MEDICAID RE-DESIGN IN NORTH CAROLINA: THE FUTURE IS NOW

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1 MEDICAID RE-DESIGN IN NORTH CAROLINA: THE FUTURE IS NOW 1 LANIER CANSLER, PRESIDENT TARA LARSON, SENIOR HEALTHCARE POLICY SPECIALIST Cansler Collaborative Resources, Inc. Session Agenda 2 Identify strategies for determining provider service costs in a changing reimbursement market Describe the key elements in evaluating the potential of mergers, acquisitions and exploring the public/private partnerships Discuss the administrative and clinical changes and the competencies required for implementation of Medicaid redesign in NC Discuss ways in which the Program Design can incorporate Medicaid funded services as an entitlement with State funded services that are not an entitlement So what is the Vision? Managed Care? Block Granting? To use data? IT Systems talking to each other? To do whole person care, all in an environment that has questions and uncertainty? How do all the dots fit together? How do I prepare? 3 1

2 Sustainability thru Managed Care Increased Demand for Services and Supports 4 Whole Person Care Medicaid Transformation 1115 Waiver Information Monitor the Medicaid Transformation website Medicaid Medical Care Advisory Committee (MCAC) 5 Considerations Legislative Approval Standard Plans Tailored Plans Carolina Cares Timelines Cansler Collaborative Resources, Inc. 6 Standard Plans, BH I/DD Tailored Plans and Specialized Foster Care Plan Pending State legislative authorization, North Carolina intends to permit CPs and PLEs to develop and offer two types of products: standard plans and tailored plans. Standard Plans will serve most Medicaid enrollees, including adults and children. They will provide integrated physical health, behavioral health and pharmacy services at the launch of North Carolina s Medicaid managed care program. BH I/DD Tailored Plans to serve special populations with unique health care needs. North Carolina plans to launch a BH I/DD tailored plan no later than two years after the launch of Medicaid managed care. The plan will provide integrated physical health, behavioral health, I/DD, TBI and pharmacy services to enrollees with serious mental illness, serious emotional disturbance, substance use disorder, I/DD and/or TBI needs. Specialized Plan for Children in Foster Care will be for children in county-operated foster care, children in adoptive placements and former foster youth who aged out of care up to age 26. The PHP that offers the specialized plan for children in foster care must meet a set of requirements ensuring robust care management and medication management specifically for this vulnerable population. 2

3 Impacts to the Behavioral Health and Behavioral Health/IDD System 7 Don t think about just as specialty system any longer Individuals can be served in different options of coverage As such, providers will want to be part of all the different options or at least make informed decisions of which payers to contract with FFS, SP and Tailored Plans IMD exemption Medicaid Design and other Influencing Factors 8 Data Analytics Health Information Exchange Providers and practices will need to be able to share data in more real time Based on feeds from various sources in order to address whole person care Pay for Performance or Value Based Purchasing Whole Person Care and Data 9 This is the most exciting part and the real difference data can make \ Care Coordination Platforms Timeliness of support or intervention Looking at all the venues of services and supports Ability to inform the discussion with the individual based upon information and not rely on verbal reporting More wholistic approach to resources available or not available to support the individual More efficient use of time Establishing behavioral health health homes with targeted resources both financial and subject expertise 3

4 Robust Health Homes and Provider Networks Care Management IT platform Care Management Functions defined Greater accountability Expected outcomes Increased timeliness to service and supports - access standards Quality Standards and performance measures Highly Trained Work Force 10 It s Not Your Daddy s Oldsmobile 11 Simply billing a unit of service may no longer work Revenue will likely be impacted by outcomes achieved Multiple approaches toward reimbursement for services will likely be employed Success in negotiating an approach to sustainable reimbursement will require documenting the cost of providing a service Managed Care and Data Needs 12 In traditional Fee for Service or MC FFS State established fee schedules May or may not have used providers to do cost modeling of rates or cost reports Access to data through paid claims In Managed Care Able to have different rates and incentive different or various outcomes IMPORTANT to know the TRUE cost of service, not what the Fee Schedule rate is or what you get reimbursed at A position of knowledge in negotiating rates or alternative payment structures Case rates, episode of care, etc. Different rates for same services in different geography 4

5 Elements of Cost 13 You must identify the elements of costs in order to establish an accounting system that provides the ability to track and properly allocate costs Clinical and Financial models must be aligned Direct Service Costs The cost of specific items that are directly related to providing a unit of service and incurred solely as a result of providing the service Direct Allocable Service Costs The cost of specific items that are required to provide a service, but may be incurred whether the unit of service is delivered or not Administrative and Other Indirect Costs The cost of coordinating and supporting the delivery of services Allocating Costs 14 Once the elements of cost have been identified, and the ability to properly track those costs has been established, then determining the actual cost of providing a unit of service is possible Direct Service Costs are specific and direct Direct Allocable Service Costs are allocated over the units of service impacted Administrative Costs and Other Indirect Costs are allocated over all units of service Wanna Get Married? 15 Being alone may make it difficult to cope in this changing world Extra costs will be incurred and expectations will rise in meeting the increasing complexities of the healthcare system New Focus on Comprehensive Care Determining and tracking costs Evaluating and Documenting Outcomes Implementing EHR and HIE 5

6 Choosing a Partner 16 Understanding the benefits and detriments How would this partner enhance your position within the healthcare system? Important to have a solid understanding of the potential partner financial, operational, reputation, beneficial relationships, and governance Is there a shared vision or mission? Exploring Options 17 Considering the Pros and Cons of various options Alliance / Joint Venture Acquisition Merger In Summary 18 The Goals of reform are solid. The path is there, with construction and some really sharpe curves There are plenty of opportunities to provide feedback Time to adopt strategies and to make business decisions accordingly 6

7 QUESTIONS? 19 Cansler Collaborative Resources, Inc. Lanier Cansler (919) Tara Larson (919)