3130 Fairview Park Drive, Suite 800 Falls Church, VA phone: (703) fax: (703)

Transcription

1 3130 Fairview Park Drive, Suite 800 Falls Church, VA phone: (703) fax: (703) December 9, 2010 West Virginia Department of Health and Human Resources Office of Purchasing ATTN: Donna Smith One Davis Square, Suite 100 Charleston, WV Re: RFP MED Dear Ms. Smith: The Lewin Group is pleased to submit our technical proposal to provide administrative and operational services for the West Virginia Bureau for Medical Services Medicaid managed care program. Lewin offers an exceptionally qualified team that has worked closely with the Bureau for Medical Services since We welcome the opportunity afforded by this RFP to offer our technical and analytic expertise in continued support of the West Virginia Bureau for Medical Services. The Lewin Group will provide expertise in Medicaid managed care operations, capitation rate development, and program evaluation and improvement strategies, alongside our in-depth understanding of the current federal regulatory environment. Our project team reflects these capabilities, providing high-level policy and program experience, operational expertise, broad national exposure, and West Virginia knowledge. The Lewin Group accepts all RFP terms, and certifies that our bid price was arrived at without any conflicts of interest. I am authorized to bind The Lewin Group to the terms set forth in the enclosed proposal to the West Virginia Department of Health and Human Resources. My contact information is: Lisa Chimento, Chief Executive Officer The Lewin Group 3130 Fairview Park Drive, Suite 800 Falls Church, VA Phone: (703) lisa.chimento@lewin.com Thank you for your consideration of our proposal. We look forward to the opportunity to address any questions you have. Sincerely, Lisa Chimento Chief Executive Officer

2 Table of Contents EXECUTIVE SUMMARY (4.1.4)... 1 VENDOR S ORGANIZATION (4.1.5)... 4 Business name and address:... 4 Subcontractor detail:... 4 Financial information:... 4 Additional RFP Requirements:... 7 LOCATION (4.1.6)... 8 VENDOR CAPACITY, QUALIFICATIONS AND RELEVANT EXPERIENCE (4.1.7)... 9 The Lewin Group Organizational Structure... 9 Experience and Capabilities PROJECT APPROACH AND SOLUTION (4.1.8) Statement of Understanding Scope of Work: Yearly Operations Plan (3.2.1) Scope of Work: Program Management and Improvement (3.2.2) Scope of Work: Program Evaluation and Improvements (3.2.3) Scope of Work: Federal Regulatory Compliance (3.2.4) Scope of Work: Additional Services (3.2.5) VENDOR STAFFING (4.1.9) Key Project Personnel Project Staff Organization SUBCONTRACTING (4.1.10) SPECIAL TERMS AND CONDITIONS (4.1.11) SIGNED FORMS (4.1.12) RFP REQUIREMENTS CHECKLIST (4.1.13) APPENDIX A: ADDITIONAL CORPORATE QUALIFICATIONS APPENDIX B: STAFF RESUMES i

3 Executive Summary (4.1.4) In a successful effort to constrain the growth of Medicaid expenditures while improving the quality of health care services provided to Medicaid beneficiaries, the Department of Health and Human Resources Bureau for Medical Services (BMS or the Bureau) implemented fullrisk managed care contracting in The State s primary care case management program, the Physician Assured Access System (PAAS), was joined with the full-risk capitated program under one combined 1915(b) waiver in The programs are now collectively known as Mountain Health Trust (MHT) and together serve over 180,000 West Virginia beneficiaries. Today, West Virginia is moving closer to the goal of having a statewide, comprehensive managed care program. Over the next six years the Mountain Health Trust program has more to do, both to build on past successes and to manage emerging challenges to positively affect the program in the future. Opportunities and challenges now facing the State include: Ensuring that the State is purchasing the best value service for the best price; Successfully completing the implementation of major program changes and effectively monitoring the expanded program; Preparing for federal health reform; and Continuing to operate the program and serve beneficiaries currently enrolled. As the incumbent contractor and a nationally-recognized Medicaid policy firm with best-inclass capabilities, The Lewin Group is ideally and uniquely equipped to assist the Bureau for Medical Services in responding to all of these challenges and opportunities. We have supported the Bureau with the development, implementation, and operation of the program since its inception, and over the past 15 years, Lewin has gained deep experience with West Virginia, as well as with other Medicaid programs across the country. Our team is personally committed to the success of the program: Lisa Chimento, Lewin s chief executive, has supported MHT since its inception, and several additional project members have assisted MHT for more than a decade. Our partnership has resulted in significant successes for the West Virginia Medicaid program: Expansion of the MCO model statewide, with at least two MCOs offering members a choice in 42 of the State s 55 counties; Increased use of appropriate preventive health services and corresponding decreases in emergency room visits, hospitalizations, and other unfavorable health outcomes; High levels of member satisfaction, with 92 percent of MCO parents rating their children s personal doctors at 7 or above (10 being the highest possible), higher than the national Medicaid average, and 83 percent of adult beneficiaries reporting high satisfaction with their personal doctor or nurse; Performance above the national average for Medicaid programs in the areas of cervical cancer screenings, controlling high blood pressure, comprehensive diabetes care, adult access to preventive and ambulatory care, and timeliness of prenatal and postpartum care; and 1

4 Over $25 million in cost savings since the inception of the Medicaid MCO program by slowing the growth in the use and cost of medical services and administrative efficiencies. We are proud of our long term relationship with West Virginia and the growth of the program over the last several years. We understand the needs of the Bureau and are prepared to meet these needs. Bureau for Medical Services Needs A consulting team with detailed and long term knowledge of the West Virginia Medicaid program, that can begin work immediately upon contract award Skilled actuaries and a rate-setting team to ensure that West Virginia Medicaid funding is spent efficiently and MCOs are paid accurately Consulting partners to assist the State in preparing for program expansion and other program requirements as it prepares for a major program expansion in 2014 under health reform National experience and innovative ideas to ensure that program improvements and other quality improvement activities are at the forefront of Medicaid policy The Lewin Group Capabilities As the incumbent contractor, we have a strong working relationship with the Bureau and deep knowledge of the program as well as effective working relationships with other entities that regulate and operate the program, including CMS, the MCOs, and other MHT vendors Our team s rate-setting expertise in West Virginia and experience in over 30 other states provides the basis for designing and securing approval of more sophisticated payment arrangements, including risk adjustment and pay-for-performance As a firm, we are at the forefront of health reform modeling and implementation efforts and can provide timely and credible support to the State We bring to bear knowledge and experience from many other successful state Medicaid managed care programs, including former State Medicaid Directors, and leverage best practices from around the country to benefit the MHT program Having a team with sufficient depth to handle the technical challenges in the Scope of Work as well as sufficient breadth to ensure timelines are met is critical to the successful execution of this engagement. This scope demands a variety of expertise in areas such as rate-setting, policy analysis, procurement support, quality monitoring, data analysis, and regulatory compliance, and a team that is integrated among the disciplines in order to solve complex problems. Lewin offers a large team of cross-trained staff able to support multiple activities at varied levels of intensity across each contract year. Our team structure has allowed us to meet the specific requirements of the Scope of Work and support a host of other BMS needs including: Responding to unexpected events, such as major changes in program direction and MCO entry into or departure from the program; 2

5 Adapting to changing requirements such as developing capitation rates for additional benefits, modifying program documents to address new federal rules around benchmark benefits, and adjusting program expansion timelines; and Supporting BMS in a variety of emerging policy and operational issues, such as pharmacy carve-in and additional federal reporting requirements. We propose the same highly-trained team for this effort, with new additions to meet the program s growing needs. We will maintain our current strategy for senior leadership of the project, with Lisa Chimento and Moira Forbes acting as co-project Directors. To appropriately address the four task areas included in the RFP, we have assembled four teams, each with a lead and support staff. Jennifer Tracey will continue to be responsible for overall management of the teams, as well as serving as the co-team lead for the Operations Plan task. Chris Park and Tom Carlson, FSA, will continue to lead our rate-setting work, with input from Jeff Smith, a nationally-recognized risk Our key staff are personally vested in the ongoing success of this program and look forward to the opportunity to fully engage in supporting BMS with the further maturation of the Mountain Health Trust program. adjustment expert, as appropriate. Our subcontractor, Michael Madalena, will continue to work with Lewin, BMS, and the MCOs on encounter data activities, with oversight from Steve Johnson, Ph.D., a Lewin senior staff member. Dr. Johnson has over 30 years of experience working with health plan data, including 10 years overseeing similar activities for the State of New York, and will serve as team lead for the Program Management and Improvement task. Jessica Boehm, who has supported the Bureau in several capacities over the past several years, will serve as team lead for the Federal Regulatory Compliance and Project Evaluation and Improvement tasks. Other staff with previous experience supporting the MHT program will remain on the team, and we will draw on our extensive team of policy experts, data analysts, and Medicaid/CHIP experts as needed to support regular and ad hoc tasks. Our proposed team will provide the Bureau with unmatched experience gained in West Virginia and other states, as well as continuity and the ability to launch a full effort immediately upon contract award. Our nationally-recognized experts and experienced, dedicated West Virginia team will be able to assist the Bureau in assessing a range of emerging issues and implementing a variety of program innovations, including: Evaluating the appropriateness of risk adjustment or other payment methodologies; Refining the program monitoring dashboard to provide robust management information; Assisting BMS in considering the pros and cons of competitive bidding approaches; Modeling the potential size and utilization of health reform expansion populations; and Adopting additional quality improvement and performance incentive strategies. We understand that the Medicaid world is changing constantly and West Virginia may require additional, ad hoc services as part of this contract. As we have for the previous 15 years, our team is prepared to be flexible in meeting the needs of the program and providing required assistance. 3

6 Vendor s Organization (4.1.5) Business name and address: The Lewin Group 3130 Fairview Park Drive, Suite 800 Falls Church, Virginia Subcontractor detail: The Lewin Group will continue to partner with Michael Madalena, located at 551 Justabout Road, Venetia, Pennsylvania, More detail on Mr. Madalena s role is included in Section Financial information: The Lewin Group, incorporated in North Carolina on April 12, 1996, became a wholly-owned subsidiary of Ingenix in June of Ingenix, a wholly-owned subsidiary of UnitedHealth Group (UHG), was founded in 1996 to develop, acquire and integrate the world's best-in-class health care information technology capabilities. The Lewin Group s financial information is not provided at the Lewin level; it is consolidated at the Ingenix business segment level and reported to UnitedHealth Group for consolidated SEC reporting/filing. UHG's latest audited 8-K & 10-K (links provided below) itemize the Ingenix business segment financial information - of which The Lewin Group is a part. Excerpts from the UHG filings describing the Ingenix business segment and its respective financial results are provided below. UHG Form 8-K First Quarter 2009: UHG Form 8-K First Quarter 2010: 4

7 UHG Form 8-K First Quarter 2009 Ingenix Excerpts: 5

8 UHG Form 8-K Second Quarter 2009: Ingenix Excerpts: 6

9 Additional RFP Requirements: Disaster Recovery Plan As required in Section 1.24 of the RFP, Lewin has a disaster recovery plan in place. A copy of the plan is attached here. As indicated, the disaster plan includes periodic testing of the plan. 3.3 Special Terms and Conditions Bid and Performance Bonds: Non-applicable Insurance Requirements: The Lewin Group will provide proof of insurance at the time of contract award License requirements: The Lewin Group s Certificate of Authority to do business in West Virginia is attached. We are seeking a Certificate of Good Standing from the Insurance Commissioner Litigation Bond: Non-applicable 3.3.5: Debarment and Suspension: The Lewin Group is not debarrered or suspended. 7

10 Location (4.1.6) The Lewin Group is located at 3130 Fairview Park Drive, Suite 800, Falls Church, Virginia, The Lewin Group s offices feature comprehensive facilities that enable thorough and efficient project support. The Lewin Group offices in Falls Church cover three floors of a modern office building. The headquarters is easily accessible by car or Metro, and is 20 minutes from downtown Washington, DC, and within a half an hour from both major airports. Additionally, Lewin is close to both the Baltimore and Washington, DC locations of the Centers for Medicare and Medicaid Services. Our location offers relative proximity to Charleston, West Virginia. The Falls Church office provides the amenities and convenience typical of the work space used by leading professional services firms. All floors have two or more fax machines and several printers and copiers (both color and black and white). Twelve conference rooms are available within Lewin s office space for hosting meetings for groups of up to 20. An additional large conference seats 90 auditorium style, and can hold 130 standing. Each conference room has at least one conference telephone, as do all offices. In addition, one of the smaller conference rooms has been installed with a certified video teleconferencing system, which is 98 percent compatible with all other videoconferencing centers/equipment in the United States and worldwide. The Lewin Group will continue to partner with Michael Madalena, located at 551 Justabout Road, Venetia, Pennsylvania,

11 Vendor Capacity, Qualifications and Relevant Experience (4.1.7) Today, West Virginia is moving closer to the goal of having a statewide, comprehensive managed care program. Over the next six years the Mountain Health Trust (MHT) program has more to do, both to build on past successes and to manage emerging challenges to positively affect the program in the future. Opportunities and challenges now facing the State include: Ensuring that the State is purchasing the best value service for the best price; Successfully completing the implementation of major program changes and effectively monitoring the expanded program; Preparing for federal health reform; and Continuing to operate the program and serve beneficiaries currently enrolled. As the incumbent contractor and a nationally-recognized Medicaid policy firm with best-inclass capabilities, The Lewin Group is ideally and uniquely equipped to assist the Bureau for Medical Services in responding to all of these challenges and opportunities. We have supported the Bureau with the development, implementation, and operation of the program since its inception, and over the past 15 years, Lewin has gained deep experience with West Virginia, as well as with other Medicaid programs across the country. Many of our proposed team members have worked with the Bureau for a decade or more and have a personal commitment to the ongoing success of the program. Our specific capacity and qualifications to support the Bureau in these important endeavors are described in more detail below. The Lewin Group Organizational Structure The Lewin Group is a premier national health and human services consulting firm with 40 years of experience delivering objective analyses and strategic counsel to public agencies, non-profit organizations, and private companies across the United States. Lewin has worked with over 40 states, including West Virginia, on a variety of Medicaid and state health reform initiatives and has both deep and broad expertise in the development, implementation, and operation of Medicaid managed care programs. The firm is renowned for its objectivity, analytical capability, strategic vision, and commitment to client satisfaction. Lewin helps clients to: Improve policy and expand knowledge about health and human services systems; Enact, run, and evaluate programs to enhance delivery and financing of health care and family services; Deal with shifts in health care practice, technology, and regulation; Optimize performance, quality, coverage, and health outcomes; and Create strategies for institutions, communities, governments, and people to make health care and human services systems more effective. The Lewin Group has a well-earned reputation for delivering significant value to its clients. This value comes from our professional and experienced staff, our insights into the issues that clients face, our rigorous approach to analyzing and solving problems, and our commitment to 9

12 independence, innovation, and integrity. The Lewin Group s more than 110 consultants are drawn from industry, government, academia, and the health professions. Many are national authorities whose approaches to advancing health care and human service systems stem from personal experience with imperatives for change. The proposed project co-directors, Lisa Chimento and Moira Forbes, are both recognized experts in Medicaid managed care and their insights in this field have recently been sought by the Medicaid and Children s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) and the Centers for Medicaid and Medicare Services (CMS). The Lewin Group is a wholly-owned subsidiary of Ingenix Public Sector Solutions, Inc., which in turn is a wholly-owned subsidiary of UnitedHealth Group. Ingenix, whose focus is on knowledge and information lines of business, develops, publishes, and licenses data management and decision support tools and also provides clinical and health services research, development and marketing services on a global basis. Ingenix is one of UnitedHealth Group s independent wholly-owned operating companies. The Lewin Group operates as a separate corporate entity, with its own operational structure and management. Experience and Capabilities The Lewin Group is the market leader in the field of Medicaid and Medicaid managed care consulting. Our experience in this realm goes back nearly two decades and includes more than half the states in the nation. Our senior staff have decades of professional experience as consultants, health plan executives, and state Medicaid agency officials. Much of our professional focus is on assisting states in creating, implementing, enhancing, and broadening Medicaid managed care programs. As shown in Figure 1 below, we have worked in almost all of the states and with numerous private sector entities on a variety of Medicaid initiatives. Figure 1. The Lewin Group s National Medicaid Experience State or local gov t Private organization(s) Both gov t and private We combine real world experience with a broad, national perspective on public policy to address areas including: 10

13 Design and implementation: evaluating local circumstances to determine the ideal managed care program configuration, developing overall program designs, specifying managed care program features, drafting waiver applications, facilitating stakeholder consensus building, and supporting program implementation and administration. Program reimbursement: designing program reimbursement and risk-sharing arrangements, developing actuarial methodologies, and setting capitation rates. Procurement: planning procurements, drafting Requests for Proposals (RFPs), crafting evaluation criteria and methodologies, training review teams, participating in proposal efforts, and developing contracts. Monitoring and evaluation: evaluating programs, performing ongoing quality monitoring, developing and implementing external quality review strategies, conducting provider and beneficiary surveys, and developing quality standards. In addition to our work with state Medicaid agencies, Lewin assists Medicaid health plans in a variety of activities, including designing service delivery arrangements, devising policies and procedures consistent with state requirements, and developing approaches to serving members with special needs. Lewin also assists health plans in preparing applications and proposals for competitive awards of risk contracts. Additionally, we work with providers of specialized services who wish to organize health plans for Medicaid sub-populations with unique needs, such as children with special health care needs and persons infected with HIV/AIDS. This private-sector experience gives our firm distinctive and realistic perspectives on the needs and capabilities of providers and MCOs regarding public sector managed care and allows us to bring cutting-edge innovation to our state Medicaid clients. Lewin s multi-faceted expertise will be valuable as we guide the State of West Virginia in furthering the development of the Mountain Health Trust program. Below, we detail Lewin s experience for each task delineated in West Virginia s RFP. In Appendix A, we include a matrix listing selected states and other clients for which we have provided that experience, and additional descriptions for each of those clients, specific to the project. Task 3.2.1: Yearly Operations Plan, including rate setting and contracts The Bureau requires support in the management and implementation of the Mountain Health Trust program, including development of a robust Operations Plan that will enable the Bureau to efficiently and effectively administer and manage the program. Key components of this task are procurement, rate setting, contract negotiation, program management, and ongoing monitoring of program vendors and performance. The Lewin Group has assisted West Virginia in all of these areas since 1995 and performed similar activities in a number of other states, as described in more detail below. Subtask : Yearly capitation rates Since 1995, Lewin has set rates for West Virginia s MHT program and will be able to continue this work immediately upon contract execution. Lewin has a detailed understanding of West Virginia s eligibility and claims systems, in addition to our knowledge of the specifics of West Virginia s Medicaid program (i.e., eligibility categories, fee-for-service (FFS) payment methods, 11

14 benefits packages) which allows us to set rates accurately. We understand the current Medicaid Management Information Systems (MMIS) requirements and specifications for the monthly data transmissions. Over the past two years, Lewin has incorporated numerous changes to the program, including: changes in Mountain Health Choices (MHC) benefit limits under the new State Plan Amendment; the removal of Section 1931 Parents and Caretakers/relatives from mandatory enrollment in the benchmark authority; the behavioral health and children s dental expansion; and the expansion to Supplemental Security Income (SSI) beneficiaries. As West Virginia s Medicaid program continues to face new changes and challenges, our knowledge of the provider community and service delivery system will help to inform the design and analysis of the impact of programmatic changes. Lewin has established Medicaid managed care capitation rates in 12 states: Colorado, Connecticut, Delaware, the District of Columbia, Iowa, Kansas, Massachusetts, Montana, New Mexico, New York, Oregon, and West Virginia. In several of these states, Lewin has established capitation rates for multiple comprehensive physical health and specialty carve out programs over multiple years. Lewin developed the capitation rates using either Medicaid FFS claims data, managed care organization (MCO) encounter data, or both. Our standard rate setting work involves designing needed data requests; programming claims and eligibility files; performing data validity checks and correcting data as needed; establishing appropriate rate cohorts; adjusting the raw claims data for claims completion, retrospective eligibility periods, and other factors; and developing inflation trend factors. We have developed rate setting methodologies that have incorporated individual or aggregate reinsurance, risk sharing and risk corridor arrangements, and incentive payment structures. Therefore, we are highly familiar with the actuarial process of establishing capitation rates that meet federal requirements and contrasting capitation rates to FFS cost levels. Lewin has worked with several states to develop capitation programs for specialty services, behavioral health, dental health, and mental health programs; we have also worked with state Medicaid agencies on individual and aggregate reinsurance and risk sharing arrangements to protect the State and plans. In addition, Lewin has closely worked with CMS and other states regarding the changing nature of Medicaid managed care cost-effectiveness. Through our experiences with the Bureau and with other states, Lewin has developed a reputation for strategic approaches to rate development and high quality technical analyses needed to accurately calculate rates. Subtask : Procurement The Lewin Group has extensive experience designing and managing procurements and has worked with numerous states, the federal government, and several private-sector organizations on various procurement tasks, including developing overall procurement strategies, drafting RFPs, developing scoring criteria and review guides, training state evaluation teams, participating in proposal review, analyzing provider networks, developing site visit protocols, and conducting site visits to MCOs. Lewin has conducted Medicaid managed care procurements in Connecticut, Florida, Maryland, Montana, New Mexico, New York, Texas, and West Virginia. Lewin has also assisted in other purchasing activities such as conducting market analyses and negotiating with selected contractors. 12

15 Lewin developed the original RFP for the MHT program, managed the procurements of MCOs for the program, and developed the revised MCO contracts that will serve as the basis for future procurements. For the past 15 years, Lewin has supported the Bureau in efforts to encourage additional MCOs to participate in the MHT program, and has developed cooperative relationships with key decision-makers at several of these plans. These relationships, as well as Lewin s familiarity with Medicaid MCOs in other states and specialty health plans, were advantageous in attracting an additional MCO, WellPoint (UniCare), to the State. Lewin has developed RFPs and managed procurements for other contractor types as well. In New Mexico, New York, and West Virginia, Lewin assisted in selecting and contracting with an enrollment broker and an external quality review organization. Lewin also assisted the Texas Medicaid program in the selection of a claims processor for the Medicaid FFS program. Lewin is currently working with the State of Missouri to develop an RFP for a contractor to oversee the state s expanded Medicaid direct school-based services and administrative claiming program as well as developing tools for the state to utilize in proposal review. Finally, Lewin has provided extensive procurement support to clients arranging health care delivery and administrative services for other populations, including state employees, general assistance recipients (e.g., California County Medical Services Program), and CHAMPUS (the Department of Defense s TriCare program). Subtask : Develop MCO contracts The Lewin Group has experience drafting entire contracts and contract amendments for fullyand partially-capitated Medicaid health plans, as well as other alternative arrangements (e.g., a consortium of community health centers, special needs plans). For the States of West Virginia, New Mexico, New York, and Texas, Lewin worked with State staff to prepare Medicaid managed care contracts, ensuring that contract language complied with federal regulations and guidelines and State requirements, and participated in discussions with CMS staff, incorporating their comments as needed. For West Virginia, Lewin has assisted the Bureau in implementing and operating a full-risk managed care contracting program, including the operations of MHT s contract negotiations. Lewin also assisted Delaware, New Mexico, and Texas with all aspects of contract negotiations, including meetings with health plan representatives and their legal counsel. In the past, Lewin has assisted the Bureau in bringing the MCO contract into full compliance with federal regulations, and Lewin understands the future implications of health reform to continue to assist the Bureau. In addition, Lewin has strong relations with the MCOs and other MHT vendors, as well as the Philadelphia Regional Office of CMS, who is responsible for monitoring MHT, which will help the Bureau gain approval of contract changes and amendments. Subtask : MCO contracting strategy Lewin s experience with performance-based contracting will help the Bureau develop a strategy that meets the combined challenges of promoting a competitive managed care contracting system while simultaneously encouraging MCO performance improvements in key areas and supporting traditional Medicaid providers as important elements of West Virginia s health care 13

16 delivery system and safety net. As contracting strategies change over time, our team is prepared to work with the Bureau to understand current best practices in the field and to tailor these to West Virginia s needs. The Lewin Group has experience developing performance-based contracting strategies in numerous states, with particular focus on ensuring that the areas of focus are measurable and meaningful to both the state and the contractor. While it is often tempting to include all of the various types of behaviors or health system and status improvements in the incentive system, a long list of measures and goals can dilute the particular reward associated with any one of them. Lewin s experience in Massachusetts and Florida focused on financial incentives tied to improving performance rather than merely meeting stated goals as a way of encouraging continuous progress and minimizing gaming of the system. In Connecticut, Lewin developed a system to reward health plans with auto-assignment for providing additional services. In Minnesota, we worked closely with State staff, its contractors, and the MCOs to develop a performance contracting system. We spent considerable time gathering best practices from other states and meeting with the MCOs and with state staff to develop a program tailored specifically for Minnesota. In West Virginia, our detailed understanding of the Bureau s goals and the current strengths and shortcomings of the MCOs performance in West Virginia, as well as the strong relationships we have developed with the MHT MCOs, are especially critical to the successful completion of this task. One of the most important components of the performance incentive system will be the MCOs confidence in the measurement system and how it will be applied. Lewin s credibility with the MCOs, our reputation for analytic quality and objectivity in our work in West Virginia and elsewhere, and our collaborative approach are important strengths that we bring to this task. Subtask : Provider networks analysis and monitoring We understand that provider networks are at the heart of a successful MCO program and have devoted substantial expertise to this effort in other states. The Lewin Group has developed network evaluation tools for numerous states that enroll TANF and SSI beneficiaries, including Connecticut, New Mexico, New York, Texas, and West Virginia. Our network adequacy model uses defined time and distance as well as provider composition access standards and ratios as the standard by which networks are judged. We use our model to ensure that access, measured by numbers of points of access, is improved; to comply with federal guidelines regarding equal or better access as compared with FFS Medicaid and waiver terms and conditions; and to give Medicaid enrollees choices of providers within networks. Lewin s network adequacy models have been accepted by CMS to demonstrate that state Medicaid managed care programs meet or exceed the federal requirement that managed care enrollees be provided with access to providers that is equal or greater than FFS. In addition to our experience with the network adequacy models described above, Lewin s background in Medicaid managed care and significant experience developing managed care programs for various special needs populations provides us unique insights into the critical access requirements of Medicaid beneficiaries. Similarly, Lewin has developed and evaluated network criteria for CMS to include the Special Needs Plans (SNPs). We supplement our mapping and database analysis of provider networks which generally focus on ratios and 14

