1. State Innovation Models Initiative: Medicaid Delivery System Innovation & Payment Redesign Jim Roberts, Policy Analyst NW Portland Area Indian Health Board Quarterly Board Meeting Thunder Valley Casino Resort July 7, 2015

2. Objectives of the Affordable Care Act: Insurance Market Reforms Expand Medicaid Coverage State & Federal Insurance Exchanges Workforce Development Increase Access, Improve Quality, & Lower costs

3. Center for Medicare & Medicaid Innovation ACCESS, QUALITY, AND COST : Affordable Care Act (ACA) established the Center for Medicare & Medicaid Innovation Center 1.Test new innovative payment and service delivery models to reduce program expenditures 2.New models must preserve or enhance the quality of care provided to Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) beneficiaries Eliminate waste, fraud, and abuse

4. CMMI Payment & Service Model Categories Defined in the ACA Section 1115A 1.Accountable Care 2.Bundled Payments for Care Improvement 3.Primary Care Transformation 4.Medicaid & CHIP Initiatives 5.Initiatives focused on Medicare & Medicaid enrollees 6.Initiatives to Speed Adoption of Best Practices 7.Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Model

5. State Innovation Model (SIMs) Grants to States & Facilities CMMI has provided over $1.3 billion in grants to States and Facilities (providers) to test payment and service delivery models o Round One: $640 million to 25 States o Round Two: $1 billion to 28 States, 3 Territories, & the District States are eligible & received: o Model Pre-Testing Awards o Model Test Awards Round 1 o Model Test Awards Round 2 o Model Design Awards Round 1 o Model Design Awards Round 2

6. What are the SIMs Grants? Model Pre-testing Three states received pre-testing assistance and funding to work on a comprehensive State Health Care Innovation Plan. States that received pre-testing awards under the State Innovation Models initiative had six months to submit their State Health Care Innovation Plans to CMS.

7. What are the SIMs Grants? Model Test Awards – Round 1 Over $250 million in Model Test awards is supporting six states to implement their State Health Care Innovation Plans. o Oregon received $45 million A State Health Care Innovation Plan is a proposal that describes a state’s strategy to use all of the levers available to it to transform its health care delivery system through multi-payer payment reform and other state-led initiatives

8. What are the SIMs Grants? Model Test Awards – Round 2 Round Two SIM Initiative Model Test awards issued on December 16, 2014. 38 total SIM awardees (including 34 states, three territories and DC) o Idaho $40 million o Washington $65 million States will work to develop state-based innovation in health system transformation.

9. What are the SIMs Grants? Model Design Awards – Round 1 Sixteen states received Model Design awards under the first round of the SIMs Initiative. o Idaho received $3 million States will develop and use Health Care Innovation Plans to inform their applications for a Model Test Award or another Model Design Award under the second round of this initiative

10. What are the SIMs Grants? Model Design Awards – Round 2 The SIMs Initiative Model Design Awards will provide financial and technical support to awardees for their planning and design efforts. 18 States received $39.5 million In planning and designing their proposals, states must: o develop multi-payer payment and service delivery models o engage a broad range of stakeholders.

11. Why is this important for Tribes? State proposals will change Medicaid delivery systems and redesign payments; migration from FFS to volume and value-based purchasing State Health Care Innovation Plans (ID, OR and WA) had very little if any Tribal input or consultation Past experience in Medicaid system (managed care) and payment reform has been very disruptive for the Indian health system Key Indian states are in the wake of reform: (ID, OR, WA, MN) generally centered in Medicaid Expansion States Likely little impact on Encounter Rate but bundled services, value- based purchasing, and incentive payments will impact availability of services that can be billed. Delivery System Reform Incentive Payments (DSRIP) will increasingly become more important for the I/T/U Medicaid Managed Care will continue to become more rigid and network will become tighter

12. Delivery System Reform Incentive Payment (DSRIP) Provides States with savings to support hospitals and providers and how they change providing care to Medicaid enrollees DSRIP payments are performance based incentives Medicaid Providers MUST meet certain milestones or performance metrics o Metrics are common across ALL providers and measured at early years of the Waiver o Metrics include both infrastructure development or system redesign and focus on health outcomes in later years o Infrastructure Example: implementation of chronic care registries o System Redesign Example: Medical homes or integration of physical and behavioral health o Outcome Measures: clinical indicators to improve health of population

13. Where do we go from here? Healthier Washington Initiative and Global Waiver: o Tribal Technical Workgroup o NPAIHB/AIHC Letter and White Paper recommendations (handouts) o Series of meetings over next two months Oregon 1115 CCO Waiver Renewal is pending o NPAIHB Meeting with OHA on 6/24 th ; develop a Tribal Chapter in the Waiver o Need to schedule meeting with Oregon THDs Idaho Health Care Innovation Plan and SIM Grant o Pending discussion about engaging Tribes o Teleconference or webinar with State o Arrange Workgroup follow up meetings at Idaho State/Tribes Meetings

14. NPAIHB/NIHB Contract to evaluate CMMI & State Implementation of SIM Process $50,000 Proposal submitted to NPAIHB to evaluate CMMI and State implementation to include Tribes in State Innovation Model work. Case Study approach: Minnesota and Washington Follows Case study methodology that NIHB used in 1997 to develop Medicaid Managed Care Study. Develop advisory committee in each state to guide development of case study reports Identify common themes, issues and then develop recommendations for each state as well as nationally Will include recommendations for CMMI Convene national venue to discuss findings, refine report recommendations and then submit to CMS/CMMI

15. Questions?