Washington State Health Reform
Quarterly Meeting
Northwest Portland Area Indian Health Board
January 20, 2015
Agenda
1.
2.
3.
Integrated Purchasing of Medicaid Physical and Behavioral Health Care
 Background
 Coming Changes
 Planning Calendar
 Possible System Models
 Possible Service Models
 Other Questions
 Comments – January 5, 2014
Accountable Communities of Health
 Background
 Comments – January 5, 2014
Governor’s Health Innovation Leadership Network
 Seeking recommendations for Tribal Representative and Urban
Indian Organization Representative
2
1. Integrated Purchasing of Medicaid
Physical and Behavioral Health Care
 BACKGROUND
3
Apple Health (Medicaid) Managed Care
• Since early 1990s, Medicaid transitioning beneficiaries to
health plans with CMS approval
• Today, over 90% of full-benefit Medicaid eligibles covered
through Apple Health Managed Care Plans
• State 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 population
• Currently, 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.
4
Managed Care Today: Not Integrated
State contracts with entities to provide Medicaid services by county
Entity
Physical health care
MCOs
Mental health care
• Below “access to care” standard
• Above “access to care” standard
MCOs
RSNs
MCO = Medicaid Managed Care Organization
RSN = Regional Support Network
Other Medicaid services (such as chemical dependency treatment and
dental services) are provided outside of managed care (on a fee-forservice basis)
5
Legislative Directives (Senate Bill 6312)
Purchasing Reforms
Clinical Integration
 Regional purchasing - DSHS & HCA jointly  Primary care services available in
establish common regional service areas
for behavioral health and medical care
purchasing
mental health and chemical
dependency treatment settings and
vice versa
 County authorities elect fully integrated
 Access to recovery support services
purchasing (Early Adopter RSAs) by April
2016, with opportunity for shared savings  Opportunity for dually-licensed CD
incentive payment (up to 10% of state
professionals to provide services
savings in region)
outside CD-licensed facility
 Other RSAs – separate managed care
contracts for physical health (MCOs) and
integrated behavioral health care (newly
created Behavioral Health Organizations)
6
Goals: Integrated Purchasing of Managed Care
•
Provide more holistic, better managed care for people with cooccurring 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 providers
 Quality metrics in managed care contracts
 Sanctions 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.
7
1. Integrated Purchasing of Medicaid
Physical and Behavioral Health Care
 COMING CHANGES
8
Parallel Paths to Integrated Purchasing
2020:
Full Integration of Behavioral
Health and Medical Care
Across the State
Transition Period
Apple Health
Managed Care
Plans
Behavioral
Health
Organizations
2016
2014 Legislative Action:
2SSB 6312
By 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 care
services to Medicaid
clients
Fully Integrated Purchasing in
“Early Adopter” RSAs, with
shared savings incentives
Regional
Service Areas (RSAs)
Medicaid Managed Care Purchasing in 2016
State will contract with entities to provide Medicaid services by RSA
Today
Beginning April 1, 2016
By County
All Other RSAs
Early Adopter RSAs
Physical health care
MCOs
MCOs
MCOs
Mental health care
• Below “access to care” standard
• Above “access to care” standard
MCOs
RSNs
MCOs
BHOs
MCOs*
FFS
BHOs
MCOs
Chemical dependency treatment
*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 Organization
FFS = Fee-For-Service (not managed care)
MCO = Medicaid Managed Care Organization
RSA = Regional Service Area
RSN = Regional Support Network
10
Regional Service Area Designations
By April 1, 2016, HCA and DSHS will regionalize purchasing of health care services.
11
North 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 RSA
• BHO: Single BHO will serve new North Central and
Spokane RSAs during the transition
• 2020 Full Integration: Fully integrated managed care is
required in 2020 by Senate Bill 6312. North Central and
Spokane RSAs will be separate regions for purposes of
integrated physical and behavioral health managed care
systems in 2020.
12
Special 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 2016. Nonbinding letters of intent are due in January 2015.
