Presentation on theme: "Washington State Health Reform"— Presentation transcript:
1Washington State Health Reform Quarterly MeetingNorthwest Portland Area Indian Health BoardJanuary 20, 2015
2AgendaIntegrated Purchasing of Medicaid Physical and Behavioral Health CareBackgroundComing ChangesPlanning CalendarPossible System ModelsPossible Service ModelsOther QuestionsComments – January 5, 2014Accountable Communities of HealthGovernor’s Health Innovation Leadership NetworkSeeking recommendations for Tribal Representative and Urban Indian Organization Representative
3Integrated Purchasing of Medicaid Physical and Behavioral Health Care Background
4Apple Health (Medicaid) Managed Care Since early 1990s, Medicaid transitioning beneficiaries to health plans with CMS approvalToday, over 90% of full-benefit Medicaid eligibles covered through Apple Health Managed Care PlansState 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 populationCurrently, 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.
5Managed Care Today: Not Integrated State contracts with entities to provide Medicaid services by countyEntityPhysical health careMCOsMental health careBelow “access to care” standardAbove “access to care” standardRSNsMCO = Medicaid Managed Care Organization RSN = Regional Support NetworkOther Medicaid services (such as chemical dependency treatment and dental services) are provided outside of managed care (on a fee-for-service basis)
6Legislative Directives (Senate Bill 6312) Purchasing ReformsClinical IntegrationRegional purchasing - DSHS & HCA jointly establish common regional service areas for behavioral health and medical care purchasingCounty 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 versaAccess to recovery support servicesOpportunity for dually-licensed CD professionals to provide services outside CD-licensed facility
7Goals: 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 providersQuality metrics in managed care contractsSanctions 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.
8Integrated Purchasing of Medicaid Physical and Behavioral Health Care Coming Changes
9Regional Service Areas (RSAs) Parallel Paths to Integrated Purchasing2014 Legislative Action: 2SSB 6312By 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 careservices to Medicaid clients2020:Full Integration of Behavioral Health and Medical Care Across the StateTransition PeriodApple Health Managed Care PlansBehavioral Health OrganizationsFully Integrated Purchasing in “Early Adopter” RSAs, with shared savings incentives2016Regional Service Areas (RSAs)
10Medicaid Managed Care Purchasing in 2016 State will contract with entities to provide Medicaid services by RSATodayBeginning April 1, 2016By CountyAll Other RSAsEarly Adopter RSAsPhysical health careMCOsMental health careBelow “access to care” standardAbove “access to care” standardRSNsBHOsMCOs*Chemical dependency treatmentFFS*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 OrganizationFFS = Fee-For-Service (not managed care)MCO = Medicaid Managed Care OrganizationRSA = Regional Service AreaRSN = Regional Support Network
11Regional Service Area Designations By April 1, 2016, HCA and DSHS will regionalize purchasing of health care services.
12North 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 RSABHO: Single BHO will serve new North Central and Spokane RSAs during the transition2020 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.
13Special 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.
