the ACHs are contemplated to be non-governmental partnerships, HCA will be responsible for ensuring that the government-to-government relationship is respected.

HCA’s Response State Commitment: Are there state dollars to fund this? The CMMI grant is supporting this effort. The legislature put up $1 million last year. State agencies are contributing in-kind support. HCA: ACHs have more to learn from Tribes than from almost any other sector. How can we learn from Tribes about serving communities and addressing health disparities? How can ACHs bring resources to help address Tribal concerns? ACH Sustainability: What is the plan for ACH sustainability? The ACH initiative is a demonstration, to enable ACHs to show their value. As the ACHs show their value, various funding sources would likely become possible. ACH Cultural Competency: Having non-Natives raise cultural competency questions would be helpful. HCA could include requirements for ACH participants to receive cultural competency training.

Governor’s Health Innovation Leadership Network
Healthier Washington Governor’s Health Innovation Leadership Network

Health Innovation Leadership Network
The Governor’s Office seeks recommendations for two people to serve 1-year terms on HILN: A Tribal representative, and An Urban Indian Organization representative.

What is HILN? HILN is a public-private network to accelerate Healthier Washington efforts. With the award of the CMMI grant, the Governor is creating HILN from the members of the Executive Management Advisory Council (which informed the State Health Care Innovation Plan).

What is HILN intended to do? Monitor, inform and accelerate Healthier Washington progress Identify barriers and opportunities for alignment, scale and spread

Please let me know if: You have any recommendations You have any questions about HILN

RESOURCES HCA Healthier Washington:
DSHS Developing Behavioral Health Organizations: Washington Adult Behavioral Health System Task Force:

Washington State Health Reform

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