13
Medicaid Purchasing in “Early Adopter” RSAs
•
•
•
•
•
•
Standards being developed jointly by HCA and DSHS
County authorities in an RSA must agree to become
Early Adopter RSAs
Procurement process will be necessary to select MCOs
Compliance with Medicaid and State managed care
contracting requirements
Shared savings incentives
• Payments to Early Adopter counties targeted at 10% of
savings realized by the State, based on outcome and
performance measures
• Available for up to 6 years or until fully integrated
purchasing occurs statewide
Models continue to be discussed broadly
Some Criteria for
MCO Early Adopter Participation
Managed care organizations must:
• Meet network adequacy standards established by HCA and
pass readiness review
o Provide full continuum of comprehensive services, including critical
o
provider categories (e.g., primary care, pharmacy, and behavioral
health)
Ensure no disruption to ongoing treatment regimens
• Be licensed as an insurance carrier by the Office of the
Insurance Commissioner
• Meet quality, grievance and utilization management and
care coordination standards and achieve NCQA accreditation
by December 2015
15
Currently Proposed Roles
HCA










County
ACH
MCO














Final accountability for contracts in all RSAs
Oversee MCO performance
Collect data from MCOs and share data with County/ACH
Analyze data or contracts
Impose sanctions for nonperformance
Incentives for exceeding minimum performance
Establish “early warning system” for problems
Inform/engage ACH/County where appropriate to amend contracts to improve regional responsiveness
Determine whether to become Early Adopter
In Early Adopter RSAs, designate Implementation Team members to work with HCA/DSHS in AH contracting
activities:
o Develop contract language for the fully-integrated managed care program
o Review draft contracts
o Participate in procurement review and selection process for the RSA they represent
o Review data and information gathered through health plan readiness assessment process
Designate one member of HCA/DSHS Monitoring Team to participate in ongoing quality and performance monitoring
Alert HCA as to health system issues at local level and make recommendations for improvements
Create mechanism for receiving performance data
Share 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 planning
Partner with MCOs in at least one local health transformation project
Designate participants for HCA/DSHS Monitoring Team to do ongoing quality and performance monitoring
Alert HCA as to health system issues at local level and make recommendations for improvements
Determine which RSAs to bid on
Supply network information in all RSAs
Supply response to RFP in Early Adopter RSAs
Pass readiness review
Partner with ACH in at least one local health transformation project
Participate in ongoing meetings of ACH
16
1. Integrated Purchasing of Medicaid
Physical and Behavioral Health Care
 PLANNING CALENDAR
17
Medicaid Integration Timeline
2015
2014
2016
Early Adopter Regions
JUL
JUN
Prelim. Model
models Vetting
OCT-DEC
Regional
data;
purchasing
input
JAN-MAR
Full integ. Draft
contract
MCO/Stakeholder
Feedback
MAR
Full integ. RFP
Draft managed
care contracts/
Preliminary Rates
JUN
MCO
Responses
Due
AUG
Vendors
selected
NOV
JAN
Final managed Signed
care contracts contracts
Common Elements
MAR
SB 6312;
HB 2572
enacted
JUL
Prelim.
County
RSAs
SEP
Final
Task
Force
RSAs
BHO/ AH Regions
NOV
DSHS/HCA RSAs
Joint purchasing policy
development
OCT-DEC
BHO Stakeholder
work on rates;
benefit planning
for behavioral
health
DEC-FEB
Review and
alignment of
WACs for
behavioral
health
MAY-AUG
Submit 2016 federal
authority requests
Provider network review
P1 correspondence
MAR-MAY
Development of
draft contracts
and detailed
plan
DEC- JAN
Federal authority
approval;
Readiness review
begins
BHO detailed plan
requirements
Draft BHO managed
care contracts
2016 AH MCOs
confirmed
AH RFN (network)
RSA – Regional service areas
MCO – Managed Care Organization
Key Opportunities
BHO – Behavioral Health Organization
AH – Apple Health (medical managed care)
SPA – Medicaid State Plan amendment
CMS – Centers for Medicare and Medicaid Services
Early Adopter Regions: Fully integrated purchasing
BHO/AH Regions: Separate managed care arrangements for physical and behavioral health care
November 4, 2014
AH
BHO
detailed contract
signed
plan
response
JAN
BHO
detailed
plans
reviewed
AH
network
due
Revised
AH MC
contract
OCT
JUL
NOV
MAR
CMS
approval
complete
APR
Integrated
coverage
begins in
RSAs
APR
Final BHO
and rev. AH
contracts
for Tribal Feedback and Consultation
HCA Calendar for Early Adopter
Planning & Implementation
Key Purchasing Milestones
January 2015
•
•
•
Early Adopter Model Options completed
for discussion
Draft MCO Contract available for review
Non-binding letters of intent due from
potential Early Adopter RSA counties
Late March 2015
•
RFP to be issued for MCO vendor
selection, using MCO Contract
June – August 2015
•
MCO vendor selection process
(Note: County decisions on Early
Adopter RSAs to be made prior to final
vendor selection)
December 2015 –
March 2016
•
Early Adopter RSA implementation
readiness review process
April 2016
•
Performance monitoring begins
19
Tribal
consultation/
comments on:
1. Draft MCO
Contract,
2. Early Adopter
Model
Options, and
3. Criteria for
MCO vendor
selection
(part of RFP
process).
1. Integrated Purchasing of Medicaid
Physical and Behavioral Health Care
 POSSIBLE SYSTEM MODELS
20
Potential BHO RSA Model: Physical & Behavioral Health Purchasing with
Separate Managed Care Arrangements
DRAFT
State
Collaboration
Accountable Communities of Health
Counties
Behavioral Health
Organizations
• Mental health (Access to
Care Standard (ACS))
• Substance use disorders
Apple Health
Managed Care Plans
• Physical health
• Mental health (nonACS)
DRAFT
Carved-Out
Services &
Tribal
Programs
Mental Health &
Chemical
Dependency
Providers
Physical Health, &
limited Mental Health
(non-ACS) providers
Individual Client
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Business
Community/Faith-Based Organizations
Consumers
Criminal Justice
Education
Health Care Providers
Housing
Jails
Local Governments
Long-Term Supports & Services
Managed Care Organizations
Philanthropic Organizations
Public Health
Transportation
Tribes
Etc.
Potential Early Adopter RSA Model: Fully Integrated Physical & Behavioral Health
Purchasing with Standard Managed Care Arrangements
Early Adopter
Agreement
State
Counties
in RSA
DRAFT
Collaboration
Accountable Communities of Health
DRAFT
Carved-Out
Services &
Tribal Health
Programs
Licensed RiskBearing Managed
Care Plans
Physical Health, Mental Health and Chemical
Dependency Providers
Individual Client
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Business
Community/Faith-Based Organizations
Consumers
Criminal Justice
Education
Health Care Providers
Housing
Jails
Local Governments
Long-Term Supports & Services
Managed Care Organizations
Philanthropic Organizations
Public Health
Transportation
Tribes
Etc.
Potential Early Adopter RSA Model : Fully Integrated Physical & Behavioral Health
Purchasing with Single Shared Regional Behavioral Health Network
Early Adopter
Agreement
State
Counties
in RSA
DRAFT
Collaboration
Accountable Communities of Health
DRAFT
Carved-Out
Services &
Tribal
Programs
Licensed RiskBearing Managed
Care Organizations
Single shared
regional network
of essential
behavioral health
providers
Physical Health, Mental Health and Chemical
Dependency Providers
Individual Client
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Business
Community/Faith-Based Organizations
Consumers
Criminal Justice
Education
Health Care Providers
Housing
Jails
Local Governments
Long-Term Supports & Services
Managed Care Organizations
Philanthropic Organizations
Public Health
Transportation
Tribes
Etc.
1. Integrated Purchasing of Medicaid
Physical and Behavioral Health Care
 POSSIBLE SERVICE MODELS
24
Current Medicaid + Non-Medicaid
Service Administration
AI/AN
Population
MC
Plan?
Yes
Medicaid
Clients
No
Medicaid
Funded Services
Entity
State/Local
Funded Services
Physical + some
mental health
MCO
Examples:
Mental health
RSN
Chemical
dependency
County FFS
Physical + some
mental health
FFS
Mental health
RSN + FFS
Chemical
dependency
County FFS
Non-Medicaid
Clients
25
Entity
•
Involuntary
Treatment Act
•
RSN
•
Therapeutic Courts
•
County
•
Transitional Care
Coordination from
Prison or IMDs
•
RSN/
County
•
Inpatient chemical
dependency
treatment
•
State
•
IMD/State Mental
Health Hospital
inpatient care
•
State
Medicaid-Funded Services –
Early Adopter RSAs & Behavioral Health
AI/AN
Population
MC
Plan?