14Medicaid Purchasing in “Early Adopter” RSAs Standards being developed jointly by HCA and DSHSCounty authorities in an RSA must agree to become Early Adopter RSAsProcurement process will be necessary to select MCOsCompliance with Medicaid and State managed care contracting requirementsShared savings incentivesPayments to Early Adopter counties targeted at 10% of savings realized by the State, based on outcome and performance measuresAvailable for up to 6 years or until fully integrated purchasing occurs statewideModels continue to be discussed broadly
15Some Criteria for MCO Early Adopter Participation Managed care organizations must:Meet network adequacy standards established by HCA and pass readiness reviewProvide full continuum of comprehensive services, including critical provider categories (e.g., primary care, pharmacy, and behavioral health)Ensure no disruption to ongoing treatment regimensBe licensed as an insurance carrier by the Office of the Insurance CommissionerMeet quality, grievance and utilization management and care coordination standards and achieve NCQA accreditation by December 2015
16Currently Proposed Roles HCAFinal accountability for contracts in all RSAsOversee MCO performanceCollect data from MCOs and share data with County/ACHAnalyze data or contractsImpose sanctions for nonperformanceIncentives for exceeding minimum performanceEstablish “early warning system” for problemsInform/engage ACH/County where appropriate to amend contracts to improve regional responsivenessCountyDetermine whether to become Early AdopterIn 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 programReview draft contractsParticipate in procurement review and selection process for the RSA they representReview data and information gathered through health plan readiness assessment processDesignate one member of HCA/DSHS Monitoring Team to participate in ongoing quality and performance monitoringAlert HCA as to health system issues at local level and make recommendations for improvementsACHCreate mechanism for receiving performance dataShare 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 planningPartner with MCOs in at least one local health transformation projectDesignate participants for HCA/DSHS Monitoring Team to do ongoing quality and performance monitoringMCODetermine which RSAs to bid onSupply network information in all RSAsSupply response to RFP in Early Adopter RSAsPass readiness reviewPartner with ACH in at least one local health transformation projectParticipate in ongoing meetings of ACH
17Integrated Purchasing of Medicaid Physical and Behavioral Health Care PLANNING CALENDAR
18Medicaid Integration Timeline 201420152016Early Adopter RegionsJUN Prelim. modelsJUL Model VettingOCT-DEC Regional data; purchasing inputJAN-MARFull integ. Draft contractMCO/Stakeholder FeedbackMARFull integ. RFP Draft managed care contracts/ Preliminary RatesJUN MCO Responses DueAUG Vendors selectedNOV Final managed care contractsJAN SignedcontractsCommon ElementsJULPrelim.County RSAsSEP FinalTask Force RSAsNOV DSHS/HCA RSAsJoint purchasing policy developmentMAY-AUG Submit 2016 federal authority requestsProvider network reviewP1 correspondenceDEC- JAN Federal authority approval;Readiness review beginsMAR CMS approval completeMAR SB 6312; HB 2572 enactedAPRIntegrated coverage begins in RSAsBHO/ AH RegionsDEC-FEB Review and alignment of WACs for behavioral healthMAR-MAYDevelopment of draft contracts and detailed planJULBHO detailed plan requirementsDraft BHO managed care contracts2016 AH MCOs confirmedAH RFN (network)OCT BHO detailed plan responseAH network dueNOV JAN AH BHO contract detailed signed plansreviewedRevisedAH MCcontractAPR Final BHO and rev. AH contractsOCT-DEC BHO Stakeholder work on rates; benefit planning for behavioral healthRSA – Regional service areasMCO – Managed Care OrganizationBHO – Behavioral Health OrganizationAH – Apple Health (medical managed care)SPA – Medicaid State Plan amendmentCMS – Centers for Medicare and Medicaid ServicesEarly Adopter Regions: Fully integrated purchasing BHO/AH Regions: Separate managed care arrangements for physical and behavioral health careNovember 4, 2014Key Opportunities for Tribal Feedback and Consultation
19HCA Calendar for Early Adopter Planning & Implementation Key Purchasing MilestonesJanuary 2015Early Adopter Model Options completed for discussionDraft MCO Contract available for reviewNon-binding letters of intent due from potential Early Adopter RSA countiesLate March 2015RFP to be issued for MCO vendor selection, using MCO ContractJune – August 2015MCO vendor selection process(Note: County decisions on Early Adopter RSAs to be made prior to final vendor selection)December 2015 – March 2016Early Adopter RSA implementation readiness review processApril 2016Performance monitoring beginsTribal consultation/comments on:Draft MCO Contract,Early Adopter Model Options, andCriteria for MCO vendor selection (part of RFP process).