17 points of access within specific provider types with a desk review of MCOs overall provider network capacity to ensure that important state goals, such as the inclusion of traditional Medicaid providers, are met. The Lewin Group uses Microsoft s MapPoint software to conduct mapping and geographic analyses for a variety of clients including state Medicaid agencies, hospital systems, MCOs, and public health agencies. Task 3.2.2: Program Management and Improvement The Bureau requires support in the ongoing management of the Mountain Health Trust program, its expansion, and continuous improvement. Major activities in this task include encounter data analysis and related reporting and development of options for program expansion. The Lewin Group has supported the Bureau for Medical Services for over 15 years in ongoing program management, including numerous program expansions and modifications. We have also consulted with numerous states on a variety of tasks related to program management and improvement, including providing day-to-day support for state agency staff, providing ongoing and ad hoc technical assistance, and assisting in program monitoring and evaluation activities. We have supported many state Medicaid managed care programs, including West Virginia, in identifying options for program changes, assisting in the selection and refinement of appropriate options, developing implementation plans, and assisting in the realization of selected program design options. Subtask Ongoing program management The Lewin Group has significant experience assisting states in the ongoing management of Medicaid managed care programs. Our most important engagement has been assisting the Bureau for Medical Services with the ongoing management of MHT. Since 1995, this engagement has included working closely with Bureau staff as well as representatives from other Department of Health and Human Resources (DHHR) agencies, the enrollment broker, the external quality review organization (EQRO), the encounter data analyst, the Medicaid fiscal intermediary, the Physicians Assured Access System, and other stakeholders in the MHT program. For more than a decade, Lewin has helped design and implement large-scale health programs for Medicaid agencies in 16 additional states: Arizona, Connecticut, Delaware, the District of Columbia, Florida, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Montana, New Mexico, New York, Ohio, Oregon, and Texas. Many of these projects are of a long-term nature for example, we worked for the State of West Virginia from 1995 to the present and the State of New York from 1999 to the present. We have also worked on multiple contracts across the years for Connecticut, New Mexico, Ohio, Maryland, Texas, and the District of Columbia. These and other long-term engagements generally began as shorter term contracts that were extended for multiple contract periods a testament to our clients satisfaction with our work. Lewin has also worked with numerous private sector entities to develop responses to state Medicaid managed care initiatives. This added experience gives us distinctive and realistic perspectives on the needs and capabilities of providers and MCOs regarding public sector 15

18 managed care programs. Lewin s multi-faceted expertise will be valuable as we assist the Bureau in furthering the development of its collaborative partnership with the State s MCOs. a. Subtasks : Encounter data analysis and related reporting Since 1995, Lewin has specialized in the development and application of analytic and operational processes to maximize the value of information obtainable from health care data. Lewin has over 15 years of experience gathering encounter and claims submissions from MCOs, reviewing them, and producing data reports; we also have expertise analyzing the data in order to develop provider profiles, legislative presentations, and other ad hoc analysis. As the MHT program continues to expand, it is crucial for the Bureau to make sure that health care services are being provided efficiently in order to minimize Medicaid expenditures and to ensure that members are receiving high quality care. Lewin s understanding and experience with MHT s major ongoing operational activities, including the development of performance monitoring reports, will help Lewin effectively assist MHT with program management and monitoring and ensure that regular operational activities are accomplished in a timely and satisfactory manner. b. Subtask : Program expansion options Lewin has helped design and implement large-scale health programs for Medicaid agencies across the country. Our experience in states such as West Virginia, Oregon, Montana, Kansas, Kentucky, Maryland, Texas, and New Mexico has provided us with an understanding of the specific issues that rural states face in the expansion of Medicaid managed care systems. Lewin staff are very familiar with developing innovative methods for managed care arrangements to increase access and coordination of care in rural areas. The goal of these innovative arrangements is to take advantage of existing delivery systems and encourage cooperation between public and private health care provider organizations, who often feel at odds over such issues as access and finance. Lewin designed and implemented full and partial-risk contracting models in numerous other states as well as for the Department of Defense. Our experience includes procuring Florida s disease management contractors, New York s special needs plans, Connecticut s providersponsored partial-risk plans, and Maryland s 1115 waiver MCOs, and developing actuariallysound risk adjusters for high-risk populations, including Delaware s Diamond State Cares initiative which includes seriously mentally ill, elderly, dually eligible, and institutionalized beneficiaries. Lewin has worked with several other states to implement SSI enrollment under federal 1115 waivers with stringent evaluation components, most notably Delaware, Maryland, and New York. Task 3.2.3: Program Evaluation and Improvements As the Mountain Health Trust program has expanded and matured, the need for increasingly sophisticated oversight and monitoring has grown, and this need will amplify with the planned program expansions in As such, the Bureau requires assistance in designing and implementing a Managed Care Improvement Plan (MCIP) that identifies program modifications through systematic, ongoing, and periodic program monitoring activities. The Lewin Group has significant experience in many states with ongoing program monitoring activities and has conducted comprehensive program evaluations for several waiver programs 16

19 that include plans for improvements. For example, Lewin has surveyed beneficiaries enrolled in several state Medicaid managed care programs and other specialized public health insurance programs in New York and used the findings to identify improvements and refinements for the respective programs, particularly in the areas of program oversight. Lewin has conducted multiple retrospective waiver evaluations for both 1915(b) and 1915(c) waivers and used the findings to help states identify ways to improve access, quality, and program monitoring. Lewin has also worked with state agencies and blue-ribbon commissions on special projects to identify potential program modifications to help states accomplish new program goals (e.g., expanding prescription drug coverage to the elderly) or maintain coverage levels during budget difficulties. Lewin worked closely with the State of Rhode Island (RI) to analyze data and financial projections under the current program design and under the proposed Global Consumer Choice 1115 waiver application, which sought to transform RI Medicaid into a block grant program. Lewin has prepared cost and savings estimates for a wide variety of policy and operational proposals. Subtask : Program improvement The Lewin Group has helped research and develop processes that have improved the efficiency and effectiveness of Medicaid services in states across the country. For West Virginia, Lewin has worked on a variety of engagements that include developing enrollment estimates for Medicaid eligibility changes and working with the West Virginia Health Care Authority to develop options to reduce the number of uninsured in West Virginia under a state planning grant from the Health Resources and Services Administration. In efforts to improve the delivery of health care, Lewin has supported the Bureau to identify areas for improvement using a systematic feedback approach, which includes dashboard reports. Through analysis of various program components (i.e., health outcomes, beneficiary satisfaction, quarterly reports, network access, CMS feedback, bi-annual beneficiary survey results), Lewin has detected areas for improvement. Lewin has also worked with the EQRO regarding performance monitoring. Lewin s experience will continue to inform work with the Bureau in identifying and prioritizing program improvement opportunities and implementing the necessary program modifications. Subtask : Program evaluation Lewin has analyzed utilization and cost data for multiple state Medicaid programs and a variety of public and private sector clients. For the last 15 years, Lewin has supported the Bureau in program evaluation efforts such as efficiency of health care delivery, costs, and quality of care. Lewin has accomplished these tasks through analysis of utilization and cost measures by demographics and program eligibility. Lewin has experience analyzing eligibility, cost, and utilization data to evaluate the performance of Medicaid managed care programs and other public sector health reforms. 17

20 Task 3.2.4: Federal Regulatory Compliance Successful operation of a Medicaid program requires in depth understanding of the detailed requirements in federal Medicaid law and regulation, including the provisions of the Affordable Care Act that will impact Medicaid. The Bureau for Medical Services requires support in maintaining compliance within the evolving environment of federal regulatory requirements. Lewin has assisted the Bureau for Medical Services (and numerous other states) since 1995 in working with the federal government to develop and implement program strategies, contracting mechanisms, and financing arrangements that comply with all applicable laws, policies, and guidance. Our team is especially qualified to provide expertise, policy analysis, strategic guidance, and knowledge to West Virginia that is grounded in our many years of experience in Medicaid programs throughout the country. We provide up-to-date expertise on all current health care issues and are capable of quickly processing the implications of new policy changes and legislation. We have worked with states and the federal government to understand and respond to every major piece of federal legislation affecting the Medicaid and CHIP programs over the past 15 years, including the Balanced Budget Act of 1997 (BBA), Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Deficit Reduction Act of 2005 (DRA), American Recovery and Reinvestment Act of 2009 (ARRA), Children s Health Insurance The Lewin Group has demonstrated our understanding of the intricacies of federal legislation by providing analysis of national and state-level estimates of the impact of the recently enacted Patient Protection and Affordable Care Act (ACA) and the Health Care and Education Reconciliation Act (HCERA) utilizing the Health Benefits Simulation model (HSBM), a micro simulation model developed at Lewin. These estimates, based on the final health reform bill, analyzed four areas related to health reform coverage and insurance market reforms: 1) the number and demographic distribution of people in families who become covered by Medicaid or receive premium subsidies; 2) the number and demographic distribution of people in families covered by firms that receive small business tax credits; 3) the number of people in families that benefit from the out-of-pocket limits specified in the reform plan; and 4) the number of people potentially benefitting from guaranteed issue of coverage and eliminating pre-existing condition exclusions. Program Reauthorization Act of 2009 (CHIPRA), and the ACA. We have indepth knowledge of Medicaid and CHIP laws, regulation, and policies, a strong understanding of how states and the federal government relate to one another in the Medicaid and CHIP context, and familiarity with existing evaluations, state guidance materials including State Medicaid Director and State Health Officer letters, regulations, and other policyrelated documents. Lewin has developed waivers for a number of states, including 1915(b), 1115, and Health Insurance Flexibility and Accountability (HIFA) waivers, and has worked with CMS to obtain approval for a number of innovative and unique program designs. Our strong working relationships with CMS staff in the central and regional offices benefits states that rely on our assistance to gain federal approval for state-sponsored initiatives. 18

21 Subtask : Quality assessment and performance improvement strategy and implementation plan The Lewin Group has assisted many states, including California, Connecticut, Maryland, Montana, New Mexico, New York, Oregon, Texas, and West Virginia in developing Medicaid managed care quality oversight and improvement programs. In these states, Lewin worked with state and MCO staff, stakeholders, and CMS to develop quality and reporting requirements that met state needs for monitoring and oversight and complied with federal policies and regulations. In Connecticut, Montana, New York, and West Virginia, Lewin developed the initial standards for quality assurance programs and reviewed MCO quality plans. Lewin then developed options and recommendations for strategies to monitor and evaluate the care and services provided to enrollees, including specific monitoring tools and data reporting requirements. Lewin has also worked with health plans in many states, including Pennsylvania, and we are familiar with some of the innovative strategies used nationally. Lewin has also helped states develop revised quality strategies to take into account changes in federal guidance (such as the introduction of CMS s Quality Improvement Standards for Managed Care, which replaced the earlier Quality Assurance Review Initiative guidelines) and changes in state-of-the-art managed care oversight. For example, Lewin has helped states, including West Virginia, redefine performance standards to comply with Medicaid HEDIS and redesign beneficiary surveys to become more comparable to the widely-adopted Consumer Assessment of Health Plans Survey (CAHPS) protocol. Additionally, Lewin helped Minnesota develop a performance incentive system for Medicaid MCOs. Most important to this task, however, is Lewin s strong understanding of program needs and the Bureau s and MCOs capabilities, which will facilitate the development of this plan. Lewin drafted revised standards for internal quality assurance for Mountain Health Trust MCOs to comply with changes in federal regulations, presented the standards to the MCOs, worked with them to ensure that the final standards were reachable by the MCOs while continuing to meet the State s expectations, and developed final standards that were included in the new MCO contract. We also conducted the independent evaluation of the program, which included a special focus on State oversight of the program and recommendations for improved program quality improvement. As part of its ongoing assistance with the operation of the Mountain Health Trust program, Lewin has continuously worked with the Bureau to ensure the program s compliance with the final Medicaid managed care regulations. Lewin has also helped the Bureau prepare numerous documents for CMS, such as the State s plan for ensuring quality and access for children with special health care needs (CSHCN) and the State s Strategy for Assessing and Improving Managed Care Quality. Lewin s strong experience with the MHT program and other states MCO programs provide a strong foundation to assist the Bureau in developing an innovative and flexible approach to a variety of quality initiatives and program changes. Subtask : Program monitoring The Lewin Group has played a critical role in assisting states in post-implementation and contract monitoring activities. Our general goal during this period has been to determine whether significant changes are needed in the level or type of resources devoted to the various activities, the delegation of authority for decision making, the communications mechanisms 19

22 between contractors, or other features of program management and operations. Specifically with respect to monitoring the performance of health plan contractors, Lewin has significant experience reviewing periodic implementation reports submitted by health plans and conducting post-implementation site visits, in addition to maintaining ongoing telephone contact with designated health plan representatives. Areas of emphasis have included provider contracting, marketing, enrollment issues, ongoing network adequacy, and changes in utilization management and quality review procedures necessary to comply with the requirements of the new program. The Lewin Group has extensive experience in developing, administering, and reporting findings of program monitoring protocols. For example, in West Virginia and Connecticut, Lewin conducted audits of managed care providers compliance with appointment scheduling timeframes and after-hours coverage requirements. Lewin designed and fielded large-scale enrollee surveys designed to assess satisfaction and access to care of both mainstream and special needs Medicaid enrollees in West Virginia, Connecticut, and New York. In developing these surveys, Lewin worked closely with state staff to identify specific survey objectives and design focused surveys. Lewin also conducted comprehensive retrospective evaluations of quality, access, and cost-effectiveness for the West Virginia, Texas, and Connecticut Medicaid managed care programs. Furthermore, Lewin has developed a program monitoring strategy for the MHT program that includes dashboards that provide clear, timely communication and analyses so that the Bureau can meet its management, oversight, and reporting responsibilities. Many states also have been required, through the terms and conditions of their waiver approvals, to monitor and report to CMS on specific aspects of program performance. For New York, Lewin assisted in the administration of linguistically-appropriate enrollee focus groups related to outreach and enrollment. In addition, Lewin assisted New York in preparing and submitting reports to CMS to demonstrate compliance with waiver terms and conditions. Lewin redesigned certain aspects of West Virginia s quarterly MCO reports to gather information on complaints and grievances filed by or on behalf of CSHCN and assisted the Bureau in compiling the annual statistical report on these grievances as required by the terms and conditions of the previous waiver. The current CMS 1915(b) waiver application requires states to actively monitor program performance in a variety of areas and report on the results of the monitoring activities in the next waiver application. As part of a prior waiver renewal process for West Virginia, Lewin reviewed the requirements of the revised 1915(b) waiver application, identified all of the areas that the State is required to monitor, and determined how the State and its vendors were fulfilling them. Lewin has assisted the Bureau in these monitoring activities by reviewing MCO reports, annual EQRO studies, periodic encounter data reports, and monthly enrollment broker reports on an ongoing basis. For the most recent waiver renewal process, we prepared a summary of all monitoring activities and results from the previous waiver period, as well as a cost effectiveness analysis, and drafted the State's renewal in accordance with the current CMS template. We have also prepared a plan for West Virginia s compliance with the terms and conditions of the most recent waiver approval from CMS. 20

23 Subtask Waiver and state plan preparation The Lewin Group has developed waivers or portions of them (e.g., prospective and retrospective cost effectiveness analyses) for several states in addition to West Virginia, including Connecticut, Delaware, District of Columbia, Florida, Iowa, Kansas, Louisiana, Massachusetts, Montana, New York, New Mexico, and Texas. Lewin s staff are knowledgeable about ongoing CMS developments in the waiver submission process, including the combined 1915(b) waiver form and requirements, and are able to quickly and efficiently draft waivers that meet federal requirements and minimize the degree of back-and-forth needed in the federal approval process. Lewin has also prepared applications to modify existing waivers. For example, in West Virginia, Lewin prepared a waiver amendment to allow the State to mandate enrollment in counties with only one MCO (the Options program) and also prepared an amendment to implement the single-plan rural option allowed under the final Medicaid managed care regulation, which has since been approved. While Lewin has not yet had the opportunity to assist a State in developing a state plan amendment due to the relatively recent introduction of this option for states developing Medicaid managed care programs Lewin has worked with many states to design and gain approval for innovative, not-yet-tested approaches toward health care delivery. Lewin prepared the waiver application for the State of Oregon s groundbreaking demonstration program to use savings from managed care to expand Medicaid coverage to uninsured persons. Lewin assisted New Mexico with the development of a waiver to cover uninsured adults under the HIFA waiver option, and assisted West Virginia with its uninsured reform efforts. Our waiver development work has included participating in negotiations with CMS and the Office of Management and Budget (OMB) to secure waiver approval. We have worked for several years with staff from the CMS Philadelphia Region III office as part of engagements for West Virginia, Delaware, Maryland, and the District of Columbia. Our prior experience with the Bureau for Medical Services and with other states has yielded positive feedback from both CMS and OMB. With the impeding changes brought forth by the ACA and other state or federal requirements (e.g., quality measurement, program integrity, data reporting), Lewin is prepared to provide West Virginia with strategic support in the preparation of the renewal waiver applications and any state plan amendment. We are uniquely qualified to perform this task for the Bureau given our experience developing the initial and four subsequent waivers for Mountain Health Trust as well as our work with 1915(b) and 1115 waivers in other states. Task 3.2.5: Additional Services Over the next several years, it is likely that the Bureau will require assistance with a variety of ad hoc analyses, impact studies, oversight requests, and implementation tasks. For example, many of the potential impacts of the ACA are unknown at this time but are likely to have significant impacts on state Medicaid program administration. The Bureau requires a vendor with a strong understanding of both the State s current environment and potential capacity as well as the implications of health reform in order to conduct necessary data and policy analyses, study the potential implications for the State and for MHT, and help develop and implement appropriate responses. 21

24 The Lewin Group has extensive experience in research and evaluation tasks, and on-demand and as needed requests, for both state Medicaid agencies and a wide variety of public and private sector entities. Our experience is broad and extensive, including experience in analyzing a variety of eligibility, cost, utilization, and programmatic data for the purpose of designing, implementing, and evaluating Medicaid managed care programs and other public sector health reforms. Through our past projects, Lewin is able to leverage best practices from around the country to benefit the MHT program, including our experience with actuarial analysis, development and implementation of risk-sharing methodologies, financial projections, analysis of the impact on future funding streams, and micro-simulation of different health care reform initiatives. Lewin has expertise spanning all aspects of health care reform and policy, health care financing, and health care delivery systems. Subtask : Data analysis With recently enacted legislation including the ACA, ARRA, and CHIPRA, there is great need for analysis of statistical and program data in order to project the impact of potential policies and programs and understand the effectiveness of specific legislative, regulatory, or policy changes on beneficiary enrollment policies, program retention rates, and quality of care. For example, the recently enacted health reform legislation includes a number of opportunities for states and providers to fundamentally change the way that health care is provided and paid for through publicly-funded health care programs, including a Medicaid Global Payments Demonstration, a Bundled Payment Demonstration, and a new Medicaid State Plan option that allows states to make payments to Health Homes for enrollees with chronic conditions. Program data analysis is also necessary to determine whether these programs are advancing the State s goals of assuring access to high-quality efficient health care for Medicaid beneficiaries and controlling costs. This may include analysis of provider network data and comparison across MCOs and to FFS as well as encounter data analysis to support innovations in delivery, coordination, and payment for chronic care/disease management services. The Bureau may also find value in comparisons of services provided across subsets of Medicaid enrollees and across programs. Through our Medicaid capitation rate-setting and cost-effectiveness evaluation work in 12 states, The Lewin Group has extensive experience with Medicaid fee-for-service claims data and managed care encounter data. In addition, Lewin has developed a number of nationally recognized economic models and data analysis tools, putting Lewin at the forefront of health reform modeling. Lewin has conducted numerous data analyses to identify areas for performance improvement. Lewin has analyzed utilization data to measure outcomes in state Medicaid managed care programs, such as our work in Minnesota, and other demonstration programs, such as a CMS demonstration to improve care for persons with end-stage renal disease. Lewin has developed data analyses for performance incentive development projects, federal reporting requirements, and internal program monitoring and improvement projects. Lewin will work closely with Michael Madalena to provide these analyses as requested by State staff. Both Lewin and its consultants have extensive experience with operational systems, including claims processing, utilization management, and eligibility. The Lewin team is skilled 22

25 in the processing and analysis of health care data and has developed several databases and applications. These applications range from quality and financial reporting to simulation models that predict selection bias. Subtask : Policy research The Lewin Group is well equipped to conduct policy research to identify promising approaches in a range of areas of interest to the Bureau, create recommendations, and provide technical assistance, including developing relevant tools and guidance, to help BMS adopt and implement recommended approaches. Through Lewin s work in knowledge transfer, comparative effectiveness research for public and private sector clients, and policy consulting for state governments, foundations, and associations, we have extensive experience evaluating various program options, surfacing best practices, and translating findings into actionable recommendations. The Lewin Group has expertise spanning all aspects of health care reform and policy, health care financing and health care delivery systems. Our public and private sector clients include federal, state, and local agencies, hospitals, health systems, MCOs, insurers, and physicians. We have conducted significant research into all major public health programs, including the Title V/CSHCN program, maternal and child health programs, the Children's Health Insurance Program, Medicaid, Medicare, DoD/CHAMPUS, primary health care programs, and programs to care for the uninsured. Lewin has published leading research in all of the areas identified in this RFP, including chronic care/disease management, Complete professionalism and responsiveness to the consumer s needs. Effective communication, attention to detail and quality producers of deliverables. State Benefit, Employment and Support Services Division Staff pharmacy, eligibility and coverage, quality improvement, rural health delivery, and provider access, as well as a broad range of other health-related issues. Lewin has extensive experience working with public and private sector clients, including state agencies, blue ribbon commissions, and state legislatures. For the federal Agency for Healthcare Research and Quality (AHRQ), Lewin led a learning network of 17 State Medicaid disease management and care management programs. Through the learning network, Lewin compiled State experiences with Medicaid care coordination (encompassing disease management and other care management initiatives), and worked with the States to improve and evaluate their programs. In addition, Lewin has researched the trends and key components of successful disease management programs and assisted in the design of Medicaid disease management program for enrollees with asthma, diabetes mellitus, and HIV/AIDS. Lewin projects in West Virginia, Idaho, and for the Center for Health Care Strategies focused on researching and presenting findings related to Medicaid pharmacy benefits and pharmacy expenditures, using both quantitative and qualitative research methods. Lewin assessed the impact of modifying Medicaid eligibility and coverage standards in West Virginia, California, Idaho, Washington, and North Carolina, of all which are affected, at least in part, by rural health care delivery issues. Each state study took into account that state s unique features, including programmatic goals, delivery systems, health care needs of eligible populations, and historical program costs. After health reform is fully implemented, the Bureau can expect significant programmatic changes as well as a sizeable influx of new beneficiaries. With a strong understanding of 23

26 ARRA s policy and implication on the MHT program, Lewin is prepared to assist the Bureau in refining its strategy for MCO contracting. Lewin s detailed understanding of MHT and the health care delivery issues affecting West Virginia and its citizens make Lewin particularly capable of carefully focusing its research to answer the questions most pertinent to West Virginia and to develop recommendations that are politically and operationally feasible. Subtask : Policy impact analyses and support Policy impact analysis is essential to identifying gaps or best practices in current policies, evaluating the costs and benefits of various policy options, and estimating the effectiveness of existing programs, including determining where existing policies fall short of policy goals, identifying new approaches, and estimating the potential effects of proposed changes. Policy impact analysis involves consideration of the advantages and disadvantages of different approaches supported by research and data analysis findings. Lewin is able to identify a range of policy options, estimate the cost implications for the Bureau to consider, and translate these into implementation and operational strategies that might ultimately be implemented. Depending on the goals and requirements of a specific request by BMS, Lewin can draw upon a wide range of data collection and analytic methods. The Lewin Group has unparalleled experience and expertise in analyzing policies and regulations and assessing their impact. Lewin s staff is well-versed in a wide range of policy issues and provides the Bureau with a wealth of knowledge in state and federal health policy, coupled with our long-standing experience with West Virginia s health care financing mechanisms and delivery system. We have monitored changes in state and local laws and regulations related to the health care system, the shift in responsibilities from the public to the private sector, and the devolution of responsibilities from the federal to the state and local levels. The Lewin Group objectively analyzes the impact of policy decisions using rigorous quantitative analysis and broad knowledge of macro and micro health care issues. We have worked with clients at all levels of the public and private sector, conducting analyses and evaluations of Medicaid and other public programs. Lewin staff have prepared documents and memoranda on many topics, including: federal requirements related to geographic and provider expansion of existing state programs; CMS guidance on marketing and enrollment procedures; mandatory enrollment and lock-in; contracting with alternative managed care models, such as health insuring organizations, partially-capitated plans, preferred provider organizations, and community-based models; procedures for obtaining necessary waivers; guaranteed eligibility; quality assurance and utilization management; and the role of Federally-Qualified Health Centers (FQHC) and family planning providers. Lewin has worked with numerous public and private entities to build collaborative partnerships to develop distinct local plans designed to ensure the proper balance between quality, cost, access, resources, and local needs. Many of our projects have involved meeting with advisory groups, providers, consumer advocacy groups, legislators, and the public to solicit feedback. Lewin staff have presented at these meetings, responded to questions, and reflected feedback in proposed program designs. Our public consensus work does not take the 24