Medicaid
Funded Services
Yes
Physical health,
mental health,
and chemical
dependency
services
No
Physical health,
mental health,
and chemical
dependency
services
Medicaid
Enrollees
Entity
MCO
FFS*
Questions:
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.
1. Are the proposed “essential
behavioral health functions” the right
functions to allow subcontracting for?
2. Is 18 months the right timeframe?
3. Are there other limits on
subcontracting to consider?
Not Eligible for Medicaid
*In Early Adopter RSAs, there may not be a countybased entity responsible for mental health or
chemical dependency treatment.
26
“Essential Behavioral Health Functions”
would include utilization management,
network development, provider
relations, quality management, data
management and reporting.
Medicaid-Funded Services –
Early Adopter RSAs & AI/AN Clients
AI/AN
Population
MC
Plan?
Medicaid
Funded Services
Yes
Physical health,
mental health,
and chemical
dependency
services
MCO
No
Physical health,
mental health,
and chemical
dependency
services
FFS*
Medicaid
Enrollees
Entity
Not Eligible for Medicaid
*In Early Adopter RSAs, there may not be a countybased entity responsible for mental health or
chemical dependency treatment.
27
Questions:
1.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??
2.How can HCA best support
Tribal clinics? Would Tribal
clinics consider becoming innetwork providers?
3.How can HCA facilitate better
care coordination between
BHOs and MCOs across RSAs?
State/Local-Funded Services –
Early Adopter RSAs & Non-Medicaid Funds
State/Local
Funded Services
Examples:
Potential Entities in Early
Adopter RSAs to Perform
Service
Question:
1. Each MCO administers portion
of non-Medicaid funds
•
Involuntary Treatment Act
•
Therapeutic Courts
MCO
• With services carvedin or carved-out of
MCO contract
•
Transitional Care
Coordination from Prison
or IMDs
ASO (administrative
service organization)
•
Inpatient chemical
dependency treatment
•
IMD/State Mental Health
Hospital inpatient care
•
For services carvedout of MCO contract)
County
•
Alternative to ASO
28
Who should administer these
funds and services?
2. Single MCO or Administrative
Service Organization (ASO)
administers all non-Medicaid
funds in coordination with
MCOs
3. Split design
• Each MCO administers funds
for Medicaid clients
• Single MCO or ASO
administers funds for nonMedicaid clients
State/Local-Funded Services –
Early Adopter RSAs & State Hospital Beds
State/Local
Funded Services
Examples:
Potential Entities in Early
Adopter RSAs to Perform
Service
•
Involuntary Treatment Act
•
Therapeutic Courts
MCO
• With services carvedin or carved-out of
MCO contract
•
Transitional Care
Coordination from Prison
or IMDs
ASO (administrative
service organization)
•
Inpatient chemical
dependency treatment
•
IMD/State Mental Health
Hospital inpatient care
•
For services carvedout of MCO contract)
County
•
Alternative to ASO
29
Question:
How will state
hospital beds be
allocated and how will
MCOs reimburse the
State if the hospital
bed allocation in their
region is exceeded?
State/Local-Funded Services –
Early Adopter RSAs & Crisis Services
State/Local
Funded Services
Examples:
•
Involuntary Treatment Act
•
Crisis Services
•
Therapeutic Courts
•
•
•
Transitional Care
Coordination from Prison
or IMDs
Inpatient chemical
dependency treatment
IMD/State Mental Health
Hospital inpatient care
Potential Entities in Early
Adopter RSAs to Perform
Service
MCO
• With services carvedin or carved-out of
MCO contract
ASO (administrative
service organization)
•
For services carvedout of MCO contract)
County
•
Alternative to ASO
30
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 services
• Model 2 - ASO holds Medicaid and
non-Medicaid contract with the
State
Which “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?
DRAFT
Early Adopter RSAs & Crisis Services – Model 1
DRAFT
State
Medicaid
Contract
Contract for
NonMedicaid
Crisis
Services
NonMedicaid
Contract
Medicaid Managed
Care Organizations
Medicaid
billing
Required
sub-contract
•
•
Regional Crisis
System
Managed by
ASO
Medicaid
billing
Required
sub-contract
Data reporting
Examples of Behavioral health
including:
• E&T providers
• DMHPs/CDPs – 24/7
• Crisis hot line
• Crisis stabilization
Continuum of Integrated Clinical Services
Individual Client
31
Medicaid
Contract
NonMedicaid
Contract
Medicaid Managed
Care Organization
DRAFT
Early Adopter RSAs & Crisis Services – Model 2
DRAFT
State
Medicaid
Contract
PMPM for
Medicaid
Crisis
NonMedicaid
Contract
Medicaid Managed
Care Organizations
(Penalties when
members access
crisis)
Required
Coordination
•
•
Regional Crisis
System
Managed by
ASO
Non-Medicaid
Crisis Contract
Required
Coordination
Data reporting
Examples of Behavioral health
including:
• E&T providers
• DMHPs/CDPs – 24/7
• Crisis hot line
• Crisis stabilization
Continuum of Integrated Clinical Services
Individual Client
32
Medicaid
Contract
NonMedicaid
Contract
Medicaid Managed
Care Organization
(Penalties when
members access
crisis)
Potential Crisis System Models: Descriptions
Model 1
Model 2
•
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 nonMedicaid services, provided to both Medicaid and
non-Medicaid enrollees.
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 costreimbursement basis.
•
ASO holds a contract with the State for all nonMedicaid 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.
•
•
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 StateASO contract would also include funding (as in the
case of RSNs today) for the ASO to reimburse the
county for court costs.
33
1. Integrated Purchasing of Medicaid
Physical and Behavioral Health Care
 OTHER QUESTIONS
34
Behavioral 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
providers
Opioid treatment programs
Mobile crisis, crisis residential, respite beds
35
Model of Care
• Draft Model of Care available for review
• Draft Model of Care will be background for
procurement
• Questions:
•
•
•
•
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?
36
1. Integrated Purchasing of Medicaid
Physical and Behavioral Health Care
 COMMENTS - JANUARY 5
37
Medicaid Integrated Purchasing –
Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
Mobile 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 The encounter rate is paid as a
encounter rate in Medicaid managed
wraparound payment for care to AI/ANs
care?
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.
38
Medicaid Purchasing Integration Planning –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
County 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.
39
Medicaid Purchasing Integration Planning –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
MCOs and Tribes: Why isn’t there a
Until recently, Tribes have been mostly
requirement for MCOs to collaborate with outside the MCO system. HCA is now
Tribes?
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.
40
Medicaid Purchasing Integration Planning –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
Tribal 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.
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Medicaid Purchasing Integration Planning –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
Burden 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.
42
Medicaid Purchasing Integration Planning –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
MCO 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 HCA is hosting a meeting with the MCOs
have excellent programs. MCOs should be and Tribes in Olympia on February 13,
knocking on our doors to learn and
2015 to discuss these issues.
support our programs, instead of telling
us to follow their rules. How do MCOs see
themselves helping Tribes to become
better primary care providers?
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 MCOenrolled AI/ANs. MCOs pay providers in
many ways, in attempts to reward keeping
clients healthy rather than encounters.
43
Medicaid Purchasing Integration Planning –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
MCOs 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.
44
Medicaid Purchasing Integration Planning –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
Tribes are different: Different Tribes have
different issues. These issues are more
complex than Medicaid expansion.
HCA will email 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.
45
Medicaid Purchasing Integration Planning –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
Tribes 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.
46
2. Accountable Communities of Health
 BACKGROUND
47
Healthier Washington
• Improving how we pay for services
…so people and their providers can choose the best
treatment options
• Ensuring health care focuses on the whole
person
…people’s physical and mental health care are
integrated to better meet their needs
• Building healthier communities through a
regional approach
…local organizations work together to build strategies
that work for their community
48
Healthier Washington
Strategies include:
• Accountable Communities of Health to support
locally-driven goals, approaches, and processes
• Redesign of provider payments*
to improve the quality and value of care
• Creation of a regional extension service
to share information about best practices
*Tribes are not participating in provider payment redesign effort.
49
Accountable 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 region
• Participants include: public health, housing, and social service
providers; MCOs; insurers; county and local government; Tribes;
and consumers
Clinical
ACHs
50
Community
Accountable 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:
1. Statewide procurement objectives that address regional needs
and perspectives;
2. Assessment of MCO RFP responses for the ACH’s specific region;
3. On-going oversight of MCO and BHO effectiveness;
4. 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.