20POSSIBLE SYSTEM MODELS Integrated Purchasing of Medicaid Physical and Behavioral Health CarePOSSIBLE SYSTEM MODELS
21Chemical Dependency Providers Potential BHO RSA Model: Physical & Behavioral Health Purchasing with Separate Managed Care ArrangementsStateMental Health &Chemical Dependency ProvidersIndividual ClientDRAFTCollaborationCountiesAccountable Communities of HealthBusinessCommunity/Faith-Based OrganizationsConsumersCriminal JusticeEducationHealth Care ProvidersHousingJailsLocal GovernmentsLong-Term Supports & ServicesManaged Care OrganizationsPhilanthropic OrganizationsPublic HealthTransportationTribesEtc.Behavioral Health OrganizationsMental health (Access to Care Standard (ACS))Substance use disordersApple HealthManaged Care PlansPhysical healthMental health (non-ACS)DRAFTCarved-Out Services & Tribal ProgramsPhysical Health, & limited Mental Health (non-ACS) providers
22Early Adopter Agreement Potential Early Adopter RSA Model: Fully Integrated Physical & Behavioral Health Purchasing with Standard Managed Care ArrangementsEarly Adopter AgreementStatePhysical Health, Mental Health and Chemical Dependency ProvidersAccountable Communities of HealthBusinessCommunity/Faith-Based OrganizationsConsumersCriminal JusticeEducationHealth Care ProvidersHousingJailsLocal GovernmentsLong-Term Supports & ServicesManaged Care OrganizationsPhilanthropic OrganizationsPublic HealthTransportationTribesEtc.Individual ClientLicensed Risk-Bearing Managed Care PlansCounties in RSADRAFTCollaborationDRAFTCarved-Out Services & Tribal Health Programs
23Early Adopter Agreement Potential Early Adopter RSA Model : Fully Integrated Physical & Behavioral Health Purchasing with Single Shared Regional Behavioral Health NetworkEarly Adopter AgreementStatePhysical Health, Mental Health and Chemical Dependency ProvidersAccountable Communities of HealthBusinessCommunity/Faith-Based OrganizationsConsumersCriminal JusticeEducationHealth Care ProvidersHousingJailsLocal GovernmentsLong-Term Supports & ServicesManaged Care OrganizationsPhilanthropic OrganizationsPublic HealthTransportationTribesEtc.Individual ClientLicensed Risk-Bearing Managed Care OrganizationsCounties in RSADRAFTCollaborationDRAFTSingle shared regional network of essential behavioral health providersCarved-Out Services & Tribal Programs
24POSSIBLE SERVICE MODELS Integrated Purchasing of Medicaid Physical and Behavioral Health CarePOSSIBLE SERVICE MODELS
25Current Medicaid + Non-Medicaid Service Administration AI/AN PopulationMC Plan?Medicaid Funded ServicesEntityState/Local Funded ServicesMedicaid ClientsYesPhysical + some mental healthMCOExamples:Involuntary Treatment ActTherapeutic CourtsTransitional Care Coordination from Prison or IMDsInpatient chemical dependency treatmentIMD/State Mental Health Hospital inpatient careRSNCountyRSN/ CountyStateMental healthChemical dependencyCounty FFSNoFFSRSN + FFSNon-Medicaid Clients
26Medicaid-Funded Services – Early Adopter RSAs & Behavioral Health AI/AN PopulationMC Plan?Medicaid Funded ServicesEntityMedicaid EnrolleesYesPhysical health, mental health, and chemical dependency servicesMCONoFFS*Not Eligible for MedicaidQuestions: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.
27Medicaid-Funded Services – Early Adopter RSAs & AI/AN Clients AI/AN PopulationMC Plan?Medicaid Funded ServicesEntityMedicaid EnrolleesYesPhysical health, mental health, and chemical dependency servicesMCONoFFS*Not Eligible for MedicaidQuestions: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.