27 form of public relations or lobbying, but rather involves intense work to solicit public opinion, involve stakeholders in a meaningful fashion, forge community consensus, and support decision-making by public officials. Lewin s experience assisting states in implementing new policy options, including preparing work plans, developing contractor specifications, producing detailed actuarial and related analyses, conducting initial and ongoing program monitoring, and developing necessary evaluations for state or federal reporting has been described in detail in other parts of this section of the proposal. Lewin has prepared detailed analyses for the Bureau on a wide variety of topics. Our understanding of the political environment in West Virginia, in addition to our relevant experience in other states, uniquely qualifies Lewin to continue to conduct policy analysis in West Virginia. Lewin has assisted numerous states in estimating the impacts of changes in reimbursement structure, including changes to existing payment systems and the introduction of new payment methods such as pay for performance and bundled payments. Lewin worked with the Kentucky Hospital Association to assess the Medicare-type DRG system recently implemented by the Medicaid Department and compare the adequacy of the Medicaid payment rates for Kentucky hospitals relative to payment levels in neighboring states. Lewin evaluated the equity of payment rates across hospitals in the state under the new Medicaid DRG system and recommended modifications to the payment system to make the payment system more equitable across the states hospitals. Additionally, Lewin has worked with the New York State Health Foundation to develop a roadmap to cost containment for New York with practical approaches to reducing health care costs, including scenarios involving the promotion of accountable care organizations (ACO) and medical homes, hospital pay for performance, bundled payments for episodes of care, and rebalancing of long-term care. Lewin also has experience in addressing and planning for state and federal changes in law, rules, and regulations. For the New York State Health Foundation, Lewin helped address opportunities for containing health care costs throughout the New York State health care system. The goal of the engagement was to identify up to 10 specific cost containment scenarios that could be modeled by Lewin to determine the potential for future cost containment and health care system improvement. The project was modeled after the highly successful Bending the Curve national analysis conducted by Lewin and The Commonwealth Fund and was the first-of-its kind state-level endeavor. To support the Bureau s continued compliance with the evolving state and federal regulations, Lewin will provide additional services as needed and identified by the Bureau. Lewin s staff can capably address an enormous range of issues that might arise throughout the engagement. Our states and payers practice group has approximately 30 professional consultants throughout the past decade roughly half of this group s consulting work has involved direct engagements with State Medicaid agencies. We have vast experience working with states to evaluate, develop, and strengthen Medicaid coverage and programmatic initiatives. We are privileged and excited to help Medicaid cover as many needed persons as possible, and have an equally strong interest in extending any level of available Medicaid dollars to provide as much benefit as possible. 25

28 Quality Management System: ISO 9001:2008 Lewin s proven ability to satisfy a broad range of clients depends on our ability to ensure rigorous quality control. Our approach to quality control is driven by two concerns: 1) knowing exactly what the client wants; and 2) assuring that we provide it. The table below reflects the mechanisms that the Lewin team puts in place to assure quality control. Know what's expected Provide what's expected Key Elements of The Lewin Team s Quality Assurance Strategy Regularly scheduled conference calls and on-site meetings with the Project Officer Documentation of discussions of meetings and deliverables Project staff and consultants experienced with complying with agency and other government regulations Use of project management software to track task progress and expenditures Well trained, high quality staff Clearly defined project structure with oversight of all tasks by Project Director and Project Manager All deliverables reviewed/approved by Project Director or Project Manager Review/approval by PO of all materials, especially those shared externally Adherence to Lewin s quality management system procedures and monitoring practices Regularly scheduled reviews of deliverables for quality and timeliness by Lewin senior leadership The Lewin Group is certified to the ISO 9001:2008 standard for quality management systems (QMS). We sought ISO certification to ensure that Lewin consistently uses the strong quality procedures and systems in place to provide products of high quality, on time, and on budget. Lewin s QMS includes a number of activities that senior project managers are required to perform to ensure the timely and successful performance of multiple simultaneous project tasks (Figure 2). Requirement Management control Management oversight QMS Activity Review proposal, final client contract and other relevant documents to identify client requirements Develop detailed project work plan Convene regularly scheduled top management meetings to review QMS records and metrics to assess effectiveness of QMS processes and identify opportunities for continuous improvement Perform regular review of project activities against project work plan task progress budget deliverable schedule Revise work plan or contract, as appropriate Review and approve deliverables: meets acceptance criteria accurate and concise Release to client 26

29 Requirement Meeting client expectations QMS Activity Client satisfaction survey Annually, if period of performance is longer than 12 months At project close Client feedback sought outside the survey process is a standard practice in meetings, during calls and through correspondence throughout the life of the project As we have demonstrated throughout this section, The Lewin Group is the market leader in the field of Medicaid managed care consulting, and the consultant with the most extensive experience with the Mountain Health Trust program, having worked with it continuously and extensively since its inception. Furthermore, our national experience includes Medicaid managed care project work in more than half the states in the nation. We look forward to the opportunity to continue our work with Bureau staff on the Mountain Health Trust program. References West Virginia Department of Health and Human Resources, Bureau for Medical Services Medicaid Managed Care Program Development and Support (1995-Present) Point of Contact: Brandy Pierce, Director of Managed Care and Procurement Services, Office of Medicaid Managed Care Phone: (304) Brandy.J.Pierce@wv.gov Address: 350 Capitol Street, Room 251, Charleston, WV The Lewin Group is assisting the West Virginia Bureau for Medical Services with the ongoing operation and expansion of its Medicaid managed care program, Mountain Health Trust. Lewin is working with the Director of Managed Care and Procurement Services to ensure that regular program activities are accomplished in a timely and satisfactory manner. Lewin develops managed care capitation rates for participating MCOs for each annual rate period and updates the MCO contract each year. Lewin also assists with preparation of the 1915(b) waiver renewal application and supports Bureau staff in responding to written questions from CMS. In addition, Lewin assists the Bureau in its efforts to expand the managed care program to include SSI beneficiaries and behavioral health and children s dental services, including designing a detailed implementation strategy, evaluating MCO readiness, coordinating with CMS, and responding to stakeholder concerns. Other tasks include assessing and evaluating network adequacy, monitoring MCO performance, surveying beneficiaries, preparing quarterly dashboard performance monitoring reports, reviewing MCO marketing materials, and coordinating with other vendors to administer the Mountain Health Trust program. The Lewin Group has assisted the Bureau for Medical Services in the development and implementation of the Mountain Health Trust program since the program s inception in

30 California Department of Health Care Services California HITECH Strategy and Planning ( ) Point of Contact: Toby Douglas, Chief Deputy Director for Health Care Programs Phone: Address: PO Box , MS4711, Sacramento, CA The Lewin Group led a team to develop a strategy and implementation plan for Medicaid electronic health record (EHR) incentive program payments to providers in the State of California. Lewin conducted an environmental scan of Medi-Cal providers, a provider and vendor analysis on the current penetration of EHR use, and interviews with a sample of providers. We developed a proposed staffing structure and job descriptions for DHCS oversight of the program as well as a detailed strategic plan for the Incentive Program with discrete performance targets. The team also developed a Campaign Plan to reach providers who will implement EHRs and Medi-Cal beneficiaries and defined key components of an operational implementation plan with recommendations on technical assistance to facilitate provider adoption. Missouri Department of Social Services Missouri Medicaid Review ( ) Point of Contact: Ian McCaslin, Division Director Phone: Ian.McCaslin@dss.mo.gov Address: 221 W. HIgh Street, P.O. Box 1527, Jefferson City, MO For the State of Missouri, Lewin conducted a comprehensive review of the Medicaid program with recommendations on how the State can achieve short-term Medicaid savings, providing detailed assessments on achieving longer-term program savings, and evaluated options to improve the effectiveness and efficiency of the Medicaid program. Lewin developed a series of reports as well as supporting materials, and Lewin s analyses were used by State policymakers to craft the state fiscal year 2011 budget as well as guide decisions about future Medicaid program design and operations. Specific areas of analysis included short-term cost containment opportunities, long-term care, pharmacy, care management, non-emergency medical transportation, and overall program financing and operations. Our final report provided a series of recommendations regarding the structure and operation of the program, performance metrics to guide program management, and proposed approaches and priorities for enhancing the quality and efficiency of care to advance value-based purchasing and care coordination. 28

31 Colorado Department of Health Care Policy and Financing Colorado Medicaid and CHP HMO Rate Setting (2008 and 2010) Point of Contact: Jed Ziegenhagen, Rates and Analysis Division Director Phone: Address: 1570 Grant Street Denver, CO The Lewin Group is assisting Colorado with their rate setting for Medicaid programs enrolled in managed care. Working with the Department of Healthcare Policy and Finance, The Lewin Group has conducted the following activities: reviewing programming logic for data collection and summarization, calculating and establishing trend rates, reviewing calculation of risk adjustment which was used for trend calculation and rate adjustment (for HMOs only), modeling the rate setting process in compliance with CMS rate setting guidelines, discussing assumptions and results with participating HMOs and establishing capitation rates and actuarial certification for the program. The Lewin group is setting rates for four programs, HMOs, Behavioral Health, CHP+, and PACE. 29

32 Project Approach and Solution (4.1.8) Statement of Understanding The Department of Health and Human Resources Bureau for Medical Services (BMS or the Bureau) implemented a full-risk managed care contracting program in 1996 and there are now over 165,000 beneficiaries enrolled in managed care organizations (MCO) in nearly every county in West Virginia. The State s primary care case management program, the Physician Assured Access System (PAAS), was joined with the full-risk capitated program under one combined 1915(b) waiver in The programs are now collectively known as Mountain Health Trust (MHT) and together serve over 180,000 West Virginia beneficiaries. The Mountain Health Trust program still has more to do, both to build on past successes and to manage emerging challenges to positively affect the program in the future. The Lewin Group has supported the Bureau with the development, implementation, and operation of the program since its inception and looks forward to the opportunity to continue to work with West Virginia as it moves closer to the goal of having a statewide, comprehensive managed care program. Opportunities and challenges now facing the State include the following: Ensuring that the State is purchasing the best value service for the best price. Given the changes that are in development (e.g., enrollment of 55,000 Supplemental Security Income (SSI) beneficiaries in 2011, addition of behavioral health services and children s dental services to the capitated benefit package), and potential for significant numbers of new beneficiaries (largely adults) following implementation of health reform, the Bureau must refine its strategy for MCO contracting. The Bureau can take advantage of the maturity of the program and resulting opportunities for performance-based contracting to develop a strategy that meets the combined challenges of: o o o Promoting a competitive managed care contracting system; Encouraging MCO performance improvements in key areas; and Supporting traditional Medicaid providers as important elements of West Virginia s health care delivery system and safety net. As part of this strategy, the Bureau may want to consider implementing risk adjustment and/or pay-for-performance strategies to ensure sufficient payment to maintain MCO participation while still inducing MCOs and providers to manage care efficiently without compromising quality. The State could also consider contracting directly with Accountable Care Organizations that may form in the state in response to Medicare directives under health reform. The chosen vendor must be experienced in the development and implementation of sophisticated payment methodologies and be able to assist the Bureau in developing performance targets, incentives, and penalties for MCOs that are tailored to West Virginia s specific needs. Successfully completing the implementation of major program changes during 2011 and effectively monitoring the expanded program. To complete the roll-out of the SSI expansion and inclusion of behavioral health and children s dental services into the MHT benefit package, the Bureau must complete a variety of implementation, readiness, and operational activities. To oversee the expanded MHT program with more complex 30

33 populations and benefits, the Bureau requires increasingly sophisticated oversight and monitoring capabilities, including a comprehensive Managed Care Improvement Plan that supports the identification of program improvement opportunities through systematic, ongoing, and periodic program monitoring activities. At the same time, the West Virginia Health Improvement Institute (WVHII) has taken on a key role in working with stakeholders to determine what the behavioral health integration model should look like. It will be important for the Bureau to continue to participate in WVHII workgroups to support transparent dialogue in identifying opportunities for collaboration and continuously soliciting input and feedback throughout the planning, implementation, and post-implementation processes. BMS requires a vendor that knows the State, the Bureau, the program, and various stakeholders and can bring knowledge of best practices in other states in order to: o o o Assist with implementation and monitoring of a comprehensive Medicaid managed care program, with particular focus on oversight during the immediate postimplementation period; Be able to rapidly identify and respond to emerging issues, develop program monitoring strategies that minimize burden on the MCOs, while providing clear, timely communications and analyses (such as a network dashboard ) so that the Bureau can meet its management, oversight, and reporting responsibilities; and Provide recommendations for ongoing quality assurance and program improvement that are commensurate with the overall approach to administering and enhancing the program and meet the requirements set forth in federal regulations. Preparing for federal health reform implementation. The recently-passed health reform legislation will greatly expand the number of people who are eligible for Medicaid coverage. The Lewin Group estimates that between 2014 and 2016, an additional 150,000 persons will become eligible for Medicaid in West Virginia, primarily parents and childless adults, and the Bureau will need to be prepared for this expansion of Medicaid and the managed care program. Issues to consider will include current MCO capacity, provider coverage in rural areas, the potential for new MCOs to enter the state market, and the timelines and cost implications of managed care program expansion. The Bureau will also require support in strategically addressing the potential impact of the Affordable Care Act (ACA) and other state or federal requirements as they arise (e.g., quality measurement, program integrity, data reporting). BMS will also need to work with the health benefit exchange to facilitate transitions between subsidy programs and Medicaid. The Bureau requires a vendor with a strong understanding of both the State s current environment and potential capacity as well as the implications of health reform in order to help develop expansion strategies, examine options for program expansion in detail, study the potential implications for the State and for MHT, and help with the implementation of program expansion. Continuing to operate the program. While the program continues to expand, the Bureau must still efficiently and effectively administer and manage the MHT program in compliance with all state and federal regulations, and do so in an environment of 31

34 constrained budgets and competing staff responsibilities. Major ongoing operational activities include procurement, rate setting, contract negotiation, management, and ongoing monitoring of program vendors and performance, including monitoring of both MCOs and physicians providing primary care case management services through PAAS. BMS requires a vendor that is intimately familiar with the MHT program and can effectively assist with program management and monitoring and ensure that regular operational activities are accomplished in a timely and satisfactory manner without requiring a ramp-up period. The vendor must also bring knowledge of other states practices and the technical skills to adapt to the changing environment. The vendor must also have the staffing flexibility to provide increased support to Bureau staff as program needs dictate. The Lewin Group is ideally and uniquely equipped to assist the Bureau for Medical Services in responding to all of these challenges and opportunities: As the incumbent contractor, we have a strong working relationship with the Bureau and deep knowledge of the program. We also have effective working relationships with other entities that regulate and operate the program, including CMS, the MCOs, and other MHT vendors. We bring to bear knowledge and experience from many other successful state Medicaid managed care programs and non-risk care management programs, and can leverage best practices from around the country to benefit the MHT program. Our staff s rate-setting expertise in West Virginia and experience in over 30 other states provides the basis for designing and securing approval of more sophisticated payment arrangements, including risk adjustment and pay-for-performance. Lewin is at the forefront of health reform implementation efforts and can provide timely and credible support to the State as it prepares for a major program expansion in Our team is personally committed to the success of West Virginia s Mountain Health Trust program. Lisa Chimento, Lewin s chief executive, has supported MHT since its inception and has provided numerous hours of support herself during Several additional project members have assisted MHT for more than a decade. Collectively, our team has provided more than 6,000 hours of support to the Bureau in Finally, The Lewin Group has many innovative ideas to assist the Bureau and a flexible approach that allows us to support the Bureau with a variety of initiatives and program changes, as discussed further in our approach to the Scope of Work below. 32

35 Scope of Work: Yearly Operations Plan (3.2.1) The Lewin Group is ideally suited to assist the State with all of the yearly operations listed in the RFP including Medicaid rate setting, health plan operations, and state administration of Medicaid managed care programs. The overall goal of Task is to support the Bureau in the management and implementation of Medicaid services in compliance with all state and federal regulations. The result of this task will be a robust yearly Operations Plan that will enable the Bureau to efficiently and effectively administer and manage the Medicaid program from one year to the next. Key components of this task will include those related to procurement, rate setting, contract negotiation, management, and ongoing monitoring of program vendors performance. Lewin has repeatedly demonstrated our expertise in all of these areas with our clients, especially with West Virginia. We bring breadth and depth of experience and knowledge of the Bureau and the Centers for Medicare and Medicaid Services (CMS) to support successful management and program operations, which is of particular importance given the implications of both health reform and the planned 2011 program expansion. Our team has deep experience with Medicaid managed care and associated payment models. Lewin has helped to design, implement, operate, and evaluate capitated Medicaid programs in more than 20 states. These projects have encompassed many Medicaid eligibility subgroups. We have assisted multiple states with programmatic issues targeted to specific subgroups, including: Connecticut, New Mexico, and West Virginia for the TANF population; Rhode Island, Delaware, California, New York, and Texas for adults with special needs; District of Columbia and California for children with special health care needs; and New York for persons infected with HIV and persons with mental illness. Most of our Medicaid managed care work has focused on a comprehensive capitated benefits package, although we have assisted states with specific initiatives such as pharmacy and mental health carve-outs. We also have experience evaluating a range of payment mechanisms including a pay for performance withhold/bonus system for Minnesota, incentives for utilizing select provider groups in West Virginia, and others. When California was considering expanding mandatory managed care for people with disabilities and chronic illnesses, we helped develop purchasing specifications and performance measures, recommended strategies for monitoring contract compliance, and developed a tool to assess the readiness of MCOs to serve a large influx of new beneficiaries with disabilities and chronic illnesses. The following is a high level Gantt chart outlining our work on each of the major subtasks associated with the Operations Plan. We will update this plan as needed throughout the course of the project. 33

36 Figure 2. Task Work Plan and Timetable for The details of our proposed Operations Plan, including specific detail on each subtask, are outlined below. Development of annual capitation rates ( ) The objective of this task is to develop and implement yearly Medicaid capitation payment rates that are actuarially sound and ensure the viability and cost efficiencies of the Mountain Health Trust (MHT) and Mountain Health Choices (MHC) managed care programs for the State. Lewin is ideally suited to perform this task; we have broad experience from working with numerous states on Medicaid managed care engagements, including 15 years of West Virginia specific experience. Lewin develops capitation rates in an actuarially sound manner which provides sufficient payment to maintain MCO participation while still providing a payment structure that induces the MCOs and providers to operate efficiently without compromising quality. For West Virginia, The Lewin Group will derive capitation rates based on the most recent, complete MCO encounter and financial data for the Temporary Assistance for Needy Families (TANF) population and use the most recent fee-for-service (FFS) claims data for the Supplemental Security Income (SSI) population. The most recent FFS claims will also be used to estimate the cost for behavioral health and children s dental services to support the MCO expansion for these services in the upcoming fiscal year. Once the SSI, behavioral health, and children s dental expansions are fully implemented and the MCOs build sufficient claims experience with these benefits and populations, we will incorporate the MCOs encounter and financial data into the rate setting process. We may consider adopting more innovative rate setting techniques as the MHT program evolves; we discuss some of these innovative options below. The capitation rates and associated method will be certified by project member Tom Carlson, who is a credentialed Member of the American Academy of Actuaries, as being actuarially sound and meeting all of the federal requirements and guidelines. The Last year, when CMS issued a final rule limiting the mandatory enrollment of TANF 1931 parents and caretaker/relatives into benchmark benefits plans, Lewin worked closely with the Bureau to identify options preserve the Mountain Health Choices program and assisted in the development of the State s current strategy. Within a short amount of time, Lewin revised the State s 1915(b) waiver submission to comply with the new regulations and revised the SFY 2011 capitation rates to reflect the new approach for enrolling this population. rate setting documentation will be developed in a form that meets CMS requirements, and Lewin staff will be available to assist the Bureau in responding to any CMS questions regarding the rates or certification. 34

37 Lewin is intimately familiar with West Virginia s MHT and MHC programs and our longstanding experience and history with MHT, the State s data, and our relationships with staff from both the State and other contractors will allow us to perform capitation rate development quickly and efficiently with no ramp-up time needed. Our experience and personal relationships allow us to work effectively with State staff, which greatly reduces the amount of time that State staff must invest in this work to achieve high quality results. Our historical knowledge of the MHT and MHC programs, covered populations, and benefits often allows us to bolster the knowledge of state staff who do not have the same tenure that Lewin has with the program. Our understanding of the State s eligibility and FFS claims data and MCOs encounter data allows us to make accurate adjustments to the capitation rates to reflect programmatic changes. In addition to our vast experience with West Virginia s current program, Lewin has extensive Medicaid experience with other states and health plans, which make us the best choice to guide the Bureau through future programmatic changes. With the passage of health care reform under the Affordable Care Act (ACA), states will have to deal with the expansion of the Medicaid program to populations for whom the state has little experience in providing services. Lewin is the market leader in performing actuarial and micro-simulation analyses of the cost and coverage impacts of program expansion and health reform proposals. Our national health care model is considered the gold standard for estimating the effects of health care policy, and we have recently developed national and state-level estimates regarding the number and demographic distribution of members who will become covered by Medicaid under the ACA. We will leverage Lewin s considerable experience in modeling the impacts of health reform to develop estimates of the size and costs of the Medicaid expansion population that will need to be factored into the capitation rate calculations for 2014, when much of the expansion will take effect. Our nationally recognized health reform modeling experts, John Sheils and Randy Haught, will play a critical role in helping to determine the impact of health reform on West Virginia. Initial Lewin estimates anticipate as many as 150,000 new West Virginia Medicaid beneficiaries by Our health reform experts will assist the rate setting team with determining the health care needs of this population and quantifying the impacts of these additional beneficiaries to ensure that the State s capitation rates are adjusted accordingly. With the SSI population now included in MHT, there are some new considerations that must be addressed in the rate setting process. The SSI population is generally less healthy than the existing TANF population, and with this additional acuity comes the potential for health plans to experience significant variation in overall population acuity. Many states currently employ risk adjusted payment systems to modify capitation payments to MCOs based upon the acuity of their enrolled SSI population. Risk adjusting the SSI rates can benefit the State in several ways. It can reduce the overall growth of the cost of the SSI program by more appropriately paying plans that enroll members with higher cost health conditions and less to those with less risky members. Risk adjustment will also support continued health plan participation by helping to manage the financial risk associated with enrolling the SSI. Because typical risk adjustment methodologies rely on encounter data, moving to a risk adjusted capitation rate will provide a strong incentive to the participating health plans to improve their encounter data reporting. Given the Government Accounting Office s (GAO) recent report criticizing CMS for 35

38 its laxity in overseeing states data, the Bureau may want to consider implementing risk adjustment for its TANF program, too, as a way to improve encounter data reporting. 1 Lewin staff have worked extensively with multiple state Medicaid programs that have implemented risk adjusted payment systems and can assist BMS in ensuring that capitation payments to MCOs match the acuity of their enrolled SSI population. We will prepare a detailed presentation for State staff outlining the options they have when risk adjustment is introduced into the rate setting process. There are a number of options that need to be evaluated including: choice of system, frequency of updates, and the lag between the time period used to determine risk scores and the payment period. Should the Bureau want to move towards riskadjusted rates, the Lewin team includes risk adjustment experts who have developed and implemented risk adjustment processes in many states including Maryland, New York, New Jersey, and Pennsylvania. Our experts fully understand the pros and cons of different risk adjustment models and will guide West Virginia s decision making process. Deliverables: Task Development of Capitation Rates Capitation rates, rate setting methodology, and CMS documentation submitted to the Bureau by March 1 of each year Overview of approach Lewin is the best choice to implement the most seamless and efficient rate setting process given recent changes in the MHT and MHC programs. We already are intimately familiar with the behavioral health and children s dental expansion and phased-in roll-out of the SSI population. Our historical knowledge of the program, state staff and program vendors, and previous experience in developing the capitation rates allows us to provide continuity as well as the flexibility to quickly adapt to any additional changes required moving forward. Our rate setting process entails the eight steps displayed in the diagram and detailed below. 1 Medicaid Managed Care, CMS s Oversight of States Rate Setting Needs Improvement, GAO Report to Congressional Committees (GAO ), August,

39 Figure 3. Rate Setting Process Gather/validate data and information (Step 1) Monitor federal activity (Step 2) BMS review and feedback Update methodology (Step 3) Develop capitation rates (Step 4) Present to BMS (Step 5) Present capitation rates to MCOs for comment and feedback (Steps 6) CMS review and approval Present capitation rates and methodology to CMS (Step 7) Plan for future rate setting efforts (Steps 8) Step 1: Gather and validate data and information Upon the start of each rate setting cycle, beginning July 1 of each year, Lewin will prepare memoranda to the Bureau and the participating MCOs outlining the data and information that Lewin requires for the rate setting process. Our understanding of the program, including recent changes, allows us to appropriately update the rate setting memoranda to describe how the rate methodology will take the recent changes into account. We will update our established procedures for receipt of monthly data pulls, including claims, eligibility, enrollment, and provider data from the fiscal intermediary and encounter data from the MCOs. This arrangement will not only allow us to initiate the rate setting work in a timely manner but also enhance our ability to respond to other analytic tasks as well. As part of the data collection process, we will review the FFS claims and MCO encounter data against control totals to ensure the validity and completeness of the data received. Lewin will work collaboratively with Bureau staff to assure that the recent changes in the programmatic, policy, and budgetary environment at the Bureau are accurately reflected in the rate setting process and to identify potential changes to the managed care program that require data analysis. We will identify programmatic changes, including fee schedule updates and benefit changes, to assist State staff in identifying what new or additional data may be needed. To assist State staff in evaluating potential changes to the managed care program, we will generate data analyses examining the impact of potential changes in eligibility and/or benefits on capitation rates using the data gathered under this and other tasks. 37

