DCH/Navigant Medicaid & PeachCare Strategy Report Medical Association of Georgia February 4, 2012 Cam Grayson

Building a Better State of Health Since 1849 Purpose of DCH Redesign  Formulate strategy for future of Medicaid and PeachCare for Kids  Comprehensive assessment of programs to identify redesign options

DCH Redesign Goals  Enhance appropriate use of services by members  Achieve long-term sustainable savings in services  Improve health care outcomes for members Building a Better State of Health Since 1849

DCH Redesign Strategies  Gain administrative efficiencies  Ensure timely and appropriate access  Ensure operational feasibility  Align reimbursement with patient outcomes, quality  Encourage members to be accountable for own health  Develop a scalable solution Building a Better State of Health Since 1849

Approach/Content  Project goals  Study methodology and limitations  National environmental scan  Georgia-specific scan  Options for Georgia’s design strategy  Appendices Building a Better State of Health Since 1849

Evaluating the Options  Phase I: Evaluate generic delivery system options  Phase II: Assess potential services and populations to “carve in” or “carve out”  Phase III: Develop and evaluate Georgia- specific delivery system option  Phase IV: Identify recommendations Building a Better State of Health Since 1849

Delivery Systems Building a Better State of Health Since 1849 Source: Navigant Medicaid and PeachCare for Kids Design Strategy Report, January 17, 2012, page 3-19

Generic Delivery Systems Selected  Option 6: Georgia Families Plus  Option 8: “Commercial Style” Managed Care  Option 9: Free Market Health Insurance Purchasing Building a Better State of Health Since 1849

Navigant “Carve Ins” (Population-Based)  Behavioral health services  Long-term care services  Home and community-based waivers  Dually eligible for Medicaid and Medicare  Foster care children Building a Better State of Health Since 1849

Navigant “Carve Ins” (Service-Based)  Behavioral health services  LTC services  Home and community-based waiver  Dental services  Transportation services  Pharmacy services Building a Better State of Health Since 1849

Rationale for “Carve-Ins”  Populations lack care management  Streamlines single delivery system  Clinical information linkages  Limits patient confusion by one entity  Cost efficiencies and improves quality  Reduces administrative oversight Building a Better State of Health Since 1849

Rationale for “Carve-Ins”  Vendors can leverage with providers to enforce coordination of care and outcomes using PFP and value-based purchasing  One blended/capitated rate for all services under one contract stops “dumping” Building a Better State of Health Since 1849

Permutations to Generic Delivery System  Option 1: Georgia Families Plus  Option 2: Georgia Families Plus transitioning to “commercial style” managed care program  Option 3: Georgia Families Plus transitioning to “commercial style” managed care program using ACOs and PCMHs  Option 4: Georgia Families Plus and free market health insurance purchasing Building a Better State of Health Since 1849

Underlying Assumptions  Delivery system can be implemented and applied to all populations on statewide basis  DCH can introduce on incremental basis, beginning with traditionally managed populations and adding more complex populations in future Building a Better State of Health Since 1849

Recommended Delivery Systems 1.Georgia Families Plus transitioning to “commercial style” managed care program that require ACOs and PCMHs 2.Georgia Families Plus transitioning to “commercial style” managed care program 3.Georgia Families Plus Building a Better State of Health Since 1849

Option 1: Georgia Families Plus  Enrolls all populations (foster care, dual eligibles, ABD) and all services  Uses value-based purchasing, performance measures  Uses medical homes  Obtains compliance using patient incentives  Focuses on health and wellness  Offers risk-based budget predictability Building a Better State of Health Since 1849

Option 2: Georgia Families Plus/Commercial  Option 1 plus commercial managed care levers  Many enrolled in commercial managed care  Uses copayments, deductibles, HRAs, incentive payments, and prizes  Initially excludes foster care, ABD, dual- eligible Building a Better State of Health Since 1849

Option 3: Georgia Families Plus/Commercial + Managed Care/ACOs/PCMHs  Enroll many in commercial-style managed care  Similar to former plan but requires ACOs and PCMHs  Foster care, ABD, and dual-eligible not initially targeted  Risk-based managed care Building a Better State of Health Since 1849

Option 4: Georgia Families Plus + Free Market Health Insurance Purchasing  Implements Georgia Families Plus for children, foster care, ABD  Free market health insurance purchasing program  Allows patient choice of plans  Maximizes budget predictability Building a Better State of Health Since 1849

Free Market Approach  DCH defines standard benefit package  Insurers would offer standard benefit package and health rewards account  Insurers would seek certification from state and limit participation to less than six insurers  DCH would not contract directly with health plans and would not process claims  Medicaid members given a credit to purchase Building a Better State of Health Since 1849

Next Steps for DCH  Select delivery system and “carve-in” populations and services  Improve DCH internal operational issues such as credentialing, eligibility system, CMO contract monitoring  Consider and decide on redesign Building a Better State of Health Since 1849

Key Design Options  Delivery system leverages HRAs, HSAs  Care and disease management  Medication therapy management  Contracted vendors  Special populations  Payment strategies  Penalties and rewards Building a Better State of Health Since 1849

Implementation and Operational Needs  Federal approvals  Determining basis for populations/timelines  DCH needs to change its organizational structure  Determine what other information systems and operational changes are necessary Building a Better State of Health Since 1849

Planning for Key Design and Program Features  Develop high-level implementation timeframe  Convene team to develop recommendations for detailed program  Convene advisory groups as needed  Vet program design with stakeholders  Develop strategies to mitigate risks  Develop implementation plan and timeline Building a Better State of Health Since 1849

Questions? Cam Grayson Building a Better State of Health Since 1849