28State/Local-Funded Services – Early Adopter RSAs & Non-Medicaid Funds Potential Entities in Early Adopter RSAs to Perform ServiceExamples:Involuntary Treatment ActTherapeutic CourtsTransitional Care Coordination from Prison or IMDsInpatient chemical dependency treatmentIMD/State Mental Health Hospital inpatient careMCOWith services carved-in or carved-out of MCO contractASO (administrative service organization)For services carved- out of MCO contract)CountyAlternative to ASOQuestion:Who should administer these funds and services?Each MCO administers portion of non-Medicaid fundsSingle MCO or Administrative Service Organization (ASO) administers all non-Medicaid funds in coordination with MCOsSplit designEach MCO administers funds for Medicaid clientsSingle MCO or ASO administers funds for non-Medicaid clients
29State/Local-Funded Services – Early Adopter RSAs & State Hospital Beds Potential Entities in Early Adopter RSAs to Perform ServiceExamples:Involuntary Treatment ActTherapeutic CourtsTransitional Care Coordination from Prison or IMDsInpatient chemical dependency treatmentIMD/State Mental Health Hospital inpatient careMCOWith services carved-in or carved-out of MCO contractASO (administrative service organization)For services carved- out of MCO contract)CountyAlternative to ASOQuestion:How will state hospital beds be allocated and how will MCOs reimburse the State if the hospital bed allocation in their region is exceeded?
30State/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 servicesModel 2 - ASO holds Medicaid and non-Medicaid contract with the StateWhich “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 ServicesPotential Entities in Early Adopter RSAs to Perform ServiceExamples:Involuntary Treatment ActCrisis ServicesTherapeutic CourtsTransitional Care Coordination from Prison or IMDsInpatient chemical dependency treatmentIMD/State Mental Health Hospital inpatient careMCOWith services carved-in or carved-out of MCO contractASO (administrative service organization)For services carved- out of MCO contract)CountyAlternative to ASO
31Medicaid Managed Care Organizations Early Adopter RSAs & Crisis Services – Model 1DRAFTDRAFTStateIndividual ClientMedicaid Managed Care OrganizationsMedicaidContractNon-MedicaidContract for Non-Medicaid Crisis ServicesMedicaidContractNon-MedicaidRegional Crisis System Managed by ASOMedicaid Managed Care OrganizationMedicaid billingMedicaid billingRequiredsub-contractRequiredsub-contractData reportingExamples of Behavioral health including:E&T providersDMHPs/CDPs – 24/7Crisis hot lineCrisis stabilizationContinuum of Integrated Clinical Services
32Early Adopter RSAs & Crisis Services – Model 2 DRAFTDRAFTStateIndividual ClientMedicaid Managed Care Organizations (Penalties when members access crisis)MedicaidContractNon-MedicaidPMPM for Medicaid CrisisNon-MedicaidCrisis ContractMedicaidContractNon-MedicaidRegional Crisis System Managed by ASOMedicaid Managed Care Organization (Penalties when members access crisis)Required CoordinationRequired CoordinationData reportingExamples of Behavioral health including:E&T providersDMHPs/CDPs – 24/7Crisis hot lineCrisis stabilizationContinuum of Integrated Clinical Services
33Potential 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.
34Integrated Purchasing of Medicaid Physical and Behavioral Health Care OTHER QUESTIONS
35Behavioral 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 providersOpioid treatment programsMobile crisis, crisis residential, respite beds
36Model of Care Draft Model of Care available for review Draft Model of Care will be background for procurementQuestions: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?
37Integrated Purchasing of Medicaid Physical and Behavioral Health Care COMMENTS - january 5
38Medicaid Integrated Purchasing – Thoughts/Concerns from January 5, 2015 Tribal Thoughts/ConcernsHCA’s ResponseMobile 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.
39Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseCounty 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.
40Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseMCOs 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.
41Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseTribal 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.
42Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseBurden 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.
43Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseMCO 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.
44Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseMCOs 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.
45Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseTribes 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.
46Medicaid Purchasing Integration Planning – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseTribes 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.
48Healthier WashingtonImproving how we pay for services …so people and their providers can choose the best treatment optionsEnsuring health care focuses on the whole person …people’s physical and mental health care are integrated to better meet their needsBuilding healthier communities through a regional approach …local organizations work together to build strategies that work for their community
49Healthier Washington Strategies include: Accountable Communities of Health to support locally-driven goals, approaches, and processesRedesign of provider payments* to improve the quality and value of careCreation of a regional extension service to share information about best practices*Tribes are not participating in provider payment redesign effort.
50Accountable Communities of Health 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 regionParticipants include: public health, housing, and social service providers; MCOs; insurers; county and local government; Tribes; and consumersClinicalCommunityACHs
51Accountable Communities of Health 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.
52Accountable Communities of Health An Accountable Community of Health is not intended to:Add approval layersReplace government entitiesDivert state fundsBear financial risk
53Accountable Communities of Health Two ACH Pilot Grants have been awarded to:CHOICE Network (Cascade Pacific Action Alliance)Counties: Mason, Thurston, Lewis, Grays Harbor, Cowlitz, Pacific, WahkiakumNorth SoundCounties: Snohomish, Skagit, Whatcom, San Juan, IslandACH Design Grants to be awarded
54How 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 StructureGoverned 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?YesNo
55How 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.
56Accountable Communities of Health The ACH Timeline
57Accountable Communities of Health Total Four-Year ACH Budget: $10.8 millionACH Design and Implementation (including personnel, travel, consultants, grants)Year 1~ 2 Pilot ACHs~ 8 Design RegionsYears 2 – 4~ 10 ACHsACH-Tribal Coordination
58Accountable Communities of Health Total Four-Year ACH-Tribal Coordination Budget: $300,000Proposed Funding Structure for RFP:Year 1 (pre-implementation year): $75,000Year 2: $150,000Year 3: $50,000Year 4: $25,000Proposed Contract Deliverables to HCA:Protocols, templates, coordination plans for ACHs to engage with Tribes in their regionsData analytic recommendations for ACHsRecommendations for maintaining ACH-Tribal coordination process
59Accountable Communities of Health ACH-Tribal CoordinationPrinciplesHealth disparity reduction is a key goal of ACHsACH participants are expected to understand and respect the Tribal-State government-to-government relationshipFrameworkTribal representation on local ACH governance/oversight boardTribe may invoke right to have State participate in any ACH meetingsState must be cc’d on all written communication from ACH to Tribes
60Accountable Communities of Health ACH-Tribal CoordinationFinancial SupportDeliverablesPrinciplesFrameworkHow can HCA facilitate productive relationships between ACHs and Tribes/Urban Indian Organizations in order to improve the health of American Indians/Alaska Natives?
61Accountable Communities of Health Comments – January 5
62Accountable Communities of Health – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseACH 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.
63Accountable Communities of Health – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseACH 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.
64Accountable Communities of Health – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseACH 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.
65Accountable Communities of Health – Tribal Thoughts/Concerns from January 5, 2015 HCA’s ResponseState 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.
66Governor’s Health Innovation Leadership Network Healthier WashingtonGovernor’s Health Innovation Leadership Network
67Health Innovation Leadership Network The Governor’s Office seeks recommendations for two people to serve 1-year terms on HILN:A Tribal representative, andAn Urban Indian Organization representative.
68Health Innovation Leadership Network 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).
69Health Innovation Leadership Network What is HILN intended to do?Monitor, inform and accelerate Healthier Washington progressIdentify barriers and opportunities for alignment, scale and spread
70Health Innovation Leadership Network Please let me know if:You have any recommendationsYou have any questions about HILN
71RESOURCES HCA Healthier Washington: DSHS Developing Behavioral Health Organizations:Washington Adult Behavioral Health System Task Force: