Orientation to DCH Navigant Report
Wendy White Tiegreen, M.S.W.
Deputy Chief of Staff
Department of Behavioral Health & Developmental Disabilities
DCH Medicaid Redesign Initiative
• Georgia Department of Community Health (DCH)=State
Medicaid Authority
• Summer to Fall 2011: comprehensive assessment and
recommended redesign of Georgia's Medicaid Program
and Children's Health Insurance Program
(CHIP/PeachCare for Kids®)
• Navigant Consulting retained to conduct this review.
• Goal: “to help us look at various strategic options geared
toward achieving long-term program and financial
sustainability.” (http://dch.georgia.gov/00/channel_title/0,2094,31446711_175210527,00.html)
DCH Medicaid Redesign Initiative:
DBHDD
Behavioral Health Context:
DBHDD is the policy manager, definition designer, provider network manager,
utilization review organization, co-funder for DCH/Medicaid.
In other words, DBHDD=Managed Care Organization for DCH for
the following populations:
• Aged, Blind, Disabled (Adults and Youth)
• Foster Care Youth
• Managed Care Covered (CMOs) in the “Gap”
• Over 50,000 “covered lives”
• ~32,000 Adults
• ~20,000 Youth
DCH Medicaid Redesign Initiative:
DBHDD
DBHDD is Partnered with DCH on Leveraging Federal Funds:
35%
Leveraged
through DCH
from CMS
65%
Legislative
Appropriation to
DBHDD
DCH Medicaid Redesign Initiative:
Reform Context
Medicaid Expansion (2014):
• Millions of low-income adults without children
• Many low-income parents
• Some children now covered through the Children’s Health Insurance Program
(CHIP)
• People who already are eligible for Medicaid under current rules but have not
enrolled.
In total, Medicaid/CHIP, is expected to cover an additional 16 million people by
2019.
SOURCE: Kaiser Family Foundation
DCH Medicaid Redesign Initiative:
Reform Context +
• CMO Contracts already extended, redesign called for
• Continued growth in Medicaid:
• DCH forecasted the need for $120.4 million for
projected enrollment growth in FY 2013 (gpbi.org)
• Since the recession began in 2008, total enrollment in
Medicaid and PeachCare has increased by more than
200,000 individuals, about 14 percent (DCH, January 2012)
Navigant Recommendations
Medicaid and PeachCare for Kids® Design Strategy Report
EXECUTIVE SUMMARY, January 23, 2012
DCH should become a “value‐based purchaser” by:
•
•
•
•
•
Increasing communication among all stakeholders
Reducing administrative complexities and burdens for providers and members
Standardizing, centralizing or streamlining appropriate processes and forms across the CMOs
Increasing patient compliance through incentives and disincentives
Increasing focus on health and wellness programs and preventive medicine
Other opportunities for improvement include:
• Tracking progress over time in achieving quality of care improvements using the(Healthcare Effectiveness Data and
Information Set) HEDIS® and HEDIS®‐like measures
• Considering an approach to manage care for Georgia’s most expensive Medicaid members: those who are dually
eligible and those who are aged, blind and disabled
• Considering short‐ and long‐term plans for the use of technology including electronic health records and
telemedicine
Navigant Recommendations
Narrowed Overall Options to 3:
• Option 6: Georgia Families Plus;
• Option 8: “Commercial Style” Managed Care; and
• Option 9: Free Market Health Insurance Purchasing.
Additional Recommendations for Specific Target Populations
Navigant Recommendations
Option 6: Georgia Families Plus; (GA Families=Current CMO
Model)
Expands upon the current Georgia Families program by:
• Incorporating extensive value‐based purchasing
• Further encouraging use of medical homes, for example, through PCMHs
• Reducing administrative complexities and burdens for providers and members
• Increasing patient compliance through incentives and disincentives beyond those
currently used in Georgia Families
• Increasing focus on health and wellness programs and preventive medicine
• Continuing to build upon current efforts to focus on quality
• Carving in more services (e.g., transportation) and populations (e.g., dual eligibles)
Navigant Recommendations
Option 8: “Commercial Style” Managed Care
Expands upon Option 6, Georgia Families Plus program, a full
risk‐based managed care program with value‐based purchasing:
• Employs all levers and innovations typically used in commercial market, including incentives
and, for some members, deductibles and copayments, to encourage members to be active
participants in their health care and to comply with treatment plans
• Establishes HRAs for members where rewards (e.g., incentive payments) are deposited for
members who meet goals for healthy behaviors to purchase preapproved health care‐related
services or items
• Balances in HRAs could be used in a shared savings model whereby members, upon leaving
Medicaid or reaching the end of the benefit year, have the option to spend a portion of
remaining funds on pre‐approved items such as health club memberships
Navigant Recommendations
Option 9: Free Market Health Insurance Purchasing
• DCH would provide a credit to members for purchase of insurance
through the free market
• DCH would not contract directly with health plans and would not
process claims
• DCH would partner with the Department of Insurance to define the
standard Medicaid benefit packages participating health plans must
offer and certification requirements specific to Medicaid (e.g., covered
benefits, provider network composition and reporting)
• DCH would contract with or serve as a choice counselor, helping
members to select a healthplan
Other…
Other…
Other…
Foster Care
Behavioral
Health
Long-Term
Care
Navigant Recommendations
Overarching Design
Navigant Recommendations
Behavioral Health Options (Navigant Report, Appendix L):
•Carve in behavioral health services. In this risk‐based
managed care delivery
•Carve out services to be managed by a different vendor or
community vendors.
•Carve out population with physical health to also be
managed by behavioral health providers.
Navigant Recommendations
Carve in behavioral health services.
Navigant: In this risk‐based managed care delivery system, behavioral
health services would be included in the benefit package, along with
physical health services, and the cost of the benefit would be included in
the capitation rate, similar to the current model for Georgia Families. The
health plan would be responsible for managing the behavioral health
benefit for its enrolled population, either through a subcapitated
arrangement or by developing its own behavioral health provider network,
payment rates and policies governing the behavioral health benefit.
Navigant Recommendations
Carve in behavioral health services, in other words:
Integration is an omnibus concept, defined in many ways. There can
be financial, structural and/or clinical practice integration.
Integration that is financial (benefit packages, “carve-ins”, shared risk
pools or other incentives) or structural (services delivered under the
umbrella of the same organization, BH specialty services co-located
with primary care services) does not necessarily assure clinical
integration. (NCCBH, Mauer 2006)
Navigant Recommendations
Physical Health
Behavioral
Health
Navigant Recommendations
Faux Carve-Ins
Physical Health
Behavioral
Health
Navigant Recommendations
Carve out services to be managed by a different vendor or
community vendors.
In this risk‐based managed care delivery system, behavioral health
services would be carved out to a different vendor specifically
focused on managing behavioral health services. The vendor would
be responsible for managing the behavioral health benefit for the
same population managed through the physical health plan and
developing its own behavioral health provider network, payment
rates and policies governing the behavioral health benefit.
Navigant Recommendations
Behavioral
Health
Physical Health
Dental
Other
Navigant Recommendations
Carve out population with physical health to also be
managed by behavioral health providers.
In this model, individuals with specific behavioral health diagnoses
would be carved out of the physical health delivery system. Their full
needs, both physical health and behavioral health, would be managed
and coordinated by behavioral health care providers.
NOTE: Not mutually exclusive to other two options!
DCH Plan
•Feedback Due to DCH by February 29, 2012 (Next Week)
• http://dch.georgia.gov/00/channel_title/0,2094,31446711
_180745696,00.html
•2 Modes for Feedback:
• Detail feedback submitted through “Feedback Tool” (500
Character Limit)
• Brief Comment (no attachments) through:
MyOpinion@dch.ga.gov
DCH Plan
Assessment – Completed
August – December 2011, completed.
Recommendation – Underway
January 2012, posting of Strategy Report.
January – April 2012, review and analysis of the Strategy Report.
April 2012 – Finalization of the Redesign Model.
Procurement – Later in 2012, 2013
April – July/August 2012, procurement planning.
July/August 2012, procurement documents to be posted.
January 2013, contract award to successful vendor(s).
Implementation – Planned for Early 2014
January/February 2014, implementation begins.