40 Once we have submitted the information request to the Bureau and the MCOs, we will follow up with the respective parties to review the information and ascertain whether there are issues that we should consider in refining the rate setting methodology. Our established working relationship with Bureau staff and the MCOs should facilitate the process of gathering necessary data and information and minimize the impact on BMS staff time. Step 2: Monitor Federal Activity Lewin will monitor federal legislation and mandates to assess their implications on the rate setting process. As Lewin reviews the existing rate setting methodology, we will identify the provisions within the ACA and other federal legislation and regulations that will affect the design of the MHT and MHC programs and the derivation of the capitation rates, including the regulations contained in 42 CFR For example, provisions within the ACA require that Medicaid pay primary care providers at 100 percent of Medicare rates for calendar years 2013 and 2014 this will impact both the Medicaid FFS fee schedule as well as the capitation rates for the three managed care contract years that fall across those two calendar years. We will crosswalk the requirements of these policies to the existing rate setting methodology and identify the changes needed. Lewin will ensure that BMS fully understands the implications of new legislation and regulations and will collaborate with BMS to identify the options available to BMS to stay in compliance with any new regulations. Although this step is displayed on our timeline as occurring in the initial months of each rate setting cycle, our focus on federal activity will be continuous and we will alert BMS of issues and opportunities as they arise. One opportunity created by the ACA is the equalization of drug rebates for Medicaid MCOs. The ACA has extended the federally-mandated drug rebates to prescriptions provided by Medicaid MCOs. Lewin has provided ad-hoc analyses around the prescription drug carve-in option over the past three years and recently updated that analysis to account for the rebate equalization under the ACA. With the rebates equalized, there are now opportunities for the Bureau to leverage the MCOs ability to increase generic drug use, lower dispensing fees, and reduce overall utilization of prescription drugs. For these reasons, the Bureau may want to consider carving the prescription drug benefit into the managed care benefits package in the future. Step 3: Update methodology Each year at the beginning of the rate setting process, Lewin reviews the details of the previous year s rate setting analyses, considers what was learned the previous year, and makes refinements to the methodology. Lewin will work to update the rate setting methodology to reflect any changes in the State Medicaid program and incorporate any new guidelines for capitation rates that have recently been established in federal regulation, as identified in Step 2. Lewin will use as its starting point our current methodology created for the Bureau for the development of the SFY 2011 capitation rates for the TANF and SSI populations. This SFY 2011 methodology has been reviewed and accepted by CMS and demonstrates the strengths of Lewin s previous rate setting work and our ability to update the rate setting methodology to reflect numerous changes to the managed care program over the previous year. In addition to developing capitation rates for the behavioral health, children s dental, and SSI expansion, the SFY 2011 TANF capitation rates necessitated several changes to account for regulations governing the populations included in the MHC program. Pregnant women, the medically 38

41 needy, and dually enrolled Title XIX/Title V children with special health care needs were moved under the MHT program and Section 1931 Parents and Caretaker/relatives were no longer mandatorily enrolled in MHC. Additionally, a new State Plan Amendment changed many of the benefit limits on services provided to children under the MHC program. Based on these major changes to the populations included under MHC and MHT and changes in benefit design under MHC, Lewin collaborated with BMS to develop rate cohorts that provided a comprehensive rate structure to account for the populations covered under MHT and the option of the 1931 Parents and Caretaker/relatives to enroll in either MHT or MHC. With the SSI population scheduled to transition into managed care, BMS may want to consider implementing a risk adjusted payment methodology, for reasons described previously. The Lewin team has extensive knowledge of various risk adjustment methodologies and models used by other states and have designed and implemented the risk adjustment programs in nine states. Should BMS want to explore risk adjustment, we will evaluate each plan s performance in comparison to its case mix, network design, administrative costs, and utilization trends to assess whether any risk adjustment is necessary. If the MCOs experience and financials exhibit a significant differential in risk, we can advise BMS on the risk adjustment options and which would be the most effective method of addressing risk differentials between the MCOs. Regardless of the method chosen, any risk adjustment will be calculated in accordance with CMS requirements and other applicable federal regulations. Step 4: Develop capitation rates Step 4 of the capitation rate development entails processing and analyzing the claims and eligibility files received from the fiscal intermediary; analyzing MCO financial statements and encounter data to develop utilization and administrative adjustments; incorporating trend and other adjustment factors; and estimating final capitation rates. The most important features of Lewin s approach to this step are careful attention to the details of the claims and eligibility files and our quality review process. Throughout this process, Lewin s team will carefully examine the claims and eligibility files as a part of our quality review process. We will review each set of tabulations for accuracy at multiple levels and compare the results to available state benchmark data and other sources to verify consistency. Senior actuarial members of the Lewin team will also conduct a thorough review of the data and formulas included in the spreadsheets resulting in the final capitation rates. The process of establishing actuarially sound capitation rate ranges during Step 4 will include the following general tasks: Developing a rate update model that includes the current base period costs, usage, and covered months by type of service and demographic rate cohort, program enrollment (e.g., TANF Basic, Enhanced, Traditional Packages, SSI) and region within the capitated package. Revising rate adjustment factors used in the prior year s rate setting effort and updating these factors, if there is evidence of the need to modify these adjustments (e.g., for MCO administrative costs we annually examine MCO financial reports, recalculate regional 39

42 cost factors each year, and evaluate selection bias annually to determine any changes that are appropriate). Trending the base period costs forward to the necessary rate periods using a combination of historical FFS and MCO experience, scheduled price updates for West Virginia s Medicaid fee schedule, CMS Office of the Actuary National Health Expenditure Projections, and other national and regional trend sources. Developing managed care efficiency adjustment factors to account for the efficiencies of the MCOs in delivering care over the existing FFS program. Assuring that the overall rate setting process, as well as the resulting set of rates, is actuarially sound and meets all requirements specified in the Medicaid managed care regulations and CMS rate setting checklist. Step 5: Present documentation and preliminary rates to the Bureau and MCOs Once a preliminary set of capitation rates has been produced and Lewin has assessed the impact of the new capitation rates, we will submit to the Bureau a deliverable providing the technical documentation for our implementation of the rate methodology, preliminary capitation rates, and an analysis of the impact of the rates. The organization of the documentation will facilitate comparison to the CMS rate setting checklist to verify full compliance. The documentation will be extremely specific in terms of selection criteria, algorithms used to match the eligibility and claims data, methods and assumptions used to develop price and utilization trends, benefits adjustments between Basic, Enhanced, and Traditional packages, and other adjustments such as the managed care and regional factors. Lewin will update the rate methodology and assumptions, the resulting capitation rates, and the impact analysis as appropriate based on comments received from Bureau staff. Then, the revised versions will be submitted to the Bureau. The certified actuary for this project, Tom Carlson, will be involved in updating the methodology and in making key decisions during the rate development such as determining the methods for managed care adjustments and trending. Mr. Carlson has worked on MHT capitation rates for the past two years and is familiar with the MHT program and the MCO contractors. Once final capitation rates are developed, Mr. Carlson will provide the Bureau with a statement as to the appropriateness of the methodology and capitation rates. This statement will meet the actuarial soundness and certification requirements established by CMS. Step 6: Present final rates to the MCOs Once the capitation rates have been finalized, Lewin staff will prepare written documentation and give a presentation to MCOs, highlighting changes in the rate setting method and providing an analysis of how the updates to the capitation rates will impact the MCOs projected revenue for the upcoming year. Lewin will solicit feedback from the MCOs regarding the development of the capitation rates. Having worked with the participating MCOs over the past fourteen years, Lewin is familiar with their concerns regarding the capitation rates and will work with BMS to incorporate any reasonable adjustments into the final capitation rates. 40

43 In addition, Lewin will provide support to BMS, as needed, to discuss the capitation rate setting methodology with other MCOs interested in entering the program. Over the past couple of years, Lewin has supported BMS by answering questions and providing additional information to Centene as it explores possible entry into West Virginia s managed care program. Step 7: Support CMS review Lewin staff will prepare detailed documentation for the rate setting methods, including the actuarial certification of the rates. The documentation will be prepared to conform to the most current version of CMS capitation rate setting checklist, so that the CMS regional office will be readily able to verify compliance. In addition, we will prepare a detailed exhibit for the MCO contract describing the rate development and final rates. In conjunction with the capitation rate setting process, Lewin will prepare all analyses and documentation required for the upper payment limit and cost effectiveness section of the state s current 1915(b) waiver. Throughout this task and subsequent submission to CMS of the demonstration of costeffectiveness for the state s waiver renewal, Lewin will be available to respond to questions from CMS. Because The Lewin Group was the Bureau s original contractor for the rate setting task and the originator of the existing methodology, we believe that CMS s familiarity with the methodology and our understanding of the specific issues will be invaluable to ensuring that future upper payment limit, capitation rates, and methodologies are consistent with the waiver and the federal guidance we have received over the years. For the most recent waiver renewal in 2010, our intimate knowledge of the managed care program allowed us to quickly adjust both the capitation rates and waiver cost effectiveness calculations in response to recent federal regulations regarding the State s benchmark authority. The late establishment of this final rule required Lewin to quickly adjust the cost effectiveness analyses to include a projection for the parents and caretakers/relatives who opt out of MHC. In addition, our prior experience with the Bureau and with other states has yielded positive feedback from both CMS and OMB. Because our approach to rate development and the integrity of our analyses are known and respected throughout CMS regional and central offices and OMB, we expect that any issues raised will be quickly and easily addressed. Our approach will be modified, if necessary, based on cost effectiveness guidelines released by CMS in the future. Step 8: Plan for future rate setting efforts After the capitation rates have been finalized, Lewin staff will review the methods used in the prior year s rate setting efforts and consider whether there are areas where the data or methods for rate setting could be improved through a long-term effort. Lewin expects that efforts such as this may be important to improving the data and methods used in rate setting efforts in the future. Implementation The Lewin Group will develop the capitation rates and submit the methodology and CMS documentation to the Bureau for Medical Services by March 1 of each year. The figure below summarizes the specific work steps required for This task will repeat annually through the course of the contract. 41

44 Figure 4. Task Sample Work Plan and Timetable for 2011 Development of requirements for participation and agreement specifications ( ) The objective of this task is to assist the Bureau in obtaining provider agreements to participate in the Mountain Health Trust program, to develop requirements for participation and agreement Lewin provided extensive training to the State of Washington, under a contract for specifications, as necessary and appropriate, and to the Agency for Healthcare Research and support the Bureau in evaluating and reviewing Quality, in preparation to evaluation of a proposals. West Virginia must ensure participating Medicaid care management procurement. MHT plans meet network sufficiency and quality standards prior to contracting. With at least one MCO in each of the 55 counties in the State and two or more MCOs in 42 counties, increasing the number of MCOs may no longer be a primary contracting The training agenda included: 1. General evaluation guidelines 2. Scoring guidelines 3. Evaluation tool and score sheet 4. Overview of RFP requirements goal for the Bureau. However, given the projected increase in Medicaid enrollment due to the ACA, the 5. Evaluation schedule Bureau may now want to focus on the recruitment of MCOs that have experience serving the Medicaid population in other states. The addition of MCOs with Medicaid experience will improve beneficiary choice of MCOs and providers and will provide another mechanism for the transfer of best practices from other Medicaid programs to the State of West Virginia. Lewin has extensive experience working with MCOs to enter the Mountain Health Trust program. Upon establishment of the program, Lewin assisted the Bureau with conducting the initial readiness assessments to determine if The Health Plan and Carelink were prepared to begin enrolling beneficiaries. Since that time, Lewin has also assisted the Bureau in reviewing UniCare s readiness to serve MHT program enrollees. Currently, Lewin is supporting the Bureau in preparing application materials and other requirements for Centene s participation, which involves review of Centene s policies and procedures for meeting the program s operational and network requirements, assessment of the provider network, and on-site reviews. The Lewin Group will work with this and other interested MCOs, review and update existing provider agreements, and assist the Bureau with additional contracting as needed. 42

45 Deliverables: Task Development of Requirements for Participation and Agreement Specifications Prepare and submit agreement materials within 30 days of request by the Bureau for Medical Services. Provide other agreement support as requested. Overview of approach The Lewin Group will provide comprehensive MCO procurement support as requested by the Bureau. Currently, West Virginia allows MCOs to submit an application for participation in MHT at any time. For MCOs that are interested in joining the program, Lewin will provide appropriate materials, including an application, readiness review criteria, and onsite guides, as well as work with the MCO and the Bureau to ensure procurement requirements are met. Develop Procurement Materials Lewin will work closely with the Bureau to develop a comprehensive set of materials to procure new participants to the Mountain Health Trust program. The Bureau needs a procurement process that uses materials that ensure MCO applicants fully demonstrate readiness to serve MHT enrollees, while making sure that MCOs are not unduly burdened by procurement activities that duplicate Department of Insurance (DOI) requirements and that do not duplicate requirements contained within the MCO s contract with the State. Key procurement materials will include the State s Mountain Health Trust Medicaid MCO Provider application, as well as the development of a request for proposals or request for applications if the Bureau decides at a later point to conduct a competitive MCO procurement. In addition, Lewin will use its experience assisting the Bureau with the upcoming managed care expansions in In November 2010, Lewin assisted BMS with restructuring the State s Mountain Health Trust Medicaid MCO Provider Application to incorporate key programmatic elements to ensure that new MCO entrants are well prepared to serve SSI beneficiaries and deliver behavioral health and children s dental services upon the planned program expansion in to develop additional provider agreement requirements as well as readiness review criteria and onsite guides for new entrants into the MHT program. Lewin will also work closely with the DOI, through the Bureau, to coordinate review of materials such as provider agreement contract templates. New provider agreement content may include additional monitoring requirements and reports, outreach and member services requirements, staffing ratios, or hiring requirements given the addition of SSI members, behavioral health services and health reform requirements. Lewin will also research procurement approaches that have worked in other states and may be effective for West Virginia. With the potential of over 150,000 new Medicaid beneficiaries to be covered in managed care due to the SSI expansion and coverage expansions from health reform, evaluating and improving the procurement process may attract new MCOs to the MHT program. Provide Assistance to Evaluation Teams, Site Visit Support, and Network Reviews To support the Bureau s evaluation teams and review of applications, Lewin will develop a comprehensive evaluation tool to provide reviewers with guidance on reviewing MCO 43

46 documentation for key operational areas. Lewin will also provide technical assistance to Bureau staff in reviewing these materials and evaluating sufficiency. Given the current non-competitive approach to contracting, we assume that the Bureau will wish to continue its approach of working with potential vendors to come into compliance in areas in which the initial documentation is insufficient. Lewin will support the Bureau in efforts to help potential vendors understand and comply with program requirements, including providing technical assistance to potential vendors as requested by the Bureau. If the Bureau decides in the future to move to a competitive procurement for MCO services, Lewin can assist the State with developing a proposal evaluation tool to include a detailed scoring methodology. Lewin will develop a site visit protocol based on key areas of interest to the Bureau and any areas of concern identified during the document review. We will discuss the framework for onsite reviews and coordination with the EQRO and CMS as needed. Lewin will focus on whether MCOs have systems in place to serve complex members and coordinate between physical health and behavioral health. Evaluation of readiness will include components of network member services such as materials, outreach and education, quality, care management, utilization management, IT resources, and overall staffing. We will review an applicant s policies and procedures related to these areas and assess the MCO s network to provide and deliver services. As needed, Lewin will conduct follow-up calls with MCOs to address outstanding issues. As the West Virginia Medicaid managed care program continues to expand, both with SSI enrollment in the short term and with health reform in the long term, the Bureau may consider reassessing the optimum number of MCOs to participate. It will be critical for BMS to balance contracting with more MCOs to maximize beneficiary and provider choice and provide stability in the case of an MCO exit, while minimizing BMS coordination and management time and MCO administrative expense. We will work with the Bureau to achieve the right balance, taking into consideration that each plan must have an adequate number of enrollees to manage risk and ensuring two or more MCOs in each county where that is required. Lewin will assist the Bureau in conducting site visits to MCO offices to evaluate readiness for contracting. If necessary, Lewin will conduct followup site visits to re-evaluate outstanding areas of concern. Lewin will provide the Bureau with a written summary of the findings of the site visit and our contracting recommendations. As a key part of the readiness process, Lewin will review provider networks to ensure that new MCOs can provide the range of services required by the contract and meet provider ratio requirements, particularly in primary care and key specialty areas. (See Subtask for more detail on Lewin s approach to evaluating provider networks.) Finally, Lewin will assist Bureau staff in negotiating contracts with selected managed care organizations and then planning for implementation of enrollment in conjunction with Bureau staff and the program s enrollment broker. 44

47 Implementation Following is a summary of the work steps required for This task will repeat throughout the course of the contract, as needed. Figure 5. Task Work Plan and Timetable for 2011 Development and maintenance of provider/mco and other vendor agreements/contracts ( ) The objective of Subtask is to develop and maintain vendor contracts in accordance with current and future federal regulations and guidelines. Lewin will develop new vendor contracts as necessary and will review and update contracts if federal contract requirements are amended or newly promulgated. Existing MHT vendor contracts that may require review and updating include, but are not limited to, the Bureau s contracts with its MCOs, PAAS providers, the external quality review organization (EQRO), and the enrollment broker. Lewin has the expertise needed to successfully perform this task, including well-established relationships with the MCOs and CMS and an in-depth historical knowledge of West Virginia s Medicaid services. We have been an integral resource for the Bureau for over 15 years; our understanding Lewin is currently assisting the Bureau with identifying additional requirements that the State may want to consider adding to the current External Quality Review Organization (EQRO) Request for Proposal. Lewin examined federal requirements which guide the reviews and examined the content of other states EQRO proposals to propose additional content to increase the State s purchasing power. of the program s history and our knowledge of the MHT expansions will be valuable resources in updating the contracts. We also have a detailed understanding of key timeframes and challenges associated with approval and finalization of contracts. 45

48 Deliverables: Task Development and Maintenance of Provider/MCO Agreements Lewin will develop federally required information and agreements within 30 days of request by the Bureau. Overview of approach Lewin will develop any new vendor contracts as requested by the Bureau, commensurate with relevant federal regulations, within specified timeframes. Lewin will use its detailed knowledge of the MHT program to determine the information to include in provider agreements. We will work closely with the Bureau to ensure contracts fully capture the vendor Scope of Work, including integrating lessons learned from the planned 2011 program expansions, as needed. Lewin will also assist the Bureau in presenting and obtaining feedback from vendors on new contracts and subsequently making necessary changes. The Lewin Group will finalize vendor contracts, present such contracts to CMS, and make revisions to ensure CMS approval, if needed. This subtask may occur on an ongoing basis, depending on the Bureau s needs. Monitor Federal Regulations and Requirements for Contract Adjustment Implications Lewin will monitor federal promulgation of requirements and regulations that affect MHT vendor contracts and develop necessary contract modifications and addenda, which is a critical task given the recent passage of health reform legislation. At a minimum, Lewin will use its contacts at CMS, including the West Virginia CMS project officer, central office staff at the Center for Medicaid, CHIP, and Survey & Certification (CMSC), the CMS website, and other publicly available resources, such as the Federal Register and the National Association of Medicaid Directors website, to monitor the promulgation of federal requirements on an ongoing basis. Lewin has developed a database to In 2009, Lewin alerted BMS to the upcoming changes related to Mental Health Parity, prior to the release of formal CMS guidance, and the potential impact on Mountain Health Choices. Lewin was able to interpret the legislation to determine the impact it would have on the Mountain Health Choices benefits package. Because of this, BMS was able to better prepare for needed programmatic changes, which eventually impacted beneficiary benefits and MCO reimbursement. track pertinent Medicaid and health reform federal requirements and will provide updated analysis of new regulations on a bi-weekly basis, assessing their impact on the Bureau, the MHT program, and the Mountain Health Choices program. Lewin will attend briefings (to the extent feasible) on regulations to ensure maximum understanding of such regulations. Similar to our approach in guiding the Bureau on modifying vendor contracts to comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, Lewin will review requirements and regulations expected to affect MHT and develop a brief overview of the impact of the regulation and degree to which contract changes will be required. When requirements and regulations necessitating changes to vendor contracts are identified, Lewin will promptly notify the Bureau and develop a specific work plan and timeline to develop contract modifications. Track Contract Changes Over Time Monitoring changes to the MCO contract over time in a single location will help the Bureau easily identify trends and document the rationale for MCO contract provision changes. This 46

49 database can also be used to track desired changes to the MCO contract for the upcoming fiscal year. Specific elements of the database will include, but may not be limited to, contract reference (e.g., section, paragraph), previous contract language, revised contract language, rationale for change, and requestor. We will review the database with the Bureau twice annually, or more frequently if critical issues are identified. As appropriate, we will discuss significant changes with CMS and the MCOs throughout the year to gain buy-in from MCOs and other important stakeholders and help to keep program updates on schedule. We also will share the contract review schedule with MCOs and CMS, including drafts and review timeframes at beginning of each year. Lewin will work on getting feedback from MCOs early in the contract review process to determine where clarifications and updates should be made for future contacts. Complete Contract Review and Applicable Changes Lewin suggests starting the contract review early for fiscal year 2011 to build in adequate time for review by the Bureau, CMS, and MCOs given the potential for significant changes in Mountain Health Choices in light of the recent program expansions. Lewin can also assist the Bureau with revamping the contract structure moving forward if the expansions identify significant new issues that do not have a place in the current contract. Lewin will present amended contracts to vendors and obtain their feedback on contract changes. After revising the contracts to appropriately reflect vendor comments, we will work to ensure MCO acceptance of the revised contract language. The Lewin Group will then present the revised contract to CMS and upon receiving feedback, will refine the contracts as needed to win approval by CMS. We are currently using this process to review and revise MHT MCO contracts in preparation for possible program expansions or changes in areas including SSI and behavioral health. Moving forward, Lewin will continue to closely review MCO contracts to ensure all federal regulations are met. Implementation Tracking changes to the MCO contract over time will allow the Bureau to develop a single repository for both previous MCO contract changes and planned MCO contract changes for the upcoming fiscal year, as well as identify contracting trends. Lewin will develop the database, continuously update it, and review the database with the Bureau. The database will serve as a critical tool for updating the MCO contract and documenting MCO contract changes from year to year. Upon fulfilling the requirements of this task, a comprehensive contract for the Mountain Health Trust program will be developed that will account for all relevant federal and state regulations, address the concerns of CMS, set the stage for programmatic expansions and monitoring efforts, and provide a roadmap for MCO performance and setting the Bureau s expectations. The figure below summarizes the specific work steps required for one year. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed. 47

50 Figure 6. Task Sample Work Plan and Timetable for 2012 Development of strategy for MCO contracting ( ) The objective of Subtask is to assist the Bureau in refining its strategy for MCO contracting, taking advantage of the maturity of the program and resulting opportunities for performance-based contracting. The Bureau must have a managed care strategy that meets the combined challenges of promoting a competitive managed care contracting system while simultaneously encouraging MCO performance improvements in key areas and supporting traditional Medicaid providers as important elements of West Virginia s health care delivery system and safety net. The Bureau must continue to engage the MCOs currently participating in the managed care program while paving the way for new MCOs to participate in West Virginia, a significant challenge due to the rural nature of the state (entry of new MCOs into the managed care program is discussed in Subtask ). Lewin will help to manage the evolution of the program given the significant programmatic changes that are in development (e.g., enrollment of 55,000 SSI individuals in fiscal year 2011), and potential for significant numbers of new beneficiaries after health reform is fully implemented. One critical decision the State must make is to determine how many new MCOs to bring into the program now, with the inclusion of the SSI population, and later, with the expansion driven by Lewin previously assisted the Bureau with conducting research to determine options for imposing financial penalties for late reports submitted by the MCOs, as required by the MCO contract. Our staff researched the range of financial penalties imposed by other states and reviewed sample MCO contract language to provide recommendations to West Virginia. Lewin assisted the Bureau with determining the best option and then subsequently revised the MCO contract to include a financial penalty of $250 per calendar day for each day a report is late. the ACA. Too few new MCOs may overtax the existing capacity and result in inadequate access to care, improper delivery of services, and poor health outcomes. Too many new MCOs could result in insufficient enrollment to sustain efficient operations, leading to unnecessary pressure to increase capitation rates or, ultimately, MCO withdrawal from the program or financial 48

51 failure. Lewin staff have worked with a number of state Medicaid programs to develop criteria to determine the ideal number of new MCOs to bring into the program to strike a balance between providing sufficient member choice and efficient program operations. The state will want to protect itself from the chaos that comes from unwanted MCO withdrawal while having to manage as few MCOs as possible. The Lewin team has extensive experience with states in designing procurement provisions to meet the state s goals, including RFP development and scoring and the use of a competitive bid strategy. Deliverables: Task Development of Strategy for MCO Contracting The Lewin Group will develop a contracting strategy for submission to the Bureau within 30 days of request. Overview of approach Leveraging Lessons Learned and Best Practices Lewin will perform a detailed review of the lessons learned from program expansions in State Fiscal Year 2011 for use in subsequent program expansions to include additional beneficiaries (e.g., enrollment of additional beneficiaries due to the ACA) and services (e.g., pharmacy services). Specifically, we will propose recommendations for improvements based on MCO reports on the utilization of services, grievances and appeals, exemptions to seek care from out-of-network providers, provider complaints, incident reports, and surveys of TANF and new SSI beneficiaries regarding their experience and access to services. Some of the lessons that Lewin has already identified include increased oversight of MCO subcontractors and their contracting strategies, engaging affected stakeholders early in the process prior to public announcement of the changes, and providing additional lead time for the MCOs to develop sufficient networks. Lewin also will study the potential impact of new federal legislation on the managed care program, including the impact of CHIPRA requirements on quality measurement and the Members of our team assisted the State of Maryland with the development of a payment incentive to encourage Medicaid MCOs to continue statewide delivery of managed care. The development of the incentive payment was in response to several MCOs desiring to contract their service areas and only remain in more urban areas of the State. The payment incentive was successful in encouraging MCOs to maintain their statewide service areas to ensure that Medicaid beneficiary access was not adversely impacted. Lewin is able to leverage lessons learned from our experience working with the Bureau over the last 15 years such as: Increased oversight of MCO subcontracts Engaging stakeholders early in the process Allowing MCOs enough lead time to develop sufficient provider networks impact of ACA requirements on program integrity and data reporting. Lewin will help the Bureau benefit from experiences in other states by conducting a literature review and leveraging our prior experience in other states to identify additional best practices and lessons learned, avoiding approaches that may be unsuccessful. After the program expansion, Lewin will closely evaluate the provision and coordination of behavioral health services. We will evaluate service encounter data, MCO quarterly reports, and provider networks to evaluate beneficiary access to services and identify areas for improvement. Lewin will also track and evaluate the timeliness of required MCO reports. Our 49

52 experience and research findings will help to develop performance targets, incentives, and penalties for MCOs tailored to West Virginia s specific needs. Lewin has long-established relationships with the MCOs serving the managed care program, which we can leverage to get buy-in from the MCOs into new program initiatives. Building on Lewin s Monitoring and Evaluation Expertise As discussed in Section 4.1.7, The Lewin Group brings strong experience in monitoring and evaluating MCO initiatives in other states to the Mountain Health Trust program. We recently evaluated a pay-for-performance program for Pennsylvania s Medicaid MCOs. Lewin s team determined whether the MCOs achieved minimal or optimal performance based on a series of HEDIS quality measurements including regular cancer screenings, diabetes care, and cholesterol management. We also reviewed MCO performance scores to determine which plans would receive bonus payments and the size of those payments. The payfor-performance payments provided the MCOs with an incentive to not only improve their services, but also to maintain their high level of services for beneficiaries. Our staff has also designed payfor-performance programs including the selection of measures, processes to measure the performance of participating providers on a risk-neutral basis, and development of a scoring algorithm to determine a provider s portion of shared savings. We will work closely with the Bureau and the EQRO on any potential clinical improvement performance targets and gathering performance data, including identifying overall improvements to the managed care program. We previously worked collaboratively with the EQRO to develop targets for the State s strategy for improving quality in the managed care program, working to select HEDIS measures that reflect program goals. MCO Performance Scorecards Another monitoring strategy Lewin can assist the Bureau in developing and implementing is publishing MCO performance scorecards for public release. Both advocates and legislators have recently requested that performances measures of the Mountain Health Trust program be Working with one large state s managed Medicaid program, service utilization data was summarized and compared to NCQA quality standards. The HMOs were graded on their overall performance and their relative performance and any improvement shown. If they achieved target performance and improvement the HMO received a bonus payment from the state. This program applied existing industry accepted quality measures (from NCQA) and paid out amounts that had been withheld from the monthly HMO capitation, which made the program credible and budget neutral. Members of our team assisted the State of Alabama with creating a payfor-performance system for the State s primary care case management system. The program created financial incentives to reward primary care physicians for reaching targets associated with increased office visits and decreased emergency room utilization, as well as increased use of generic medications. posted on the Bureau s website on a regular basis. Although the Bureau s Annual Report provides some information on MCO performance, publishing scorecards containing information on MCO performance in the areas of access and quality, as well as key clinical measures, would be a valuable tool for demonstrating the effectiveness of the program expansion and would offer beneficiaries an additional tool by which to select an MCO. 50

53 Implementation The figure below details the specific work steps required to further implement performancebased targets for MCO contracting for one year. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed. Figure 7. Task Sample Work Plan and Timetable for 2011 Perform analyses and ongoing monitoring of MCO provider networks ( ) The objective of this subtask is to ensure that the Mountain Health Trust MCOs continue to provide beneficiaries, via adequate provider networks, the level of access required by the program waiver and necessary to achieve program goals. Quarterly analysis of MHT provider networks within each health plan enables the Bureau to quickly identify and address any significant changes that could negatively impact enrollees access to care. These analyses will be increasingly important as the SSI population is phased in, as SSI beneficiaries generally require more frequent provider visits as well as a greater range of physician specialties, and as the single-plan rural option continues to be implemented, to ensure the beneficiaries without a choice of plans continue to have appropriate access to services within a single MCO s network. Successful performance of this task will lead to: Updated standards and regular monitoring of provider networks; An automated method for MCO provider network submissions; and A transparent process and sharing of information with BMS in a standardized quarterly report. Bringing the Bureau the Benefit of Lewin s Extensive Experience In addition to extensive network review experience in West Virginia, Lewin has conducted analyses of provider networks for a variety of state Medicaid agencies including Texas and New York. Lewin worked jointly with CMS on a first-of-its kind effort to develop and establish a set of national provider and facility network criteria for the Medicare Advantage program. As part of this significant undertaking, Lewin analyzed approximately 30 physician specialties and 20 facility types to create county-level requirements for new MCOs entering the Medicare Advantage marketplace. The criteria included creating the minimum number of providers an MCO must have in its network to enter a county and the creation of time and distance requirements. CMS used the criteria in 2010 for the first time to standardize and automate the evaluation of provider networks for new Medicare Advantage plans across the country. A sample of the types of criteria developed by Lewin, by designated county types, is included 51

54 below. In developing the nationwide network criteria, Lewin utilized its relationship with GeoAccess and Ingenix to produce detailed network analysis maps and overall access reports to ensure that time and distance criteria were appropriate to meet the needs of the Medicare Advantage population. Figure 8. Sample CMS Medicare Advantage National Network Criteria Specialty Geographic Type Large Metro Metro Micro Rural Time (minutes) Distance (miles) Time (minutes) Distance (miles) Time (minutes) Distance (miles) Time (minutes) Primary Care Allergy & Immunology Cardiology In West Virginia, Lewin is extremely familiar with the counties and the individual facilities and providers who participate in Mountain Health Trust. We have many years of experience working with provider network data from West Virginia and we have built strong partnerships with the major stakeholders for this task, including the MCOs, our data subcontractor Michael Madalena, and the fiscal intermediary for West Virginia Medicaid. Lewin has several ideas to improve and streamline the monitoring of MCO provider networks. One of the main challenges with MCO monitoring is that as time passes and more beneficiaries enroll in Mountain Health Trust, utilization of fee-for-service providers can no longer be used as the baseline to measure MCO provider network adequacy. Lewin will work to develop better methods to identify network providers using encounter data. We will use service volume to set TANF and specialty standards. We will work to create standardized data collection formats including defined provider types. Lewin will provide guidance on how to crosswalk provider types into different categories, which also will help promote standardization and transparency. We will also consider new methods for MCOs to submit network data for review including the potential for an online submission portal. Distance (miles) Lewin s proposed innovative monitoring approaches of MCO provider networks will provide the following benefits to the Bureau: Standardized data collection formats Centralized provider database Online submission portal for MCOs Deliverables: Task Perform Analysis and Ongoing Monitoring of MCO Provider Networks The Lewin Group will prepare and submit network analyses to the Bureau on a quarterly basis, within 45 days of the end of each quarter. Lewin will submit expansion county network analyses within 45 days of request. Overview of approach Assessing Plan Networks The Lewin Group will perform a complete comparative analysis of the FFS and health plan networks in the 55 MHT counties on an annual basis, in addition to quarterly analyses of network reports. We will also evaluate MCO networks in additional expansion counties as they 52

55 are identified, when a new population (such as SSI) is to enter the program or when a new MCO seeks to contract with the MHT program. Lewin will compare MCO provider networks against new sets of network standards that are transparent to MCOs and based on new methodology. The new methodology will meet the requirements for network analysis required under the CMS 1915(b) waiver form. Reviews will focus on TANF-specific and SSI-specific networks to ensure that access to needed providers, particularly specialists, is adequate in each county for each MCO. We will prepare network adequacy for individual MCO reports and the full program. To further assist with analyzing access, Lewin staff will use MapPoint software to examine network adequacy by mapping providers and facilities across the State to ensure adequate coverage. Lewin will generate maps depicting providers, clinics, and hospitals by specialty and location. These maps will facilitate the identification of areas where networks could or should be improved. A sample map is included below, demonstrating that beneficiaries in Region 11 have access to dentists within driving time. The blue shading depicts the actual region; the red line depicts driving time. Figure 9. Sample MCO Network Adequacy Map As part of the network reviews, Lewin will request that the MCOs submit National Provider Identifiers (NPIs) for each provider in the network and map NPIs to provider specialty codes as required by the program integrity requirement of the federal health reform law. As another component of the network reviews, Lewin will obtain copies of the initial and most recent Medicaid provider network directories from each MCO, as well as the quarterly MCO primary care provider (PCP) and specialist panel reports provided to the Bureau. We will use these data and current FFS network information to review provider ratios against the ratios established in the Network Adequacy Methodology. These data will allow us to make a comparison of PCP and key specialist availability in each county prior to and during waiver cycles. It will also help to monitor access during the upcoming program expansion in

56 Formalize Regular Reviews Conducting regular reviews with MCOs will become increasingly important given the planned expansions and phase-in of SSI. To support the Bureau in this effort, Lewin will develop and share with MCOs a schedule for regular network reviews that will include initial submissions, follow-up reviews, and additional communication regarding deficiencies. Formalizing this process will help establish it as part of the ongoing MCO monitoring activities and elevate network adequacy as a more important issue for CMS and other stakeholders. Lewin also will explore the feasibility of creating a network dashboard to keep MCO, CMS, and others informed about network monitoring developments. Monitor Access In addition to evaluating network adequacy at the onset of this contract and as the program is expanded, Lewin will conduct quarterly reviews of each MCO s network to monitor access to providers. Using information contained in quarterly reports submitted by each MCO, Lewin also will review (on a county level): Ratios of PCPs and key specialists to members; Quarterly changes in panel size; Types of PCPs available; and Numbers of specialist referrals. Lewin will determine which PCPs are in multiple networks and aggregate the panels to determine if any are approaching the panel size limit of 1,500. If ongoing network problems are detected (e.g., a particular PCP loses large numbers of members during several consecutive quarters), Lewin will request that the MCO and/or enrollment broker provide evidence of measures taken to investigate the reason for the changes, and, if any access or quality issues are detected, evidence of actions that plan took to resolve the problem and prevent recurrences. As the MHT program expands into additional counties or new populations are added to the program, Lewin will evaluate the provider network of each MCO entering the expansion county to ensure access to needed providers is adequate. Also, when a new MCO applies to participate in the program, we will provide a Medicaid provider list by county to assist the MCO in establishing its provider network. Lewin will lay out a schedule for submitting networks for each SSI phase-in region and the final dates for approving and credentialing the MCO provider networks. Implementation The Lewin Group will submit network analyses to the Bureau within 45 days of the end of each quarter. Lewin will submit expansion county network analyses within 45 days of request by the Bureau. The figure below summarizes the specific work steps required for one year. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed. 54

57 Figure 10. Task Sample Work Plan and Timetable for 2011 Scope of Work: Program Management and Improvement (3.2.2) The focus of Task is on activities related to the ongoing management of the Mountain Health Trust program, its expansion, and continuous improvement, including participation in Task Force activities, encounter data analysis and related reporting, and options for program expansion. Each of these activities will be used to inform the Managed Care Improvement Plan, described in Task The Lewin Group has supported the Bureau for Medical Services for over 15 years in ongoing program management including numerous program expansions and modifications. Lewin has the capacity and expertise needed to fully support the Bureau in updating and implementing its Managed Care Program Management Plan, with the goal of providing high quality services that meet all state and federal regulations. Lewin has conducted numerous analyses to identify areas for performance improvement. For example, Lewin has analyzed utilization data to measure outcomes in Medicaid managed care programs and other demonstration programs, such as a CMS demonstration to improve care for persons with end-stage renal disease. Lewin has developed data analyses for performance incentive development, federal reporting requirements, and internal program monitoring and improvement. For example: Lewin conducted an independent assessment of New Mexico s managed care program, Salud!, and behavioral health managed care program including access, quality, and costeffectiveness. Lewin reviewed state contractual requirements, provider networks, satisfaction surveys, national performance standards, HEDIS results, CAHPS scores, and financial reports. We also conduct performance reviews of various organizations, collecting and analyzing cost and utilization data for multiple payers. The Lewin Group is currently working with AHRQ to provide evidence-based technical assistance to 24 Chartered Value Exchanges (CVEs), community coalitions that must have active participation by representatives from providers, purchasers, health plans and consumer organizations. CVEs are charged with measuring and reporting on physician or hospital practice in a meaningful and transparent way to influence value-based decisionmaking by consumers and purchasers of health care. 55

58 Performance measures are only as good as the data and analysis used to develop the numerators and denominators. An effective performance measurement program requires an effective information technology infrastructure, valid analysis methodology, and a direct clinical relationship to practice guidelines. Our team can bring this expertise in addition to our experience with state clients in the quality improvement arena. The following is a high level Gantt chart outlining our work on each of the major subtasks associated with the Managed Care Program Management Plan. We will update this plan as needed throughout the course of the project. Figure 11. Task Work Plan and Timetable for The details of our proposed Managed Care Program Management Plan, including specific details on each subtask, are outlined below. Participate in ongoing program management activities ( ) Lewin will work with the Bureau to develop a comprehensive program management strategy for the Medicaid managed care program that will align with the Managed Care Improvement Plan outlined in Task Lewin will develop a strategy that will allow the Bureau to assign significant portions of program operations management to Lewin. We have strong experience in monitoring Medicaid managed care programs in West Virginia as well as 16 other states. Lewin has over 15 years of experience working with BMS and the MCOs that administer the managed care program, including setting managed care rates and managing several managed care initiatives such as analyzing pay for performance models, developing dashboards for 56

59 monitoring MCO performance, ongoing reevaluation of MCO network adequacy, and identifying program improvement opportunities based on beneficiary survey results. We have also worked with numerous private sector entities to develop responses to state Medicaid managed care initiatives. This added experience gives us distinctive and realistic perspectives on the needs and capabilities of providers and MCOs regarding public sector managed care programs. Lewin s multi-faceted expertise will be valuable as we assist the Bureau in furthering the development of its collaborative partnership with the State s MCOs and support the Bureau s ongoing management of the MHT program. Overview of approach The Lewin Group will assist the Bureau with ongoing program management activities, ad hoc requests, and small research projects. Lewin will assist the Director of Managed Care and Procurement Services in ensuring that regular program activities are accomplished in a timely and satisfactory manner. Examples of the types of ongoing activities for which Lewin has provided assistance in the past (and expects to perform similarly in the future) include responding to CMS requests for information on specific aspects of the MHT program, such as EPSDT compliance rates, providing summary information on the MHT program for new agency staff, clarifying contract and benefit package terms for vendors, preparing comments on proposed federal regulations that will impact the MHT program, investigating complaints and grievances, and reviewing MCO materials. Working sessions As a part of our management strategy, Lewin will schedule regular communications with the Bureau in the upcoming year to prepare for the implementation of expanded coverage in the managed care program. To support the most efficient use of Bureau staff time and resources, Lewin will bring key decision points to leadership in briefings and memos. Lewin will also conduct working sessions that include key vendors such as the enrollment broker, the fiscal intermediary, and the EQRO to help develop a partnership with all BMS vendors. These meetings will continue into 2012 to address implementation issues or concerns. The working sessions with key vendors will likely cover several topics including the discussion of key dashboard and other programmatic data, the need for greater coordination on stakeholder feedback, discussions of lessons learned throughout the implementation process, and preparation for future managed care expansions. Lewin will also receive updates on key vendor activities. These working sessions will ensure that all contractors actively contribute to the monitoring of the managed care program. Lewin will also assist BMS with the planning and scheduling of quarterly MCO task force meetings, including drafting agendas and ensuring participation by key staff from the MCOs and BMS other vendors. Technical assistance and program monitoring Lewin will leverage its current working relationship with the MCOs to offer technical assistance and follow-up. The types of assistance that Lewin has provided in the past (and expects to perform in the future) include reviewing MCO member materials for compliance with contract terms, reviewing revised enrollment applications for the enrollment broker to ensure compliance with federal requirements, and reviewing proposed standards for MCO quality assurance programs for the EQRO. 57

60 Lewin understands CMS recent concerns about Mountain Health Choices within the Medicaid managed care program and is cognizant of the areas in which CMS wants to see improvement. Given CMS recent concerns about MHC and in light of the upcoming expansion, monitoring is even more important than in previous years. Lewin can elevate key issues for BMS to review and use quarterly reports and network analyses to determine issues facing the managed care program as well as following up on any stakeholder concerns that reach BMS. Lewin can leverage its relationships with the MCOs to determine the validity of these stakeholder issues and develop strategies to resolve them. We will continue to develop our role in program evaluation, including expanding our monitoring dashboard to include additional measures for SSI, dental, and behavioral health. For example, we will work on incorporating additional trend analysis (e.g., multiple year data) into the dashboard. We will also examine what information other states collect and conduct analysis that is sensitive to the concerns of stakeholders. Other program management activities Lewin will attend other meetings as requested. These may include meetings with potential MCO contractors to solicit their participation in the MHT program, other state agencies and programs (e.g., HealthCheck) to discuss areas of mutual concern, state agency staff and/or legislators to provide briefings and updates of the status of the program, CMS or other external auditors to discuss the ongoing operations and future direction of the program, or any other meetings requested by the Bureau. Lewin will coordinate with other state contractors as requested and appropriate to support ongoing coordination for the Bureau. Since the program s inception, Lewin has worked with the enrollment broker and the external quality review organization, frequently interacting with the MHT contract managers at those organizations on issues related to the ongoing management of Mountain Health Trust. Lewin will review materials and reports provided by other vendors, report to the Bureau as requested, and incorporate findings into broader program monitoring activities. We will also work with other state contractors such as the Medicaid fiscal intermediary, as requested or required. Lewin will help with the coordination of the Physician Assured Access System (PAAS) and will assist with the development of mechanisms and materials to evaluate and compare performance across both MHT and PAAS. This may include reviewing draft waiver materials for both programs to ensure that the designs complement each other; designing, conducting, and/or analyzing surveys for enrollees of both programs; and developing comparison materials for potential enrollees or CMS. Lewin will assist the Bureau in identifying areas where coordination is necessary and ensuring that sufficient coordination takes place. Summary Program management and monitoring may be an overwhelming job, particularly in 2011, with resources of the Bureau, MCOs, and other vendors focused on major expansions. As such, The Lewin Group will assist BMS in all program management activities. We will conduct working sessions with the Bureau to prepare for program expansions, provide technical assistance to the MCOs and other vendors, and coordinate with other State contractors and agencies to support ongoing program management and improvement across programs. Lewin will work to ensure 58

61 that data collection is sufficient to track MCO performance and that of the MHT program overall, without placing excessive burden on the Bureau, MCOs, or other contractors. We will leverage our strong experience working in West Virginia and the relationships we have established with MHT stakeholders to support the Bureau throughout ongoing management activities of the program resulting in the efficient and effective administration of managed care services for beneficiaries. Implementation The Lewin Group will participate in ongoing program management activities. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. Figure 12. Task Sample Work Plan and Timetable for 2011 Capture encounter, claims and eligibility data on a monthly basis ( ) The objective of this task is to collect and analyze encounter data on an ongoing basis to enable the Bureau to conduct regular program monitoring. Overview of Approach In order to develop an efficient methodology to gather the claim/encounter data, we will work collaboratively with the Bureau and each of the entities that submit data. During this process, existing data extracts and other information sources will be examined for completeness. Following this assessment, the sources of data will be compared to the needs and requirements of the Bureau. Modifications to source data extracts will be negotiated with each of the data sources (if necessary). Once necessary modifications are completed, data receipt will begin. The following summarizes the steps in this process: 1. Meet with BMS to discuss the outputs and analyses required. Review the sources of data with BMS. 2. Review existing data extracts for completeness and capability to meet the data requirements of the Bureau. The sources of data to be reviewed in this step include: MCOs Fiscal intermediary The data submission requirements of the ACA represent significant challenges to participating entities. For example, NDC codes will be required to be submitted for all service line items for injectable materials. Historically, plans have disregarded NDC codes during the adjudication process and relied solely on HCPCS codes for pricing and adjudication. Because of our long history and extensive experience with the participating plans, information such as NDC codes for injectable materials will rapidly become actionable information. 59

62 o o Eligibility extract Claims extract (includes PAAS, fee-for-service Medicaid, and carve-out services provided to MCO enrollees). 3. Begin source data revision process with each of the data sources (if necessary) and establish data transmission methodologies. 4. Receive test data submissions from each source and review for accuracy, completeness, and data quality. Test data transmission methodology determined in Step Three as well. 5. Provide feedback to each of the data sources including required revisions (if necessary). 6. Receive and process replacement test data from sources that were required to make modifications. 7. Provide feedback to each of the data sources that supplied replacement data including required revisions (if necessary). 8. Execute production (full file) tests with each of the data sources. 9. Review test production and make revisions, if necessary. 10. Production schedule (monthly receipt) commences. Implementation Steve Johnson, Ph.D, Program Management and Improvement Team Lead, is a nationally-recognized risk adjustment expert with over 36 years of experience working with health care data, primarily focusing on the analysis of Medicaid data. He developed two interactive support tools that states can use to evaluate the completeness of the encounter data they receive from their MCOs and the efficiency of MCOs in providing services to their members. The Lewin Group will capture encounter, claims and eligibility data from participating MCOs, the PAAS program, and the fiscal intermediary on a monthly basis. MCO data will be consistent with UB92 and CMS1500 formats. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. Figure 13. Task Sample Work Plan and Timetable for

63 Review encounter data ( ) Accurate and complete encounter data is a vital resource for evaluating the performance of providers in the MCO and PAAS program. The encounter data received from these providers must be extensively evaluated to determine if there are any errors or omissions in the data. Overview of Approach The Lewin Group will give immediate feedback to MCO and PAAS providers if our evaluation studies identify any problems with the encounter data, so that corrected data can be submitted on a timely basis. By closely monitoring the encounter data submitted by MCO and PAAS providers, The Lewin Group will ensure that an accurate and complete encounter database is created. Once the processes for receiving data have been completed, the processes that will be used to validate and load the production data will be implemented. This process has a number of steps, with each step building upon its predecessor: 1. Media verification is the input source (tape, CD, electronic file transfer) machine readable without uncorrectable errors. 2. Control total verification the number of records on each file will be compared to the control totals provided on the data transmission sheet, and if the data are claims, the financial totals will be checked against the data transmission sheet. 3. Physical data verification does the file line up with the specified record layout (e.g., patient date of birth is in positions 70 through 77 ). 4. Edit verification once the encounter data file has passed the first three verification steps, the data will be subjected to a rigorous set of edits to validate the accuracy of the data: a. Valid values each data element will be tested against valid values for that field, and invalid data values will be flagged as errors. b. Eligible recipients member ID numbers will be matched against the eligibility file to verify that the member was enrolled with the provider submitting the encounter and eligible for Medicaid on the date of service. c. Registered Providers the provider ID number on the encounter will be matched with the provider file to verify that the provider was enrolled and authorized to provide the service on the date of service. d. Internally Consistent- the data will be edited for internal consistency to verify that reported diagnoses and procedure codes are consistent with the member s age and gender (e.g., hysterectomies are not being performed on 5 year old males). 5. Data completeness a series of validation checks will be conducted to verify that the encounter and claim data is complete. The total number of claims/encounters and unduplicated recipients will be computed for each month for each category of service. These counts will be used to determine if the volume of data received is consistent over time. This process will identify months with lower than expected volume for follow-up 61

64 discussions with MCO and PAAS providers. Data completeness will also be evaluated by comparing the volume of encounters submitted by each MCO against the other MCOs. To control for variations in demographic mix, this analysis will be conducted separately for TANF adults and children. The completeness of the encounter data will also be evaluated by comparing the utilization and financial totals from the MCO encounter data with their financial filings with the Department of Insurance. 6. Update the encounter database Accurate and complete files that pass the completeness and edit verification tests will be added to the encounter database. At any point in the update process, any anomalies will be discussed at length with the data source s technical contact. Issues that cannot be resolved with discussion and analysis will generate a replacement submission by the source. Implementation The Lewin Group will review encounter data for completeness and inconsistencies, conduct validation of data, and consult MCOs and the PAAS program to address any data issues. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. Figure 14. Task Work Plan and Timetable for Produce monthly, quarterly, and annual encounter data reports ( ) A comprehensive reporting strategy is essential for monitoring the performance of the MCOs and comparing their performance with PAAS and other public programs. The completeness of encounter data must be monitored on a monthly basis to identify data problems quickly and permit timely follow-up with the MCOs. Monthly and quarterly reports will be used to track key measures of data completeness and program efficiency so that trends in these measures can be monitored. Annual reports will create a more comprehensive view of program performance, including measures of plan quality and efficiency. Overview of Approach In developing the reporting package, Lewin will work collaboratively with the Bureau in all phases of report development. As a starting point, existing reports will be reviewed with BMS to inventory existing measures. In addition to this review, we will make recommendations to BMS for additional measures to be considered for inclusion in the reports. Once the draft package is completed, we will present it to BMS staff for comment. The reporting package will be revised based upon comments received during the review process. The review and revision process will continue until BMS has a reporting package that achieves the goal of helping the Bureau understand the utilization patterns and trends of the population it serves. 62

65 Once the package of reports is designed and periodicity of the measures (e.g., monthly, quarterly, annually) determined, we will implement the reporting package. As part of this implementation phase, we will suggest external comparative measures to evaluate program performance. For example, the annual report will include the rate of a preventative service such as well child visits among the participating MCOs. Along the with rate of the service by MCO, the state may wish to display the same rate for the PAAS and fee-for-service programs or commercial HMO rates, as well as rates for other West Virginia public payers. To the extent that such measures are available, they will be incorporated into the BMS reporting package. To deliver reports and analyses to BMS, we will utilize a series of applications based on the Cognos suite of business intelligence tools (Cognos Connection, Report Studio, Query Studio, Analysis Studio, and Event Studio). Figure 15. Cognos Connection Screen Shot Using the database of encounters, claims, and eligibility as a basis, Lewin will implement a metadata dictionary that allows for end users to construct production reports and ad hoc queries as well as perform analysis using online analytic processing (OLAP) tools. We will construct a series of reporting objects to facilitate reporting and analysis: Combined claims and encounters (MCO and FFS); Fee-for-service medical and dental detail (includes ad-pays and other adjustments); Inpatient encounters ( MCO and FFS); Enrollment detail (MCO and FFS); Enrollment summaries (MCO and FFS); Prescription drugs (MCO and FFS); and Provider detail. 63

