Healthier Washington Through a Medicaid Lens Nathan Johnson, Chief Policy Officer, HCA MaryAnne Lindeblad, Medicaid Director, HCA

Ensuring health care focuses on the whole person Healthier Washington is creating healthier communities and sustainable health systems by: Building healthier communities through a collaborative regional approach Ensuring health care focuses on the whole person Ensuring health care focuses on the whole person Improving how we pay for services Improving how we pay for services

Integrating behavioral and physical health services Strategies Integrating behavioral and physical health services By 2020, physical and behavioral health services must be provided through a fully-integrated managed care health system. — Senate Bill 6312 (2014) In April 2016: Southwest Washington— as an Early Adopter— will have fully integrated healthcare purchasing through Managed Care Organizations (MCOs). In all other regions, chemical dependency services will be integrated with mental health services through Behavioral Health Organizations (BHOs).

Strategies Value-Based Payment HCA, as Washington’s largest purchaser of health care—with over 2 million Apple Health clients and public employees—is paving the way for more widespread adoption of value-based reimbursement. In 2016: Managed care organizations will coordinate physical and behavioral health care for Apple Health beneficiaries in southwest Washington. The state will test: - a value-based alternative Medicaid payment methodology for Federally Qualified Health Centers (FQHCs) and Rural Health Clinic (RHCs), and - a new facility type designation in Critical Access Hospitals (CAHs) that encourages sustainability.

Clinical and Community Linkages Strategies Clinical and Community Linkages Recognizing that health is more than health care…. Accountable Communities of Health bring health care providers and community partners together. Adapted from: Magnun et al. (2010). Achieving Accountability for Health and Health Care: A White Paper, State Quality Improvement Institute.. Minnesota.

Since passage of the ACA, Washington has increased its Medicaid enrollment by 44%... Apple Health Enrollment – June 2013 to May 2015 } 548,000 As of September 2015, more than 560,000 adults have been added through Medicaid expansion.

…and the enrollees and their needs are different. Before the Affordable Care Act, 60% of enrollees were children; now the majority of enrollees (55%) are adults. 22% of the new adult enrollees have a mental health diagnosis. 14% have a substance use disorder. And, while the new adult group has lower hospital admission rates than other non-disabled adults, their inpatient stays average 50% longer. Data provided by Research and Data Analysis, DSHS, June 2015.

In addition, there will soon be many more people age 65 and over in our state... Source: Washington State Department of Social and Health Services, Research and Data Analysis Division

…and their health care needs are likely to increase as they age. By 2035, the number of people age 75 or older will have risen by roughly 150%. Between 2010 and 2040, we anticipate a 181% increase in Medicaid clients over age 65 with Alzheimer’s. 70% of people who reach the age of 65 are likely to need long term supports and services at some point in their lives. Biennial expenditures by the state for long term supports and services are currently $3.4 billion—or 6 percent of all general fund spending. Data provided by Research and Data Analysis, DSHS, June 2015.

Medicaid Transformation Waiver Purpose: Leverage federal savings to invest in delivery system transformation to bring the Healthier Washington vision to scale for Apple Health. Goals: Reduce avoidable use of intensive services and settings —such as acute care hospitals, nursing facilities, psychiatric hospitals, traditional LTSS and jails Improve population health —with a focus on prevention and management of diabetes, cardiovascular disease, pediatric obesity, smoking, mental illness, substance use disorders, and oral health Accelerate the transition to value-based payment —while ensuring that tribal members’ access to specialty and community services outside the Indian Health system are maintained Ensure that Medicaid per-capita cost growth is two percentage points below national trends

Medicaid Transformation Initiatives Transformation through Accountable Communities of Health Each region, through its Accountable Community of Health, will be able to pursue transformation projects focused on health systems capacity building, care delivery redesign, and population health improvement. Service Options that Enable Individuals to Stay at Home and Delay or Avoid the Need for More Intensive Care A broadened array of Long Term Services and Supports (LTSS). Targeted Foundational Supports Targeted supportive housing and supported employment services will be offered to Medicaid beneficiaries most likely to benefit from these services. Initiative 1 Initiative 2 Initiative 3

Waiver Timeline & Process What’s next: 30-day federal comment period Negotiations with CMS Ongoing development of demonstration

All of these initiatives move us toward a Healthier Washington… ACHs designated SIM evaluation complete Fully integrated managed care in SW WA; BHOs in other regions Fully integrated managed care health systems statewide Proposed waiver approval; transformation demonstration start-up Transformation investments begin Medicaid transformation evaluation demonstration complete

Stay informed Join the Healthier Washington Feedback Network: healthierwa@hca.wa.gov Send comments and questions about Medicaid Transformation to: medicaidtransformation@hca.wa.gov Learn more and take the Medicaid Transformation waiver survey at: http://www.hca.wa.gov/hw/Pages/medicaid_transformation.aspx