51
Accountable Communities of Health
An Accountable Community of Health is not intended to:
• Add approval layers
• Replace government entities
• Divert state funds
• Bear financial risk
52
Accountable 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, Wahkiakum
• North Sound
Counties: Snohomish, Skagit, Whatcom, San Juan,
Island
ACH Design Grants to be awarded
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How are ACHs different from Oregon’s
Coordinated Care Organizations (CCOs)?
CCOs
ACHs
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
Structure
Governed 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, patientcentered 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.
Yes
No
Are they riskbearing?
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How are ACHs different from Oregon’s
Coordinated Care Organizations (CCOs)?
CCOs
ACHs
How does this
change health
care financing?
CCOs receive global budgets for physical,
To be determined.
behavioral and dental health to treat the
population, with fixed rate of increase.
Incentives are tied to achievement of
benchmarks for pre-determined measures.
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.
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Accountable Communities of Health
The ACH Timeline
56
Accountable Communities of Health
Total Four-Year ACH Budget: $10.8 million
• ACH Design and Implementation (including personnel,
travel, consultants, grants)
 Year 1
o ~ 2 Pilot ACHs
o ~ 8 Design Regions
 Years 2 – 4
o ~ 10 ACHs
• ACH-Tribal Coordination
57
Accountable Communities of Health
Total Four-Year ACH-Tribal Coordination Budget: $300,000
Proposed Funding Structure for RFP:
•
Year 1 (pre-implementation year): $75,000
•
Year 2: $150,000
•
Year 3: $50,000
•
Year 4: $25,000
Proposed Contract Deliverables to HCA:
• Protocols, templates, coordination plans for ACHs to engage with
Tribes in their regions
• Data analytic recommendations for ACHs
• Recommendations for maintaining ACH-Tribal coordination process
58
Accountable Communities of Health
ACH-Tribal Coordination
• Principles
 Health disparity reduction is a key goal of ACHs
 ACH participants are expected to understand and respect the Tribal-State
government-to-government relationship
• Framework
 Tribal representation on local ACH governance/oversight board
 Tribe may invoke right to have State participate in any ACH meetings
 State must be cc’d on all written communication from ACH to Tribes
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Accountable Communities of Health
ACH-Tribal Coordination
How can HCA facilitate
productive relationships
between ACHs and
Tribes/Urban Indian
Organizations in order
to improve the health of
American Indians/Alaska
Natives?
• Financial Support
• Deliverables
• Principles
• Framework
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2. Accountable Communities of Health
 COMMENTS – JANUARY 5
61
Accountable Communities of Health –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
ACH Accountability: What is the
mechanism for holding any of the
participants accountable? RSNs have not
worked for Tribes at all.
1. 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.
2. 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.
62
Accountable Communities of Health –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
ACH 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 Each ACH is expected to have a backbone
looking at to begin this process? Develop organization, such as non-profit
these boards?
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.
63
Accountable Communities of Health –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
ACH as Supplemental: Will ACHs compete No. ACHs will supplement Tribal services.
with Tribes in providing 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-togovernment relationship is respected.
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Accountable Communities of Health –
Tribal Thoughts/Concerns from January 5, 2015
Tribal Thoughts/Concerns
HCA’s Response
State 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 nonNatives raise cultural competency
questions would be helpful.
HCA could include requirements for ACH
participants to receive cultural
competency training.
65
3. Healthier Washington
 GOVERNOR’S HEALTH INNOVATION
LEADERSHIP NETWORK
66
Health Innovation Leadership Network
The Governor’s Office seeks recommendations for two
people to serve 1-year terms on HILN:
• A Tribal representative, and
• An Urban Indian Organization representative.
67
Health 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).
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Health Innovation Leadership Network
What is HILN intended to do?
• Monitor, inform and accelerate Healthier
Washington progress
• Identify barriers and opportunities for
alignment, scale and spread
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Health Innovation Leadership Network
Please let me know if:
• You have any recommendations
• You have any questions about HILN
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RESOURCES
HCA Healthier Washington:
http://www.hca.wa.gov/hw/Pages/default.aspx
DSHS Developing Behavioral Health Organizations:
http://www.dshs.wa.gov/bhsia/division-behavioral-heath-and-recovery/developing-behavioral-health-organizations
Washington Adult Behavioral Health System Task Force:
http://leg.wa.gov/JOINTCOMMITTEES/ABHS/Pages/default.aspx
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