66 Report Studio is a full-featured report writer that includes sophisticated scheduling as well as output delivery options such as recipients and format. Figure 16. Report Studio Screen Shot Report Studio includes a number of pre-defined formats (e.g., lists, crosstabs Pivot tables, and graphics) as well as analytic functions (e.g., mathematic, statistical, data manipulation). User interaction is primarily drag-and-drop and includes custom programming capabilities. Reports implemented in the BMS catalogue include: 1. Financial / claims summaries a. Lag charts b. Paid claims c. Enrollment d. Access measures (provider and patient crosstabs) 2. Type of service utilization a. Inpatient days/encounters b. Outpatient encounters c. Physician office encounters d. Episodes of care 3. Diagnostic utilization a. Inpatient hospital b. Outpatient hospital c. Physician office d. Other 64

67 4. Prescription drugs a. Utilization by classes b. Utilization and cost by classes by disease state classification c. Cost by classes d. Generic penetration Query Studio, like Report Studio, is primarily a drag-and-drop tool. Query Studio is designed for ad hoc interrogation of data. Since Query Studio and Report Studio share the same metadata repository, variable and definitions are identical. Queries developed in Query Studio can be imported into Report Studio as needed for more advanced development and deployment. Figure 17. Query Studio Screen Shot Analysis Studio is an OLAP tool that is designed for business user level integration of the claims/encounter database. Cubes (or OLAP objects) are presummarized views of database objects. The cube in the graphic below is a summarization of the combined MCO and FFS claims database back to SFY 2004 SFY. Because the data are represented in a summarized, highly indexed file, massive amounts of data can be analyzed and reported very rapidly with a few drags of a mouse and several mouse clicks. 65

68 Figure 18. Analysis Studio Screen Shot 1. Custom medical, pharmacy, and eligibility extracts have been delivered to third parties at BMS direction. Examples of such file construction projects are the datasets delivered to West Virginia University to analyze the effectiveness of Mountain Health Choices; inpatient hospital utilization datasets to the West Virginia Health Care Authority and West Virginia Hospital Association; and combined West Virginia public payer files to independent actuaries to study the impact of potential health care reform initiatives. 2. Internal analyses delivered to BMS. Examples of such applications include compliance analysis of Mountain Health Choices participants, CMS reporting reconciliation, inpatient hospital days reporting, and custom eligibility analyses and reporting. 3. Rate setting files and analyses. Extracts have been developed to support the development of capitation rates and payments to participating MCOs based on the encounter data submissions. As more services are included in the MCO service package (e.g., SSI population, dental, and behavioral health), the extract process will be modified to accommodate the expanded scope of services. 4. As risk adjustments are introduced to the rate setting process, the database will support those calculations. We have extensive experience using the database to support proprietary risk analysis tools, 3 rd party commercial software (e.g., Adjusted Clinical Groups, DxCG) and public domain tools (e.g., CDPS, HCC). In addition to the software tools described above, we are always ready to assist in whatever fashion the situation dictates whether that be training/support on Cognos tools, performing sophisticated analysis at BMS direction, or developing turnkey analytic applications. 66

69 Implementation The Lewin Group will produce monthly, quarterly, and annual encounter data reports for the Bureau that incorporate encounter data and FFS program data. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. Figure 19. Task Sample Work Plan and Timetable for Provide technical assistance to the MCOs on data issues ( ) The submission of clean, consistent data by the MCOs is critical to the ongoing success of MHT. At the Bureau s request, Lewin will utilize a number of technical assistance methodologies to support MCOs and other vendors, including, but not limited to, written and electronic documentation, telephone, electronic mail, knowledge management tools (such as Wiki, portals, and bulletin boards) and face-to-face meetings at the Bureau s direction. The types of assistance that Lewin has provided in the past (and anticipates to perform similarly in the future) include reviewing MCO member materials, MCO agreements with subcontractors, and marketing requests for compliance with contract terms; reviewing revised enrollment applications for the enrollment broker to ensure compliance with federal requirements; support with FFS claims data or encounter data from the enrollment broker; assisting MCOs in interpreting MCO Contract requirements; and reviewing proposed standards for MCO quality assurance programs for the external quality review organization. Lewin s long standing history with West Virginia and our strong existing working relationships with the MCOs and other vendors will enable us to most effectively meet their technical assistance needs and provide a coordinated response so that required data is collected in a timely and efficient manner. Implementation The Lewin Group will provide technical assistance to the MCOs on data issues. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as necessary. 67

70 Figure 20. Task Sample Work Plan and Timetable for Transmit monthly electronic reports to the MCOs on pharmacy utilization ( ) We will use the existing pharmacy extract format as a starting point to provide carved-out prescription drug claims to each of the participating MCOs. Discussions will take place with the plans to determine what modifications, if any, are needed to the current format. Once a format is developed that is agreeable to both the MCOs and the Bureau, we will design, implement, test, and put into production a process that either delivers, or makes available for delivery, the appropriate prescription drug data. Possible delivery methodologies include, but are not limited to, CDROM, DVD, encrypted , and secured FTP (push and pull). We will work with each of the plans to determine which methodology is acceptable. Currently, plans are receiving drug data using SFTP (push), FTP with PGP encryption (pull), and FTP with ZIP (256 bit AES) encryption (pull). Implementation The Lewin Group will transmit monthly electronic reports to the MCOs on pharmacy utilization for their enrolled members as long as pharmacy is carved out of the MCO capitation rates. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as necessary. Figure 21. Task Sample Work Plan and Timetable for Conduct analysis of Medicaid EPSDT program ( ) As an organization, we have had considerable experience with EPSDT programs from both analytic and operational perspectives. In the past, we have participated in both the production of 416 reports as well as providing the data necessary to other entities that are responsible for EPSDT and other required reporting. In addition to serving in an analytic capacity, we have also been involved with setting reimbursement rates and modeling the impact of proposed reimbursement rates. In order to fulfill this requirement, we will meet with the appropriate BMS and DHHR staff to determine what level of support is required. Based upon those discussions, we will design, implement, test, and put into production data extracts and/or reporting tools that measure EPSDT program performance. EPSDT reporting has been developed such that custom subsets 68

71 as well as customization of definitions are supported. For example, while 416 reporting to CMS is performed at the program level, plan or delivery mechanism level reports are available as well. Lewin will use these reports to respond to state and federal requests for information as needed. Implementation The Lewin Group will conduct analysis of the Medicaid EPSDT program and create custom extracts to respond to state and federal requests for information on program performance. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as necessary. Figure 22. Task Sample Work Plan and Timetable for Produce PAAS provider profiles on key services that are health care cost drivers ( ) Physicians providing primary care case management services through the Physician Assured Access System (PAAS) play a key role in ensuring that Medicaid beneficiaries receive necessary medical care services. These physicians also play an important role in making sure that their patient panels do not utilize unnecessary medical care services or receive services in a more expensive setting when lower cost alternatives are available. Profiling the utilization of health care services by the panels of physicians participating in the PAAS program can assist MHT in identifying those physicians that are successfully fulfilling their primary care case management role. Reviewing these profiles with PAAS physicians will help them to understand those areas where they are performing their case management role successfully and areas where they can improve their performance. Lewin will create provider profile reports for PAAS physicians by summarizing the annual utilization of key health care cost drivers including: emergency room visits, inpatient hospital admissions, prescription drugs, and diagnostic lab and x-ray services by members enrolled in their panel. For each health care service, Lewin will summarize the units of service and total paid dollars for each member of a physician s panel. Lewin will also summarize the total member months of eligibility for each physician s panel. The provider profile reports will combine the health care services utilization measures with the member month data to compute average annual utilization rates and the cost per member per month (PMPM) for the physician s panel. The annual utilization rates and PMPM costs can be used to compute the relative performance of each PAAS physician. 69

72 To control for differences in the demographic mix of a provider s panel, Lewin will compute annual utilization rates and PMPM costs separately for TANF Adults, TANF Children, SSI Adults, and SSI Children. Lewin will also assign each PAAS physician to one of the following peer groups: Pediatricians, Family/General Practitioners, Internists and Other Practitioners. To evaluate the relative performance of each physician, the utilization of his or her panel will be computed for each of the four eligibility categories and compared to the average utilization for each eligibility category for his or her peer group. Lewin will update provider profile reports on a quarterly basis and evaluate the utilization of health care services for the most recent complete annual period. Lewin will create a manual describing the measures included in the reports and how these measures should be interpreted by PAAS physicians to evaluate their performance. The profiles will be mailed to PAAS physicians, and physician inquiries on report content will be addressed using telephone, FAX, , or written correspondence via mail. We will also review the results of the analysis with BMS staff. In particular, providers with significantly different results from their peers will be analyzed further, allowing for corrective action as well as the monitoring of provider behavior. Implementation The Lewin Group will produce PAAS provider profiles on key services that are health care cost drivers, mail the reports to providers, and respond to provider s questions related to the profile. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as necessary. Figure 23. Task Sample Work Plan and Timetable for Produce annual report on PAAS provider performance ( ) Lewin will create a comprehensive annual report to monitor the performance of each PAAS physician. The annual report will provide BMS with a comprehensive profile that the Bureau can use to evaluate the performance of each PAAS physician. The annual report will include all of the relative health care utilization measures and costs per member, per month, described in the response to Task In addition, the annual report will include an efficiency index to evaluate the relative total cost of members in each PAAS physician s panel. To create the efficiency measure, the total cost per member, per month, will be computed for each panel member. To account for the acuity of each physician s panel, a Chronic Disability Payment System (CDPS) risk score will be calculated for each member. The risk scores will be used to compute the average acuity for each panel for each of the following 70

73 four eligibility categories (e.g., TANF Adult, TANF Child, SSI Adult, SSI Child). The average total cost PMPM will also be computed for each of the four eligibility groups. By dividing the total cost PMPM by the average risk score for each eligibility group, Lewin will compute a risk neutral cost PMPM for each of the four eligibility groups. The risk neutral cost PMPM for each physician s panel will then be compared to the risk neutral cost PMPM for the entire eligibility group to compute an efficiency index for each eligibility group. The efficiency indices for each of the four eligibility groups will be combined to compute an overall efficiency index for a physician. The annual report will also include a care coordination measure for each physician. For each member, we will create indicators to identify whether they were seen by their PCP, other primary care physicians, other specialty physicians, a free standing clinic, hospital-based outpatient department, or emergency room. These indicators will be used to classify members based upon whether they were seen by their primary care physician, seen by other primary care physicians, seen by other specialists, seen in a clinic or outpatient department, only seen in an ER, or had no visits in an outpatient setting. The coordination care efforts of a physician will be measured by evaluating the percentage of their panel that they treated, the percentage seen by other physicians or in a clinic setting, the percentage only seen in the ER, and the percentage that were not treated in an outpatient setting. BMS can use the annual report to identify physicians whose panel is utilizing excessive health care services, have high relative cost based upon their relative efficiency index, and/or are performing poorly in coordinating care for their panel. The annual report will also identify physicians who are doing an excellent job coordinating care and providing services efficiently. Implementation The Lewin Group will build on Task to produce annual reports on PAAS provider performance. The figure below summarizes a sample timeline with annual reports delivered each year of the contract. Figure 24. Task Sample Work Plan and Timetable for Develop additional profile reports for inclusion in monthly and annual reports ( ) Lewin will create additional profile reports for inclusion in monthly and annual reports, after consultation with MHT to address new and emerging areas of interest. Potential profile areas will be presented to BMS for approval. Once a topic area has been identified and approved by BMS, the profile implementation process will begin using the previously described methodology. 71

74 The utilization measures, efficiency indices, and coordination of care measures discussed in the responses to Tasks and can be used to evaluate the performance of PAAS physicians in directing the care received by those members identified in these new areas. Deliverables: Task Develop Additional Profile Reports for Inclusion in Monthly and Annual Reports The Lewin Group will submit waiver renewal documents to the Bureau 90 days before expiration of the current waiver in Lewin will prepare interim waiver amendments or state plan amendments within 45 days of request by the Bureau. Implementation The figure below summarizes the specific work steps required for the 2012 waiver renewal process and a sample interim amendment request. This task will repeat as needed for future renewals and amendment requests. Figure 25. Task Sample Work Plan and Timetable for 2012 Develop options for program expansion and assist in implementing program expansion ( ) The Lewin Group will work with the Bureau to continue to expand the managed care program. Lewin will help develop expansion strategies, examine options for program expansion in detail, study the potential implications of expansion, and help with the implementation of program 72

75 expansions. Managed care program expansion is often considered as a cost saving measure, but it must be approached cautiously and deliberately, with complete understanding of the likely impacts. Lewin has experience performing necessary analyses for a variety of states. For example, in 2005 the Illinois Legislature commissioned a study, competitively awarded to Lewin, to assess a wide range of Medicaid managed care approaches. Our work included interviews with various stakeholders, extensive data analysis, and a detailed assessment of both the qualitative and quantitative strengths and weaknesses of each Medicaid managed care model. We presented our findings in both a detailed written report and during an on-site legislative committee hearing in Springfield. Our findings are often cited during debate in the Illinois General Assembly on expanding the use of managed care in the Illinois Medicaid program. In a two-phased project, The Lewin Group developed a comprehensive set of cost estimates for potential expansion of Texas' Medicaid managed care programs. The study included a projection of potential savings as a result of implementing various managed care expansion options (such as capitation and exclusive provider arrangements), as well as a geographic analysis of potential expansion regions and population subgroups (e.g., TANF, disabled). The study also took into account the potential effects managed care expansion would have on other programs and benefits, such as pharmacy. The Lewin Group then assisted the Texas Health and Human Services Commission staff with an assessment of technical issues involved in designing an expanded Medicaid managed care program. As part of this work, we modeled expected costs and savings of various options the commission was considering, including benefit package service options, expanding eligibility, and effects of cost sharing. Technical options for inclusion of long-term care and mental health services were presented as well as research on other innovative eligibility program designs in these areas. The technical assistance aided the Commission staff in preparing a briefing for the Texas Legislature. Lewin staff also provided testimony at a special joint meeting of relevant legislative committees. Deliverables: Task Develop Options for Program Expansion and Assist in Implementing Program Expansion The Lewin Group will develop proposals outlining options for program expansion for areas without managed care entities and as SSI eligibility is expanded across the State as requested by the Bureau. The Lewin Group will develop any required materials and CMS documentation within 45 days of request from the Bureau for Medical Services. Overview of approach Upcoming managed care expansions Lewin will continue to assist the state with the expansion of SSI, behavioral health, and children s dental coverage including: Helping with the preparation of implementation timelines; Communicating with MCOs and key stakeholders; Reviewing managed care networks; Operational readiness reviews; 73

76 Answering questions MCOs have about expansions prior to going live; Supporting BMS by handling ad hoc requests; and Monitoring changes to federal regulations and determining if there is any impact on expansion plans. Lewin will perform the tasks mentioned above by identifying areas of concern through quarterly monitoring efforts, surveys and focus groups, and analyzing complaints and grievances by beneficiaries. Lewin will develop solutions to mitigate problems found with the expansions, working together with BMS and the MCOs. Lewin will help with post-implementation assessments of the success of the program expansions along with areas for improvement, by conducting beneficiary focus groups and surveys and getting feedback from MCOs and other key stakeholders. Lewin will create separate summary briefings for BMS on each expansion effort and also will report findings to CMS. Lewin s experience and knowledge of the managed care program will provide assurance that upcoming expansion implementations will be successful despite the ending of the Mountain Health Choices program. Identifying new opportunities for expansion Beyond the currently planned expansions, the Bureau may wish to identify expansions to additional populations or the provision of Lewin may analyze the benefits of implementing additional benefits in the capitated benefit a pharmacy carve-in for managed care. With the package (e.g., pharmacy, non-emergency implementation of the new health reform medical transportation). Potential expansions legislation, pharmacy rebates are similar may be statewide or piloted on a regional basis and may be provided through a fullrisk whether or not pharmacy services are carved-out of the managed care program or included within MCO or other vendors. As with all it. Federal rebates now available for drugs provided through a managed care program, and expansion options, we will work with the there are clear benefits for carving pharmacy Bureau to prepare memoranda and other services into the managed care: documents to assist the Bureau in identifying and implementing expansions. Benefit coordination by one entity; Impact of health reform legislation The recently-passed health reform legislation will greatly expand the number of people who are eligible for Medicaid coverage. Lewin will use its detailed knowledge of the health reform legislation to analyze federal and state requirements to estimate the potential number of new members in Medicaid and the capacity of the current MCOs to handle additional members by the time the legislation is totally implemented in The state will need to be prepared early for the expansion of Medicaid and the managed care program, and will need to collaborate with current MCOs to promote program expansion. Improved beneficiary outcomes; and Management of the pharmacy benefit by the MCOs leading to cost savings. Lewin will provide analysis and assistance to BMS in determining how to proceed and the impact of the pharmacy carve-in on payment rates. Lewin will also analyze other potential service areas to carve-in to the managed care program including services for dual eligibles, non-emergency medical transportation, and long-term care. 74

77 There are many issues that need to be examined to expand the managed care program. The state must consider the capacity of MCOs to handle expansion and to enroll new members, how to provide coverage in rural areas, the potential for new MCOs to enter the state market, the outreach required to promote program growth, and the timelines and cost implications to expand the managed care program. Lewin also will examine the potential of using health exchanges as an alternative method to expand coverage. Implementation Lewin will summarize the findings of these reviews and analyses in a memorandum to the Bureau, outlining each option related to overall program goals and cost implications. The memorandum also will address administrative implications (e.g., coordination with other state programs, legal and regulatory constraints). Next, Lewin will prepare appropriate waiver, contracting, and MCO assessment materials. These will include the waiver amendment to enable mandatory enrollment into a single MCO in rural areas, Requests for Proposals or Medicaid MCO Provider Applications, addenda to the MCO Scope of Work to account for additional populations and/or benefits that may be included in the expansion, evaluation approaches and criteria, and contracts. Lewin staff will also assist the Bureau in completing the waiver approval process by participating in conference calls and meetings and preparing written responses to questions. We will then assist the Bureau in implementing the procurements by reviewing written submissions, conducting readiness reviews and site visits, evaluating networks and developing enrollment capacity estimates, preparing written summaries of proposal review findings and contracting recommendations, serving as technical advisors to evaluation committees, and supporting the Bureau in contract negotiations and the actual implementation of the expansion. Finally, Lewin will analyze and help the state develop the waivers, state plan amendments, RFPs, and MCO contract updates that will be needed to accommodate the expansion of the managed care program. The figure below summarizes the specific work steps required for one year to develop and then implement the program expansion. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed. 75

78 Figure 26. Task Sample Work Plan and Timetable for 2012 Scope of Work: Program Evaluation and Improvements (3.2.3) Through our work in knowledge transfer, comparative effectiveness research for public and private sector clients, and policy consulting for state governments, foundations, and associations, we have extensive experience surfacing best practices and translating findings into actionable recommendations. Recent research projects have included surveys and analyses of other state programs in innovative areas, such as programs that serve dual eligibles and other special populations, Medicaid managed care performance incentive strategies, eligibility simplifications, Medicaid managed care purchasing specifications, 1115 waivers, and rural options. For example, we conducted research on best practices in monitoring Medicaid managed care programs and developed a paper describing how leading states are using claims and encounter data and other data sources and methods to set capitation rates and monitor and report on access and quality. Lewin and its subcontractors also designed and implemented a study of the impact of Medicaid home and community-based (HCBS) programs and other Medicaid-funded long-term care (LTC) services on quality of life, quality of care, utilization, and cost. We have conducted a review of states approaches to monitoring EPSDT services for managed care enrollees; a review of MCO/Behavioral Health Organization (BHO) relationships; and a review of performance incentive approaches used by state Medicaid managed care programs. As a result, we are accustomed to working closely with state staff to develop research agendas and design effective and cost-efficient research approaches. As the Mountain Health Trust program has expanded and matured, the need for increasingly sophisticated oversight and monitoring has grown, and this need will amplify with the planned program expansions in As such, the objective of this task is to assist the Bureau in designing and implementing a Managed Care Improvement Plan (MCIP) that identifies program modifications through systematic, ongoing, and periodic program monitoring activities. The Lewin Group will use the Plan, Do, Study, Act (PDSA) continuous quality improvement model as a guiding principle in the development and implementation of West 76

79 Virginia s MCIP, including coordination with statewide efforts described below and alignment with the Bureau s QAPI strategy as detailed in Subtask Systematic Feedback Loops for Program Improvement Over time, program process changes may be necessary not only if monitoring activities suggest areas in need of improvement, but also if the Bureau chooses to make significant changes to MHT (e.g., program expansion), or as required to come into compliance with the ACA, other federal policies and regulations, or new access and quality standards. Lewin s strong understanding of West Virginia s current performance monitoring methods and data intricacies, coupled with our national knowledge of best practices, will enable us to design a comprehensive MCIP that leverages monitoring activities already in place to develop systematic feedback loops for continuous program improvement and to support reporting to CMS as needed. Figure 27. Managed Care Improvement Plan Plan, Do, Study, Act Model Act Determine what Changes are to be made Study Summarize what was learned Plan Change or test Do Carry out plan Lewin will craft the MCIP using a PDSA model, which involves systematic feedback of performance measurement and results into program design to continuously improve planning and program delivery. When measured results are analyzed and fed back into planning and decisionmaking, the Bureau can use the information about how MHT is performing to improve program design, deliver more effective services and better attain program goals. Lewin will begin by identifying all current performance monitoring activities that may be leveraged as part of a comprehensive MCIP. Program performance assessments included in the waiver, quarterly reports submitted by the MCOs, EQRO findings, and other monitoring activities are a few examples of performance data resources. The beneficiary survey, recently conducted by Lewin, is another immediate source of information on program performance. Lewin will also work closely with contractors such as the fiscal intermediary, the enrollment broker, and the EQRO to examine potential issues across each expansion in a systematic, recurring fashion. To better assist the Bureau with ongoing management of the MCOs performance, Lewin created a high-level quarterly executive dashboard in 2009 which trends key monitoring measures such as enrollment, PCP panel size, utilization, grievances, member/provider service functions, and Mountain Health Choices. The data is shared internally at the Bureau to brief executives on Mountain Health Trust and identify potential areas for improvement. 2 For more information on the PDSA model, see: Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: The MIT Press; 2000.] 77

80 In addition, Lewin will combine various elements from the sources above in the existing quarterly executive dashboard (sample analysis shown in the following figure) to provide the Bureau with a comprehensive view of implementation progress and performance. When brought together, these elements and others that we will identify in partnership with the Bureau will provide a rich set of data for ongoing program improvement efforts. In 2009, Lewin worked closely with the Bureau on the creation of a quarterly executive dashboard to help improve management and oversight of the MHT program by the Bureau. The dashboard graphically presents key monitoring measures collected by the State through the quarterly reports submitted by the MCOs and includes the most recent version of updates to the MCO quarterly reports. Data for measures is trended across quarters to identify any areas for concern or data reporting errors that require follow-up with the MCOs. An example of an issue that Lewin would follow-up on with an MCO includes: The average member hold time for MCO A significantly increased this quarter, from 5 seconds in Q1 to 56 seconds in Q2 o This hold time is near the reported hold time for Q (58 seconds) o Member calls for MCO A decreased by 4% in Q2 Provider hold times also increased for MCO A, from 7 seconds in Q1 to 66 seconds in Q2 Lewin is in the process of finalizing additional updates to the MCO quarterly reports to address the planned expansion in 2011, and these additional measures will be incorporated into the dashboard moving forward to ensure that the State can appropriate monitor access and utilization as new beneficiaries and services transition into managed care. Figure 28. Sample Utilization Measure from Quarterly Reporting Dashboard ER Visits per 1,000 Members, per year, by MCO 2,500 2,000 1,500 1, MCO A MCO B MCO C Q ,984 2,156 1,906 Q ,648 1,478 Q ,916 1,629 78

81 Collaboration with Statewide Efforts Another source for obtaining continuous feedback includes working with the West Virginia Health Improvement Institute (WVHII), which has taken on a key role in working with stakeholders to determine what the behavioral health integration model should look like. With the Bureau s impending behavioral health carve-in, it will be important for the Bureau to participate in WVHII workgroups to support transparent dialogue in identifying opportunities for collaboration and continuously soliciting input and feedback throughout the planning, implementation, and post-implementation processes. The Lewin Group will continue to assist the Bureau in taking an active role in coordinating with WVHII, which has been instrumental in helping to obtain stakeholder feedback related to the planned program expansion. If desired, Lewin can continue to work closely with WVHII postexpansion to continue to gain stakeholder feedback and maintain an open forum for problemsolving and issue resolution. The Lewin Group will continue to support the Bureau in taking advantage of the important opportunity to coordinate with this statewide initiative, helping to ensure a successful transition for all beneficiaries. Summary In developing a strong Managed Care Improvement Plan, The Lewin Group will enable the Bureau to efficiently identify and prioritize program improvement opportunities and implement the necessary program modifications in a timely manner, resulting in a more agile managed care program that meets the needs of its stakeholders and beneficiaries. Deliverables: Task Program Evaluation and Improvements The Lewin Group will prepare memoranda and issue papers within 45 days of request by the Bureau Lewin will provide the Bureau with annual summary reports of the MHT program within 45 days of the end of the year Recommend and develop processes that will improve the efficiency, effectiveness, and quality of Medicaid services in West Virginia. ( ) The objective of this task is to assist the Bureau in providing information and developing processes that will improve the efficiency, effectiveness, and quality of Medicaid services in West Virginia. To do so, Lewin will work with the Bureau to develop a yearly Managed Care Improvement Plan. This Managed Care Improvement Plan (MCIP) will consider opportunities for clinical quality improvement, as well as opportunities to promote the effectiveness and efficiency of program administration. We have worked with numerous other states on quality improvement initiatives. For example, Lewin recently worked with the State of Missouri to conduct a substantive review of the Medicaid program and developed recommendations on how the State can achieve short-term Medicaid savings, conducted detailed assessments on achieving longer-term program savings, and evaluated options to improve the effectiveness and efficiency of the Medicaid program. 79

82 Lewin will support the Bureau in improving delivery of health care to Medicaid beneficiaries. Lewin will collaborate with the Bureau and its contractors to identify areas for quality improvement and program efficiency using a systematic feedback approach, including assessment of the utilization of benefits packages and health outcome status. We will examine data such as beneficiary complaints, quarterly reports, network access, CMS feedback, and biannual beneficiary survey results. Lewin will also continue to hold and participate in quarterly calls with the EQRO regarding performance monitoring. Through the MCIP, The Lewin Group will make recommendations and implement new processes to both improve efficiency and effectiveness and enable the Bureau to provide higher quality services to its beneficiaries. Overview of approach Oversight and monitoring activities are intended to identify program areas in need of improvement to ensure that enrollees have access to quality health care services. Critical to this is the administration of the Medicaid program. Lewin will work with the Bureau to develop a MCIP to: 1. Identify areas for program process changes through ongoing program management activities, encounter data analysis, review of MCO and PAAS provider performance, EQRO reports, and network analysis. 2. Prioritize program process changes, in partnership with the Bureau, to establish when and how program improvements will be approached and whether cost impacts are likely. 3. Develop individual Managed Care Improvement Plans, including the desired outcome, work steps, timeline, and organization/staff responsible (see Figure 29 for an example of a component MCIP). 4. Review and report on the success of improvement strategies and identify lessons learned for future improvements. Lewin works closely with the State s EQRO on an ongoing basis to coordinate monitoring activities to ensure that MCOs are delivering quality services and providing appropriate access to Medicaid beneficiaries. We facilitate monthly calls between Lewin, the Bureau, and the EQRO to discuss potential monitoring concerns and areas for potential partnership. For example, we recently facilitated a teleconference to discuss ideas for MCO performance improvement projects and other outcomes measures in light of the upcoming expansion of the managed care program. We also solicit the EQRO s feedback on the bi-annual waiver renewal and review the EQRO s annual report. Recommending Program Process Changes Lewin anticipates several areas where the Bureau will need to consider program modifications, as we have described throughout our proposal, including processes to more efficiently gauge quality and access. Certainly, we will continue to work with the Bureau to identify additional opportunities for quality improvement and overall program efficiency. For example, as part of the Conditions of Approval for the State s 1915(b) waiver renewal, CMS is requiring the Bureau to submit a variety of reports on a monthly basis to demonstrate successful expansion of the MHT program. Lewin is working closely with the Bureau to revise reports submitted by the MCOs on a quarterly basis to include the information requested by CMS. We are building on the existing MHT quarterly reports to maximize efficiency and minimize burden on State and 80

83 MCO staff. Lewin is also coordinating with other State vendors, such as the enrollment broker and EQRO, to ensure that monitoring efforts capture all of CMS requirements and are reported in a coordinated effort to CMS. After the expansion, Lewin will closely monitor provider networks, utilization of services, and grievances and appeals. In addition, we can assist the Bureau in conducting a survey of a sample of TANF and new SSI beneficiaries regarding their experiences and access related to the MHT program, behavioral health, and children s dental services. This will allow the Bureau to identify any issues and resolve them expeditiously. In addition, in 2011, we will also administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to a sample of all beneficiaries enrolled in the Medicaid program to assess beneficiary satisfaction and identify areas for improvement Subsequent external quality reviews and evaluations may also be modified to become more performance-based. While the MCOs have performed well on external quality reviews for the past several years, the EQRO audits focus largely on process and documentation and less on results. The Bureau has already required MCOs to conduct more comprehensive quality assurance and performance improvement projects. To accomplish these modifications, Lewin will work with the Bureau to identify and develop recommendations for monitoring the outcomes of those projects. Moving toward a system of performance-based monitoring will ensure that MCOs are effectively implementing the quality strategies detailed in their quality assurance and performance improvement plans. This will become increasingly important as the new regulations in the ACA begin to take effect, including significant expansion in covered lives, an area where Lewin can support the Bureau in planning as discussed in Task below. Another area that Lewin anticipates the State needing to improve efficiency and consider program modifications is overall beneficiary access to health care services. Given the upcoming behavioral health and children s dental expansion, as well as the addition of new SSI beneficiaries to the MHT program (as well as the impacts of the ACA in 2014), the Bureau will need to develop new and innovative mechanisms for monitoring access to care in a timely manner. This may involve responding quickly to CMS requests for ad hoc network analysis upon the expansion or proactively monitoring MCO provider networks on a monthly basis for up to 90 days after implementation to ensure continued beneficiary access. The development of a provider database to facilitate the collection of provider network data from the MCOs for determining network adequacy will help the Bureau to proactively monitor access and respond to any concerns that may arise that prevent appropriate access to services. Appropriately and quickly assessing network adequacy data will also enable the Bureau to approve new MCOs for participation in the MHT program and allow program expansions to go-live more quickly. Inconsistencies associated with the provider information submitted by MCOs have historically created a strain on Bureau resources as data elements lack standardization, not only between MCOs, but at times even within an MCO s own data. The development of a provider database through which MCOs would be required to submit provider data in a standard format for network adequacy review would enable the Bureau to more efficiently complete assessments and reduce the strain on resources. 81

84 To assist with the development of the provider database and analysis of specific opportunities for program modifications such as MCO reporting requirements, Lewin would work closely with the Bureau to develop a more detailed MCIP at the beginning of the new contract period. For the purposes of our proposal response, we have developed a sample MCIP addressing the development of provider database below. Figure 29. Sample Managed Care Improvement Plan Provider Database Development and Implementation of an MCO Provider Database Goal: Collect complete and standardize MCO provider network data efficiently. Action Steps Outcomes Timeframe 1. Review current data being collected 2. Identify data fields for provider database 3. Review proposed data fields with BMS and MCOs; update as needed 4. Determine where database will be hosted Comprehensive list of all current data elements collected Prioritization of data elements into standardized fields (e.g., provider name, provider address, Medicaid panel restrictions, provider speciality) Feedback is incorporated back into design Necessary hosting agreements complete Month one Month one Month two Month two 5. Beta test database Test results complete Month three 6. Revise fields and functionality as needed 7. Launch provider database for MCO use 8. Provide technical assistance to MCOs Database design is updated Database goes live Technical assistance is provided to MCOs in uploading required data Month three Month four Month five 9. Survey MCOs for feedback Month seven 10. Update and revise as needed Months four through eight Implementation and deliverables The Managed Care Improvement Plan will provide the Bureau with the capacity to make necessary program modifications efficiently and effectively, which has particular importance given expansion planning and the impacts of ACA. As part of the MCIP and for other issues, The Lewin Group will submit memoranda and issue papers regarding options for program modifications, including MCIP performance information, cost estimates, and recommendations, to the Bureau within 45 days of request and will submit implementation plans and schedules in a timely manner once specific options have been chosen. Lewin will submit annual summary reports of the MHT program within 45 days of the end of the calendar year. The report will cover the preceding fiscal year and provide an overview of the MHT program, highlighting program successes. Specifically, the report will 82

85 describe MHT program enrollment, services available to beneficiaries, cost savings resulting from the program, performance on key quality indicators, and descriptions of MCO outreach and disease management programs, as well as improvements identified and accomplished through the MCIP. A sample of the annual report currently produced by Lewin for the Bureau is included in the figure below. 83

86 Figure 30. Sample Annual Report 84

87 The figure below summarizes the specific work steps required for one year to develop and then implement the Managed Care Improvement Plan and annual report. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed. Figure 31. Task Sample Work Plan and Timetable for 2011 Analyze baseline utilization and cost data ( ) Monitoring the performance of the MCO, PAAS, and FFS programs is an important activity in times of tight Medicaid budgets. BMS must make sure that health care services are being provided efficiently in each of its programs in order to manage Medicaid expenditures. An equally important activity is ensuring that members are receiving high quality care in order to detect and treat diseases at an early stage and slow disease progression. To perform these monitoring functions, BMS needs performance reports that can be used to compare expenditures between these three programs and evaluate the quality of care rendered by the providers participating in each program. Deliverables: Task Analyze Baseline Utilization and Cost Data The Lewin Group will provide the Bureau with quarterly performance reports and strategies to improve the services. To accomplish this task, all available claim, encounter, and eligibility data will be loaded into a relational database that allows for a virtually unlimited number of analysis possibilities. Eligibility is at the heart of the database structure. Services (claims and encounters) are linked to eligibility by a composite key of patient identifier and date of service. To achieve the link, the patient identifier is matched and the date of service is compared to eligibility spans. By including date of service and eligibility span matching in the join logic, a more precise denominator is available for rate and cost of service analysis. Services are linked to a provider object using a similar technique. Because of this approach, as new attributes become available, 85

88 they can be logically linked to the appropriate entity. For example, as disease states are selected, these attributes would be added to the eligibility table. This would then allow for analysis of the disease state by any of the specified attributes (e.g., age, sex, and eligibility category) as well as by service (e.g., diagnosis, procedures, place of service), provider (e.g., specialty, type, location), utilization (e.g., encounters, units of service, days of therapy) and cost (e.g., charge and reimbursement). Using the database, a comprehensive baseline of the population will be developed. Comparisons of the cost effectiveness of the three programs must account for differences in the demographic mix of the populations being served in each program. Lewin will create reports profiling the cost and utilization of health care services in each program. Separate reports will be created by age, sex, and eligibility category. Separate reports will also be created using the demographic groups that are used in the rate setting process to capture variations in member mix between the programs. Lewin will also create profiles that can be used to evaluate the quality of care provided in the MCO, PAAS, and FFS programs. Quality of care can be assessed using a variety of measures including HEDIS measures, care coordination measures, and member outcomes. While clinical data to measure member outcomes is not readily available, proxies can be developed using emergency room visits and hospital admission rates. Reporting based on HEDIS measures, care coordination measures, and member outcomes will be driven by the relational database. Using these profiles, the program will be monitored on an ongoing basis and potential issues will be communicated to BMS. In addition to monitoring program performance, the database can be used to model the impact of strategies designed to correct deficiencies and other issues. Implementation As part of the AHRQ Medicaid Care Management Learning Network, Lewin assisted Wyoming in selecting measures to evaluate performance of its health management program. Specifically, Lewin provided technical assistance related to selecting objectives, defining measures (e.g., population), identifying data sources (e.g., claims data, self-reported, chart audit), and setting targets for improvement. To leverage the internal resources of BMS, analytic views of the database will be made available to designated BMS staff and other individuals/entities. Analysts and end users can be trained in the use of the web-based OLAP tools described earlier in this section. By having access to the analysis database, BMS will be able to conduct analyses internally as it sees fit. The figure below summarizes the specific work steps required for one year, occurring quarterly. This task will repeat annually through the end of the contract. 86

89 Figure 32. Task Sample Work Plan and Timetable for 2012 Scope of Work: Federal Regulatory Compliance (3.2.4) Task focuses on supporting the Bureau for Medical Services and Mountain Health Trust in its continued compliance with the evolving environment of federal regulatory requirements. As discussed in greater detail in Section of this proposal, Lewin has assisted the Bureau for Medical Services (and numerous other states) since 1995 in working with the federal government to develop and implement program strategies, contracting mechanisms, and financing arrangements that comply with all applicable laws, policies, and guidance. Our team is especially qualified to provide expertise, policy analysis, strategic guidance, and knowledge to CMS that is grounded in our many years of experience in Medicaid programs throughout the country. We provide up-to-date expertise on all current health care issues and are capable of quickly processing the implications of new policy changes and legislation. We have worked with states and the federal government to understand and respond to every major piece of federal legislation affecting the Medicaid and CHIP programs over the past 15 years, including the Balanced Budget Act of 1997 (BBA), Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Deficit Reduction Act of 2005 (DRA), American Recovery and Reinvestment Act of 2009 (ARRA), and the Children s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). We have in-depth knowledge of Medicaid and CHIP laws, regulation, and policies, a strong understanding of how states and the federal government relate to one another in the Medicaid and CHIP context, and familiarity with existing evaluations, state guidance materials including State Medicaid Director and State Health Officer letters, regulations and other policy related documents. Our in-depth health and human services program experience enables us to help governments understand their constituents needs. We provide options to meet those needs within the regulatory, political, and fiscal realities faced by our state and local government clients and analyze the impact on individuals, program management, and budgets. In addition to working directly with states, we frequently work with federal agencies that regulate or oversee the federal-state partnership including the CMS Center for Medicaid and State Operations, CMS Office of Financial Management, and CMS Office of Research, Development, and Information, as well as the HHS Assistant Secretary for Planning and Evaluation, the Substance Abuse and 87

90 Mental Health Services Administration, the Health Resources and Services Administration, and the U.S. Congress. The following is a high level Gantt chart outlining our work on each of the major subtasks associated with the ongoing compliance with federal regulatory requirements. Figure 33. Task Work Plan and Timetable for Develop a comprehensive quality assessment and performance improvement strategy and implementation plan ( ) The objective of this task is to support the Bureau for Medical Services in developing a coordinated, comprehensive, and pro-active approach to drive quality assurance and performance improvement program-wide by utilizing creative initiatives, monitoring, assessment, and outcome-based performance improvement to meet federal standards set forth in the Medicaid managed care regulations. The result of this task will be a Quality Assessment and Performance Improvement (QAPI) strategy and implementation plan that meets the federal requirement that state Medicaid managed care programs have a plan for assessing and improving the quality of managed care services provided by the MCO. This plan must also ensure compliance with standards established by the state agency with regular, periodic reviews to evaluate the effectiveness of the QAPI strategy. Measuring performance and tracking results through a QAPI will play an important role in the Medicaid managed care program expansion planning and implementation in new service areas, as well as preparing the Bureau for important changes associated with health reform. Deliverables: Task Develop a QAPI Strategy and Implementation Plan The Lewin Group will complete a comprehensive Quality Assessment and Performance Improvement (QAPI) strategy and implementation plan yearly, in accordance with all federal requirements Overview of approach Lewin will begin by reviewing all data used for current program monitoring and analysis activities such as encounter data, quarterly reports, HEDIS measures, and on site reviews conducted by the EQRO. Coupled with Lewin s long-standing, in-depth knowledge of West Virginia s monitoring activities, this review will provide important baseline information creating a foundation for a robust QAPI. The Lewin Group will engage key partners and stakeholders, including enrollees through the Medical Services Fund Advisory Council, the EQRO, and the enrollment broker, to obtain input, define objectives, identify targets, and gather recommendations on approaches for improving the quality of services on an annual basis. Through these activities, Lewin will take the lead in coordinating quality improvement efforts 88

91 across West Virginia s vendors, obtaining a greater understanding of the enrollment broker and EQRO s quality and access monitoring activities. In drafting the QAPI strategy and plan, Lewin will also leverage working relationships with MCOs to solicit their input in identifying additional areas for quality improvement and design. We will implement a formal process to address any identified quality and access issues as they arise, replacing the current ad hoc approach. This will include using a log to track issues identified by each contractor to support timely recognition of systematic quality and access issues that can be addressed in a more efficient and effective manner. A system-wide tracking log will also serve as a record for how the Bureau has historically managed various types of quality issues, providing an important feedback loop to support QAPI improvement over time, and will be an integral part of the strategy and implementation plan that is developed. Based on our findings, we will prepare a clear and concise written document describing how the Bureau monitors, assesses, and tracks quality and outcomes, including QAPI strategy requirements and implementation activities for MHT. Lewin will work to restructure the existing QAPI to more closely align with CMS State Quality Strategy Toolkit for State Medicaid and Children s Health Insurance Agencies, reflecting a more comprehensive strategy document. Mechanisms to track targets over time to demonstrate the success of quality improvement efforts to CMS will be an integral component of the plan, in addition to other monitoring activities that the Bureau may want to consider in order to strengthen program oversight and comply with waiver requirements. We will prepare a memorandum outlining our recommendations, which will be commensurate with the Bureau s overall approach to administering and monitoring the program and will incorporate discussion of resource issues that should be considered. Lewin s proposed QAPI strategy will fully meet requirements set forth in federal Medicaid managed care regulations. We will then meet with Bureau staff to review the recommended QAPI strategy, discuss any outstanding issues, and work with the Bureau to select a final strategy. Lewin will leverage our existing strong working relationships with CMS to solicit their guidance as we revise the plan. Lewin staff will update the approach and prepare a final comprehensive written QAPI strategy. Following review of the QAPI by the Bureau, CMS regional office staff, and others, Lewin will prepare a corresponding implementation plan. To the extent feasible, the elements of the Bureau QAPI will complement the components of the MCO s internal quality assurance activities. Implementation Lewin updated the Bureau s QAPI Strategy and Implementation Plan in April 2010 to include objectives and targets. The State will use them to measures its quality improvement over the next two years. Lewin assisted the Bureau in identifying objectives related to child and adult access to preventive health services, prenatal and postpartum care, and chronic care. Subsequently, Lewin worked closely with the EQRO to select specific targets for related HEDIS measures. After the State expands the managed care benefits package to include behavioral health and children s dental services, Lewin will evaluate the data to establish baseline measurements and benchmarks to define quantifiable measures related to these areas. The Lewin Group will complete the comprehensive quality assessment and performance improvement strategy and implementation plan yearly and in accordance with all federal 89

92 regulatory requirements. The figure below summarizes the specific work steps required for one year to identify options and recommendations, help the Bureau select a strategy, and develop an implementation plan. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed. Figure 34. Task Sample Work Plan and Timetable for 2012 Perform tasks necessary to monitor the federal waiver and prepare required reports and waiver application ( ) The objectives of this subtask are to monitor the federal waiver to ensure compliance with current and future federal regulations and guidelines and to prepare required reports and waiver applications demonstrating West Virginia continued compliance with all of CMS requirements. While the next waiver renewal is not due until 2012, Lewin recognizes that if the planned expansion is not implemented in 2011, the waiver will need to be updated. Lewin will maintain a collaborative relationship with CMS to continue to keep abreast of the changing federal regulatory monitoring requirements, which include enrollment and disenrollment, processing of grievance and appeals, violations subject to sanction, and violations of conditions for federal financial participation. In addition, Lewin will monitor quality, enrollee satisfaction, and service utilization, as well as other areas the Bureau might identify, to ensure not only compliance with federal Medicaid managed care regulations, but also that enrollees are receiving services commensurate with the Bureau s standards. Furthermore, findings of monitoring activities will facilitate identification of areas for ongoing program improvement. Lewin will work with the Bureau to identify effective monitoring strategies, as also discussed above, including the development and administration of surveys, such as the MHT enrollee satisfaction survey currently being fielded and analyzed by Lewin, the review of MCO report and data submission, on-site reviews, and other special analyses requested by the Bureau. Sample Monitoring Data Collection Tools: Beneficiary and provider surveys Disenrollment requests Grievances and appeals Enrollee hotlines Geographic mapping Network adequacy Systems performance review Performance improvement projects HEDIS measures Utilization reviews 90

93 Overview of approach To assist the Bureau with maintaining the MHT waiver, Lewin will first work to update the existing monitoring plan based on the waiver and new requirements. Monitoring activities will be designed to provide the Bureau with timely information regarding the program s compliance with federal laws, regulations, and policies, as well as the performance of MHT vendors. Lewin will track any changes to federal monitoring requirements and CMS guidance on a bi-weekly basis and will update the Bureau and the monitoring plan as necessary. Once the monitoring plan is in place, Lewin will work with the Bureau to develop and update appropriate monitoring data collection tools, such as beneficiary and provider surveys much like those Lewin has already administered on behalf of the Bureau. Lewin staff are prepared to develop other types of monitoring tools as requested by the Bureau. Lewin will also review MCO reports and data, such as quarterly reports and utilization data, submitted to the Bureau. The purpose of monitoring this information is to ensure continued MCO compliance with Overall findings from the 2009 MHT Beneficiary survey administered by Lewin include: The MCOs performed well on the child survey, improving from their 2007 results and meeting or exceeding the majority of the 2009 national Medicaid benchmarks Child and Adult PAAS results were generally positive and showed improvements compared to their 2007 results While adult MCO results were generally consistent with the 2007 results, they fell short of the 2009 national Medicaid benchmarks and were consistently lower than the adult PAAS ratings Children with Special Health Care Needs enrolled in PAAS and the MCOs experienced lower satisfaction with PAAS/their health plan and more difficulties in accessing needed care compared to children without special health care needs federal and state requirements, identify areas of particular achievement or concern, and review them for inaccuracies. Lewin will notify the Bureau of its review findings and will provide expedited notification if findings are of concern. Understanding the trends and experiences of MHT MCOs will enable the Bureau to swiftly address any concerns that may arise. Lewin will then analyze all data collected based on the CMS waiver preprint, with an additional eye on highlighting West Virginia s successes in ensuring access to services and quality. We will update the waiver renewal text based on programmatic changes, federal regulations, state initiatives, and any adjustments to the Bureau s program monitoring approach. Lewin will engage other contractors as necessary to review sections and provide guidance on displaying data in a favorable manner. We will also obtain the CMS-64 and other statewide reports to ensure financial projections tie together. Leveraging the positive working relationships that Lewin has developed with key CMS contacts over the years, we will support the Bureau in working with CMS on any major program changes, such as modifications to eligibility groups, prior to submitting waiver renewals. The Lewin Group will conduct analyses of access, quality of care, and cost-effectiveness as requested by the Bureau. Lewin will take into account the Bureau s goals when developing strategies and protocols for these special, ad hoc analyses and, to the extent possible, special analyses will be conducted using existing tools for monitoring and collecting data to minimize additional burden. Lewin will prepare memos upon request. Studies of related issue areas from other states will be reviewed to facilitate the efficient development of strategies and protocols. 91

94 The Bureau has stated publicly that it will conduct surveys or focus groups of SSI and TANF beneficiaries to identify any issues after expansion of the MHT program. As part of our efforts to monitor the federal waiver and assist with the program expansion, Lewin conduct up to four focus groups comprised of eight to twelve participants each year to assess beneficiary concerns and perceptions of the MHT program. As appropriate, the focus groups may include SSI and TANF beneficiaries, or adults who will be newly eligible for Medicaid in The focus groups will provide invaluable feedback on the program and demonstrate to stakeholders that beneficiaries have opportunities to provide input on the MHT program. While it is not possible to predict the total number of special analyses that will be conducted during the upcoming contract period, for purposes of budgeting, Lewin has assumed based on previous experience with the Bureau a total of three special analyses will be conducted. Lewin will prepare required reports to present findings from monitoring activities and submit drafts for the Bureau s review. If necessary, Lewin will convene conference calls to discuss report findings or to answer any questions. Lewin will work with the Bureau to prepare reports and waiver applications that will be submitted to CMS in a timely fashion and will be available to discuss findings with or answer questions from CMS staff. The Lewin Group s extensive repository of programmatic data will support swift and complete responses to any CMS inquiries. Implementation The Lewin Group will submit results of monitoring activities related to the waiver to the Bureau 120 days before the expiration of the current waiver. Lewin will also conduct ad hoc monitoring activities within 60 days of request by the Bureau. The figure below summarizes the specific work steps required for This task will repeat for the 2014 waiver renewal process. Figure 35. Task Sample Work Plan and Timetable for 2012 Renewal Prepare necessary waivers or state plan amendments for ongoing program and/or changes to the program ( ) The objective of this task is to support the Bureau in preparation of the necessary components of the 1915(b) renewal waiver application or any state plan amendments, including ongoing collaboration and communication with CMS to ensure effective completion. 92

95 Deliverables: Task Prepare Necessary Waivers of State Plan Amendments Submit results of monitoring activities related to the waiver to the Bureau 120 days before current waiver expiration in 2012 and then again in 2014 Conduct ad hoc monitoring activities within 60 days of request by the Bureau. Overview of approach The Lewin Group will begin by reviewing other state approaches and best practices for securing federal authority for a program West Virginia currently uses a combination of the modification, such as inclusion of a specific 1915(b) waiver and the 1937 SPA to mandatorily eligibility category. Based on our review enroll Medicaid beneficiaries in managed care and Lewin s extensive knowledge of programs. During the last waiver renewal, Lewin federal regulatory approaches, we will identified that West Virginia may also use the recommend the optimal federal authority 1932(a) SPA authority to mandatorily enroll most of the same populations currently enrolled in the for planned program changes. The Lewin PAAS and managed care program without the use Group will assist the Bureau for Medical of 1915(b) or 1115 waiver authority. Lewin Services with the preparation of the prepared a summary summarizing the various necessary renewal waiver application or regulatory authorities available for mandatory state plan amendment. The most recent enrollment of Medicaid beneficiaries. As a result, waiver renewal format requires the State to Lewin is conducting additional research to identify the optimal federal regulatory authority allowing provide a summary of all monitoring the State to preserve elements of personal activities and document results and responsibility for Medicaid beneficiaries, prepare findings. These waiver monitoring for increased program enrollment as a result of activities are described in greater detail in health reform legislation, and decrease the Subtask As the first step in administrative resources required for securing preparing to develop the waiver renewal federal approval for the program. application, Lewin will gather relevant information on waiver monitoring activities, including information from the Bureau s other subcontractors. We will ensure that the Bureau is able to document and demonstrate compliance with all the terms and conditions of the current waiver. Lewin will then review any changes to the waiver application preprint and provide recommendations to the Bureau regarding appropriate responses to any substantive changes that may be required. Lewin will draft the waiver renewal application using the CMS preprint format and provide decision memoranda for Bureau staff where necessary. For example, Lewin prepared memoranda to the Bureau regarding the coverage of children with special health care needs and TANF caretaker relatives in the State s 1915(b) waiver. Based on guidance from the Bureau, Lewin revised the waiver renewal application to ensure compliance with relevant federal regulations. Following discussions with Bureau staff, we will submit a complete draft of the waiver renewal to the Bureau for review and comment. We would suggest that this draft be shared with CMS regional office staff at this point so that the Bureau and Lewin staff can incorporate CMS s informal feedback before submitting the final waiver renewal application. 93

96 One of the most important and onerous aspects of preparing a waiver application is the research and analysis associated with the cost-effectiveness portion of the waiver. The costeffectiveness assessment required as part of the capitation rate-setting task (Subtask ) will be structured in such a way as to make the final preparation of the cost-effectiveness portion of the waiver application a simple matter. It will entail including the final tables from the analysis stage as supporting documentation for the waiver application and drafting a description of the analytic approach. Lewin s unique knowledge of the capitation rates developed for the Bureau will also enable a more efficient completion of the cost effectiveness section. Upcoming MCO service area expansions will likely necessitate that the Bureau submit waiver amendments or state plan amendments, Lewin will prepare the necessary documentation and cost-effectiveness analysis and work with the Bureau to submit the amendment request to CMS, modify the request if necessary, and obtain approval of the change. The Lewin Group has assisted the Bureau in obtaining interim waiver amendments before and is familiar with the process of working with CMS to modify or add to existing waivers. In our experience, a well-prepared waiver application that features clear and concise descriptions of the program, accompanied by documentation reflecting a thoughtful and comprehensive financial analysis of the program, will reduce the number of questions CMS will have for the Bureau. Nonetheless, there will undoubtedly be some questions and requests for clarifications from CMS staff. Lewin will assist the Bureau in any way necessary to respond quickly to requests from CMS regional and central offices and the Office of Management and Budget (OMB). Lewin will draft responses to CMS questions and participate in meetings or conference calls with the Bureau and federal officials as needed. The Lewin Group will perform any additional research or analysis that the Bureau needs to fully respond to CMS or OMB requests. Lewin has a long history of successfully working with CMS and OMB on behalf of states. Implementation The Lewin Group will submit results of monitoring activities related to the waiver to the Bureau 120 days before the expiration of the current waiver. Waivers and/or state plan amendments will be submitted within 60 days of request by the Bureau. Lewin will also conduct ad hoc monitoring activities within 60 days of request by the Bureau. The figure below summarizes the specific work steps required for the 2012 renewal process. This task will repeat for the 2014 waiver renewal process. 94

97 Figure 36. Task Sample Work Plan and Timetable for 2012 Scope of Work: Additional Services (3.2.5) As discussed in Section of this proposal, The Lewin Group has expertise in a wide variety of areas related to health policy and the development and implementation of innovative strategies to manage public sector health programs. During the past 15 years, Lewin has assisted the Bureau with numerous tasks across the spectrum of health care issues. Many of our engagements require in-depth policy analyses on all aspects of Medicaid programs. In addition to the variety of topic-specific Medicaid and CHIP policy projects described elsewhere, Lewin has conducted comprehensive reviews of several state Medicaid programs. For the State of Missouri, Lewin recently provided recommendations on how the State can achieve short-term Medicaid savings, conducting detailed assessments on achieving longer-term program savings, and evaluating options to improve the effectiveness and efficiency of the Medicaid program. Lewin is also developing supporting materials for the Medicaid agency to present to stakeholders and policy makers. For the North Carolina General Assembly, Lewin completed an independent review of the process by which benefits are added to Medicaid; how well the benefits are managed; and how the benefit package and approach compare to other state Medicaid programs and to private insurers in North Carolina. Lewin also worked with its subcontractor, the West Virginia Medical Institute, to assess the utilization review procedures employed within the North Carolina Medicaid program to evaluate whether the benefits are authorized and approved according to the stated benefit menu and prevailing clinical standards. In addition to our broad, comprehensive program assessments, we have conducted many indepth policy analyses in a variety of areas. For example: In a project jointly funded by the Center for Healthcare Strategies and the Arizona Health Care Cost Containment System (AHCCCS), Lewin assisted the State of Arizona in making a policy decision regarding whether pharmacy should continue to be included in the MCO capitation program or carved out. The Lewin Group recently assisted the Minnesota Department of Human Services Disability Services Division in developing recommendations for its Personal Care Assistant 95

98 (PCA) Program. Recommendations were made on specific components of the PCA program such as service authorization, quality of care, health and safety, compensation, living arrangements, and improvements in program integrity. Lewin assisted the City of San Francisco in preparing for the implementation of a program to expand health services to the City's uninsured population, called Healthy San Francisco. We estimated impacts on enrollment, utilization, clinic capacity staffing needs, and financial implications. Lewin is assisting CMS with an initiative that promotes value-driven health care and which aims to improve health care quality, information and cost-effectiveness for consumers. Specifically, Lewin is supporting efforts to develop and test a set of provider-based imaging efficiency measures and is also working with CMS to train providers on how to use imaging measures, which will be part of a pay-for-reporting initiative under the outpatient prospective payment system. We will continue to be flexible in working with the Bureau in our approach and staffing to meet the evolving needs of the Bureau and State of West Virginia. The following is a high level Gantt chart outlining our work on each of the major subtasks associated with the providing the Bureau with additional services. Figure 37. Task Work Plan and Timetable for Production of data and ad hoc requests for data analysis services to BMS ( ) Lewin realizes that administering a program as complex as Medicaid managed care gives rise to unexpected changes which can impact both program design and capitation rates, particularly in upcoming years with the passage of health reform under the ACA and the corresponding Medicaid expansion. These changes require quick response to ad hoc data analyses to estimate the impact to the managed care program. Lewin has the institutional knowledge of MHT and the depth and breadth of experience to respond to any request that BMS may need. We will work with BMS to identify value-added services based on the immense knowledge we have of West Virginia s Medicaid program and associated data. For the capitation rate setting task, Lewin has produced detailed databases that link claims and eligibility data for all Medicaid beneficiaries and have created further databases that segment the managed care eligible 96

99 population and services. Using these databases, Lewin can provide rapid but complete analyses of time-sensitive issues. The recent expansion of Medicaid under health reform will bring a large proportion of the uninsured population into Medicaid. As the State lacks Medicaid experience for this expansion population, BMS will need to utilize other data sources in order to estimate the size and cost of this expansion. Lewin is a nationally-recognized leader in health reform modeling and has developed national and state-level estimates regarding the size of the Medicaid expansion population. Lewin will be able to leverage our simulation model and knowledge of health reform to provide BMS data support in regard to understanding the size and cost of the expansion population. During recent years, Lewin has worked with state agencies in more than half of the nation s states on tasks related to rate setting, actuarial analyses, Medicaid managed care, and program evaluation. Within these broad areas, we have assisted states in setting capitation rates, evaluating cost effectiveness, reviewing provider accessibility, evaluating federal compliance, and researching health care trends and best practices. In addition to working with states, our staff has experience working across different CMS offices, giving us a deep understanding of their policy objectives for transparency, accountability, and program integrity. We are closely following developments in federal policy that may impact Medicaid programs and can help states consider the impact these developments will have on their programs. Our clients request and receive rapid but complete analyses of time-sensitive proposals. We are accustomed to developing research frameworks that include objectives, timelines, methodologies, and deliverables that meet clients needs and then conducting the research in a timely and thorough fashion. Implementation In response to a GAO report citing that children in West Virginia were not receiving necessary EPSDT services, the Bureau requested that Lewin conduct an analysis of EPSDT measures reported to CMS and related HEDIS measures to determine whether children were receiving EPSDT services. Lewin compared performance of the MCO and FFS programs on these measures and found that the MCOs generally outperformed the FFS program on measures of EPSDT participation. The MCOs have also demonstrated steady improvement on a number of measures related to children s preventive services over the last several years. The Lewin Group will support the Bureau in meeting all ad hoc data requests. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. Figure 38. Task Sample Work Plan and Timetable for

100 Provide data analysis support on reimbursement issues and modeling upon request from BMS ( ) Support for reimbursement analyses will be provided at whatever level BMS desires. The services that can be provided include, but are not limited to, simulation models, reimbursement relativity analysis, development of custom systems, evaluation of third party solutions, and reimbursement system development research. Because of the existence of the claim and encounter databases from our rate setting work, impact estimates based upon program experience (as opposed to industry standard probability distributions and rate manuals) can be developed quickly. These estimates will be more accurate because the models will reflect the consumption of services (in terms of case-mix, utilization, risk prevalence, and unit cost) by the West Virginia Medicaid population. Lewin has analyzed and modeled a variety of reimbursement issues for Medicaid programs. For the California Medicaid (Medi-Cal) program, Lewin compared Medi-Cal FFS outpatient provider fee schedule payment amounts with Medicare fee schedule payments amounts for 2009 and estimated the impact of setting minimum and maximum Medi-Cal fees based on a percentage of the comparable Medicare fees. We estimated the additional cost of increasing payment rates for each procedure to a minimum level of equivalent Medicare payment (80 and 100 percent) and the potential savings from reducing payment rates for higher priced procedures to a maximum level of equivalent Medicare payment (80 and 100 percent) for selected provider types. Additionally, we have estimated the impact of the changes in the Medicaid drug rebate provisions for numerous states, including the potential benefits and differences between a carve-in and carve-out model now that the drug rebates have been equalized. Our team includes experts who have implemented a variety of risk-sharing or diagnostic risk adjustment methodologies for several states, so we are fully versed in the advantages and disadvantages of each method should BMS want to introduce risk-adjusted payment rates for the managed care program. Implementation Lewin has performed periodic analyses for the State regarding the inclusion of a pharmacy carvein for the MHT program. With the recent extension of Medicaid drug rebates to Medicaid managed care under ACA, West Virginia can now leverage the efficiencies of managed care without sacrificing the substantial federal rebates it currently receives. We project that the improved management of the pharmacy benefit (e.g., higher generic fill rate, lower utilization) under managed care could create savings up to $3 to $4 million in State dollars. The Lewin Group will provide data analysis support on reimbursement issues and modeling upon request by the Bureau. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. 98

101 Figure 39. Task Sample Work Plan and Timetable for Provide data analysis support to assist with budgetary and legislative issues upon request from BMS ( ) For the MHT annual report, Lewin The breadth of experience and expertise of The Lewin has calculated estimates of the Group in modeling and evaluating changes due to health cost savings from the managed reform, Medicaid eligibility and program expansion, care program. The cost savings are based on a review of per federal and state legislative mandates, and cost member, per month medical costs containment initiatives gives us a unique understanding in a select number of counties of Medicaid programs across states and the ability to before and after managed care analyze a wide variety of budgetary and legislative issues. implementation. Based on our As mentioned previously, Lewin has extensive experience analysis, we estimate that total costs under the managed care modeling the impacts of various health reform options program were over $5 million less and we can build upon our simulation models to help the that if the population had state understand the fiscal impacts of a variety of remained in FFS. provisions under the health reform legislation. Additionally, Lewin recently worked with the State of Missouri to conduct a substantive review of its Medicaid program and developed recommendations on how the State can achieve shortterm Medicaid savings, conducted detailed assessments on achieving longer-term program savings, and evaluated options to improve the effectiveness and efficiency of the Medicaid program. Lewin developed a series of reports as well as supporting materials, and Lewin s analyses were used by Missouri s policymakers to craft the State Fiscal Year 2011 budget as well as guide decisions about future Medicaid program design and operations. We are prepared to assist BMS with budgetary and legislative assignments working in conjunction with BMS staff. Once our level of involvement is determined, we will work cooperatively with BMS (as well as entities that BMS designates) in completing the requested analyses. Implementation The Lewin Group will provide data analysis support to assist with budgetary and legislative issues upon request by the Bureau. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. 99

102 Figure 40. Task Sample Work Plan and Timetable for Create encounter data files as needed for other contracted Vendors working with the MHT, MHC, and PAAS programs ( ) Lewin will provide encounter data and FFS data extracts for other contracted Vendors working with the MHT, MHC, and PAAS programs as requested by BMS. As previously mentioned, we have already developed cooperative relationships with the existing vendors (e.g., participating MCOs, the fiscal intermediary, the EQRO) and can quickly engage the respective staff within each of these organizations to develop an appropriate data request and extract in a timely fashion. Lewin s vast experience with the MCO encounter data and FFS data through the rate setting process allows us to work with the other vendors to identify the minimum level of detail required for their data request and develop custom extracts that meet their analytic needs. For example, during the most recent SSI rate setting process, the MCOs requested detailed information regarding the SSI beneficiaries at the individual level. Lewin developed a deidentified individual-level file that summarized a person s claims history at the diagnostic and procedural (CPT, revenue code, DRG) level. This de-identified summary file provided the MCOs with detailed information regarding the health condition and service utilization patterns of the SSI population without providing any information that would allow the MCOs to identify actual individuals or favorably select particular beneficiaries for enrollment. Data extracts can be constructed in a variety of electronic formats (i.e., delimited text, fixed text, SAS, SPSS, Oracle, SQLserver, Access, etc) to meet the vendor s needs. Lewin will make technical assistance available to vendors on any issues regarding the provided data extracts through written and electronic communication, conference calls, and face-to-face meetings at the Bureau s direction. Implementation The Lewin Group will create encounter data files as needed for other contracted vendors and provide necessary technical assistance. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. 100

103 Figure 41. Task Sample Work Plan and Timetable for Conduct research and recommend approaches in key areas ( ) The main objective of this task is to conduct research and recommend approaches in key areas of interest that will assist the Bureau in improving the efficiency, effectiveness, and quality of Medicaid services. Research areas, which will be determined by the Bureau or the legislature, may include, but are not limited to: chronic care/disease management, profiles of specific disease states, pharmacy, eligibility and coverage, quality improvement, improved rural health care delivery, and provider networks. Lewin will also continuously monitor best practices in the field so that we can provide innovative recommendations to the Bureau to stay ahead of the curve in lessons learned. Our research and work in this task area will enable the Bureau to draw from the work and experience of other states and other health care related organizations to improve overall program performance, enhance beneficiary access, and develop innovative approaches to maximize efficiency and increase quality. Deliverables: Task Conduct Research and Recommend Approaches in Key Areas Respond to research requests within 30 days of request by the Bureau and provide implementation support as requested Overview of Approach Upon request from the Bureau to perform a research task, Lewin will convene a conference call with the Bureau and/or other staff, as appropriate, to discuss the request in detail. During this call, participants will discuss the research objectives, potential uses of research findings by the Bureau or legislature, anticipated research methods, and timeframes for completing the research. Lewin will then develop a draft work plan to accomplish the research objective(s) with recommended research strategies and methods, including rationale for those approaches, clearly defined research products, concrete milestones for research Lewin assisted the State of New York in collecting and analyzing information on Medicaid primary care case management (PCCM) programs for consideration in exploring a future PCCM program as an alternative to full-risk managed care in rural areas. State and Lewin staff identified five states, for which Lewin researched and reviewed state-specific information and conducted interviews to understand current PCCM and MCO program; implementation strategies, including associated DM programs; PCCM program design strategies, including program administration and characteristics; comparisons of PCCM and MCO program outcomes; and lessons learned. Based on this information, Lewin prepared a memo to summarize key components of the five state programs, particularly around common PCCM program design strategies, with a focus on program outcomes, including DM and pay-for-performance (P4P) strategies, innovative features, and lessons learned regarding PCCM programs. 101

104 activities, and assigned Lewin staff with the most experience and expertise to complete the research request. Lewin will share and discuss the draft work plan with the Bureau and/or legislative staff, and will revise it as necessary. Lewin has significant experience and expertise with several research strategies that would very effectively meet the diverse research needs of the Bureau and state legislature, including surveys, literature searches, stakeholder interviews, focus groups, and analysis of utilization, expenditure, and claims data. Research tools and protocols will be revised based on the requestors input. As a component of developing protocols and tools, Lewin will identify potential data sources, both maintained by the Bureau and from outside sources, and their validity. Lewin also has a vast library of resources and work products developed in projects for other states on various Medicaid topics as well as an extensive collection of data and knowledge staff, which Lewin may leverage to meet West Virginia s needs with minimal cost to the Bureau. Lewin will then conduct the research and will provide the Bureau and/or legislative staff periodic updates on the progress of research activities. Once completed, Lewin will prepare an informed, objective report, memo or written deliverable of research findings and submit it to the Bureau for review. Reports will provide an overview of the research activities, describe key findings, identify critical issues and key decisions, and describe available alternatives. Lewin will provide a complete assessment of advantages, disadvantages, and possible consequences of all recommended program modifications or actions, as needed. If requested, Lewin will review the report with Bureau and legislative staffs, answer questions, and obtain feedback. The report will be revised as necessary. Implementation The Lewin Group will respond to research requests within 30 days. The Lewin Group will be ready to Potential Dimensions for Data Analysis: Cost effectiveness Impact on access Impact on quality Operational challenges Appropriate federal authority Provider participation and satisfaction MCO willingness Internal capacity provide implementation support as requested by the Bureau. The figure below summarizes the specific work steps required for one research request. This task will repeat through the end of the contract as needed. Figure 42. Task Sample Work Plan and Timetable for One Research Request 102

105 Provide policy impact analyses and support ( ) The objective of Task is to assist the Bureau with ongoing intelligence regarding policy changes and the potential impact on West Virginia s Medicaid services. Medicaid policy development involves numerous stakeholders with competing interests and points of view, and it is vital that the Bureau be well-informed of the potential impacts of policy changes including detailed information and analysis on all available policy options. Lewin is well positioned to provide objective policy analysis for the West Virginia Medicaid managed care program. Our project staff are health policy experts with many years of experience working with Medicaid managed care plans in several states, bringing an extensive knowledge of other states Medicaid program best practices. Several Lewin project team members have over five years of experience working directly with the West Virginia Medicaid program, providing Lewin with a unique understanding of the dynamics of the Bureau and MHT program and the feasibility of program changes. On For the Commonwealth Fund, members of our team developed estimates of the savings that could be achieved by adopting several changes to the health care financing and delivery system. These included an analysis of changes in payment methodologies designed to create new provider incentives to improve quality while reducing costs and an analysis of public health initiatives, funding for health information technology, and comparative effective research. several previous occasions, Lewin has worked with Medicaid stakeholders in West Virginia to implement large and controversial policy changes, such as the implementation of Mountain Health Choices. Lewin also has developed working relationships with other Bureau contractors that can be leveraged to obtain information and support for new policy initiatives. Deliverables: Task Provide policy impact analyses and support On an as-needed basis, Lewin will submit materials, brief the Bureau staff, and develop memoranda or other documentation. Lewin will respond to the Bureau requests for policy impact analysis within 45 days and is prepared to provide implementation support as requested. Overview of approach Lewin will begin its analysis by identifying the operational data needed to develop and analyze the new policy initiative. Lewin will assess the impact of a policy initiative on the Medicaid budget and the parties impacted by the new policy. We will work with the Bureau and other contractors to develop implementation strategies and timelines and will draft the necessary documents to secure federal approval for the new policy initiative, if necessary. Lewin will deliver an extensive and well-researched policy analysis deliverable. Depending on the scope of the policy change, Lewin can convene focus groups with affected stakeholders such as patient advocacy groups, provider associations, and other state agencies. To support the Bureau in publicizing policy changes, Lewin will develop an effective and comprehensive strategy to communicate the new policy initiative to stakeholders and the media including developing talking points or a public letter to providers or Medicaid beneficiaries. 103

106 Lewin staff will conduct an initial review of any new or modified federal regulations and/or policy guidance and prepare a briefing memorandum for Bureau staff summarizing the regulations and/or guidance and key areas of interest to the Bureau and the MCOs. Lewin will make additional presentations of the briefing to Bureau staff, the MCOs, or others as needed, in conjunction with other on-site meetings or activities where possible (e.g., quarterly Task Force meetings). Lewin staff will then use input from the Bureau and others as appropriate to develop and analyze options for any required program modifications and recommendations for their adoption and implementation. Lewin will prepare necessary documentation for implementation, such as waivers, and prepare memoranda to assist the Bureau in designing implementing strategies. The Lewin Group will prepare materials and analyses on an as-needed basis according to timeframes agreed upon by the Bureau. Implementation While the details of each step may vary depending on the policy analysis required, the figure below summarizes the specific work steps required for one research request. This task will repeat through the end of the contract as needed. We are prepared to assist with a variety of implementation tasks, including developing contractor specifications, creating work plans, conducting detailed actuarial analyses, and monitoring implementation outcomes. Figure 43. Task Sample Work Plan and Timetable for 2012 Review, recommend, update, develop, and assist in the implementation of reimbursement schedules consistent with federal policies ( ) Lewin will review, recommend, update, develop, and assist in the implementation of reimbursement schedules as requested by BMS. As part of the rate setting task and larger policy support tasks, Lewin will monitor federal activity to identify the provisions within the ACA and other federal legislation and regulations that will affect Medicaid reimbursement policies, such as the mandate to pay primary care providers at 100 percent of Medicare rates for 2013 and 2014, or provide alternative payment structures that BMS may want to explore, such as bundled payments for episodes of care. To accomplish this, Lewin is prepared to develop necessary State Plan Amendments and respond to CMS requests. In addition, we will incorporate stakeholder input by surveying enrolled providers and present recommendations to relevant parties. 104

107 Lewin has assisted numerous states in estimating the impacts of changes in reimbursement structure, including changes to existing payment systems and the introduction of new payment methods such as pay for performance and bundled payments. Lewin worked with the Kentucky Hospital Association to assess the Medicare-type DRG system recently implemented by the Medicaid Department and compare the adequacy of the Medicaid payment rates for Kentucky hospitals relative to payment levels in neighboring states. We evaluated the equity of payment rates across hospitals in the state under the new Medicaid DRG system and recommended modifications to the payment system to make the payment system more equitable across the states hospitals. Implementation Lewin has worked with the New York State (NYS) Health Foundation to develop a roadmap to cost containment for New York, with practical approaches to reducing health care costs, including scenarios involving the promotion of accountable care organizations (ACO) and medical homes, hospital pay-for-performance, bundled payments for episodes of care, and rebalancing of long-term care. The Lewin Group will review, recommend, update, develop, and assist in the implementation reimbursement schedules consistent with federal policies. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. Figure 44. Task Sample Work Plan and Timetable for Provide additional services to comply with externally driven changes to BMS programs and requirements, including any state or federal laws, rules, and regulations ( ) Lewin has a dedicated staff person responsible for tracking and performing impact analysis on all federal regulations and grant opportunities surrounding the ACA. This staff person has access to a wide range of federal resources that provide same-day health reform updates and tracks this information using an internal Lewin database to assist staff in better understanding reform implications for our clients. The objective of Task is to support the Bureau in complying with externally driven changes to programs and requirements, including any state or federal laws, rules, and regulations. On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (ACA) into law. This legislation will have important, longstanding consequences for the Bureau, its Medicaid program, and beneficiaries as components of the law are implemented over the coming years. To that end, The Lewin Group will support the Bureau in strategically addressing the potential impact of the ACA and other state or federal requirements as they may arise so that the MHT program 105

108 continues to be in full compliance with all regulations and requirements, while providing quality care to its beneficiaries. To complete this task, Lewin will analyze and assess key health reform components that are likely to impact the Bureau and its stakeholders, track and evaluate several health-reform related funding opportunities, and provide analytic and modeling support for the Bureau. A number of the ACA provisions have implications for the Bureau s planning, such as the development of state-based health benefit exchanges and eligibility screening for Medicaid and provider payment rate changes. Increased demand for services will also be a factor as the new law expands Medicaid eligibility to a national floor of 133% of poverty, which could lead to an estimated 26% increase in enrollment in the first year and a more than 40% estimated increase in enrollment by 2019 for West Virginia. This increased demand for services will have important implications for the Bureau s planning for future procurement and MCO coverage. Lewin has many years of experience performing actuarial and micro-simulation analyses of the cost and coverage impacts of program expansion and health reform proposals and has recently developed national and state-level estimates regarding the number and demographic distribution of people in families who become covered by Medicaid. We will leverage Lewin s considerable experience in modeling the impacts of health reform to develop estimates of the size and costs of the Medicaid expansion population that will need to be considered for the capitation rates in place for For example, Lewin s data and modeling expertise can be leveraged to conduct a county-by-county assessment of the geographic distribution of newly covered lives to support West Virginia s MHT planning activities. As described in Section 4.1.7, Lewin has the depth and breadth of experience needed in addressing and planning for state and federal changes in law, rules, and regulations. For example, The Lewin Group recently completed a project with the NYS Health Foundation to address opportunities for containing health care costs throughout the New York State health care system. The goal of the engagement was to identify up to 10 specific cost containment scenarios that could be modeled by Lewin to determine the potential for future cost containment and health care system improvement. The project was modeled after the highly successful Bending the Curve national analysis conducted by Lewin and The Commonwealth Fund and was the first-of-its kind state-level endeavor. To support the Bureau s continued compliance with the evolving state and federal regulations, such as those related to the ACA, Lewin will provide additional services, including implementation support, as needed and identified by the Bureau. Services may include assistance with policy development impact analysis, requirements definition and testing activities, and support in developing proposals for health reform-related planning and implementation funding opportunities. Lewin will also continuously monitor best practices in the field so that we can provide innovative recommendations to the Bureau to stay ahead of the curve in lessons learned in managing externally driven changes such as the ACA. Lewin s long history working with West Virginia provides an important benefit in our ability to highlight and prioritize key areas that will be of particular interest and importance to the Bureau and its stakeholders and enable us to make valuable and actionable recommendations that best meet West Virginia s needs. 106

109 Implementation The Lewin Group will provide additional services to comply with externally driven changes to BMS programs and requirements. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed. Figure 45. Task Sample Work Plan and Timetable for The below high level Gantt chart illustrates the timelines for the activities required and planned milestones throughout the course of this project. 107

110 Figure 46. Sample Project Work Plan and Timetable for

111 109