Making the ACA Work for Clients & Communities

Transcription

1 + Making the ACA Work for Clients & Communities September 18, 2013 Barbara DiPietro Director of Policy National HCH Council

2 + Agenda for the Day Part 1: Outreach & Enrollment National Goals & Issues Barbara DiPietro SAMHSA Perspectives & Resources David Dickinson CA Primary Care Association Beth Malinowski Insured the Uninsured Project Kandis Driscoll Discussion Part 2: Delivery of Care & Access National Goals & Issues Barbara DiPietro Medicaid Managed Care & California s Bridge to Reform Ilia Rolon Anthony Rose Communities of Color & Other Subpopulations: Orange County Asian and Pacific Islander Community Alliance, Inc. Mary Ann Foo Discussion Health Care & Housing Are Human Rights

3 + Care Delivery Models Renewed focus on coordination and integration of services, working as teams Ultimate goals: Improve access Increase quality Decrease cost Integrated care Access Services Funding Evidence-based practices Data Health Care & Housing Are Human Rights

4 + Models of Care Patient-centered medical homes, CCEs, ACOs, etc. Integrated, team-based care (mental health, addictions, medical) Internal and/or external Focus on quality and outcomes, not quantity of procedures Electronic health records Coordinated care across multiple venues Collect data, eliminate disparities Coordinated care entities/accountable care organizations, etc. Health care viewed in a wider perspective Renewed attention to social determinants of health

5 + Identify Key Service Needs Primary care Oral health Addictions Mental health Outreach Specialty care Housing (full continuum) Medical respite care Employment Transportation

6 + Identify Key Relationships Local hospital Discharge planning sources Referral sources Jail administrators Political leaders Shelter and housing providers All health care providers Business community Emergency responders police & fire Continuum of Care Local health officer/social services director

7 + Match Resources to Needs Who provides the services in each area of identified need, and how will health care reform impact them? How will the state of the current economy impact any of these service providers? What are the greatest service gaps? What is your role in filling them? What collaborations/partnerships are possible? How are needs being communicated to state/county policymakers?

8 + Workforce Development $1.5 billion for National Health Service Corps (over 5 years) Scholarships, loan repayments Primary care physicians, family nurse practitioners, certified nurse midwives, physician assistants, dentists, dental hygienists, and certain mental health clinicians Also impacted by budget cuts (FY13 = $285M) Health Center-based residency programs (e.g., teaching health centers ) Increases to Medicaid provider payments: , raise to Medicare rate level

9 + Workforce Challenges 7,200 new primary care providers needed (2.5% of the current supply) Geographic disparities in level of disruption 44 million (14%) live in areas where 5%+ increase in demand 7 million (2%) live in areas where 10%+ increase in demand Source: Huang and Finegold. (March 2013.) Seven Million Americans Live in Areas Where Demand For Primary Care May Exceed Supply by More than 10%. Health Affairs. 96% physician practices accepting new patients 31% unwilling to accept Medicaid Increases in reimbursements help Source: Decker, S. (August 2012). In 2011, Nearly One-Third of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help. Health Affairs 31 (8):

10 + State Level Actions Part I Consider Medicaid options Health Homes Waivers to target benefit packages to specific groups Billable providers Create incentives for quality (not quantity) of care Re-assess scope of practice laws, data sharing limitations Actively participate in system of change, check/prevent abuses Include housing as a health care intervention in state plans (track homeless measures in health system)

11 + State Level Actions Part II Maximize relationships between Medicaid directors and health centers (& other health providers) Link objectives and goals to larger community health initiatives Facilitate data availability and exchange Negotiate rates using broad range of factors Social determinants of health Health status Quality outcomes Facilitate new partnerships where possible

12 + State Level Actions Part III Ensuring sufficient providers of primary care & behavioral health services New opportunities for criminal justice population Staffing case managers & benefits coordinators Training (and revitalizing) burned out workforce EBPs, new approaches to care Treating intense needs Absorbing local gaps in care Recruiting/retaining best skills Adapting clinical curricula to include social determinants of health, working with homeless population

13 + State Level Actions Part IV Budget for case managers and benefit coordinators at CBOs Allow funding to be flexible Not diagnosis-specific Provides for practical items & incentives Use peer-to-peer models, community health workers Provide personal assistance/enabling services Enrollment/navigation Transportation, translation, etc. Ensure Medicaid application works for special populations Homeless, returning citizens, those with disabilities Enrollment in health plan simultaneous to eligibility screening

14 + State Level Actions Part V Reduce Medicaid administrative barriers for providers and patients Suspend, not terminate, benefits during institutionalization Minimize authorizations, reimbursement time, empanelment delays & related complexities Reduce/eliminate co-pays and other out of pocket costs for services & prescriptions Maximize EHR to share patient info across service sectors Ensure resources to fill gaps Ongoing need for block grants, Ryan White, PATH, etc. Ensure services for those remaining uninsured Continue to pursue eligibility expansions

15 + OPPORTUNITIES RISKS Improved individual & public health Reduced personal bankruptcy & poverty Increased individual & family stability Increased employment & productivity Reduced recidivism to criminal justice Preventing & ending homelessness Fail to reach newly eligible (lack of outreach) Continued barriers to enrollment Inability to find provider(s) Difficulty engaging in care Ongoing housing instability risks engagement in care Poor transition to exchange jeopardizes gains in health, income Ongoing homelessness & poor health

16 Medi-Cal Expansion Ilia Rolon, MPH Director, Strategic Development 16

17 New Landscape in 2014 Affordable Care Act brings two new health care coverage options to increase access for about 44 million nationally and more than 250,000 in Orange County Health Benefit Exchange Medicaid expansion 17

18 Medi-Cal Expansion Overview Medi-Cal (Medicaid) will be expanded to include individuals between the ages of 19 and 65 with incomes up to 138% of the federal poverty level (FPL) effective January 1, 2014 Approximately $15,000 for an individual and $32,000 for a family of four Impact to CalOptima is significant Brings about change in our overall population, adding more than 56,000 new members Adds a new demographic to CalOptima s membership mix, which has traditionally been women, children and seniors 18

19 Medi-Cal Expansion Population In Orange County, the Medi-Cal expansion population falls into two broad categories: Low-Income Health Program (LIHP) members County s safety net program for the uninsured today, known as the Medical Services Initiative (MSI) Currently provides medical services to individuals with incomes at or below 200% FPL Approximately 46,000 will be eligible for Medi-Cal expansion Will transition to CalOptima on January 1, 2014 Newly eligible people Low-income childless adults who are not elderly or disabled 19

20 Medi-Cal Before and After ACA Before Affordable Care Act Today, individuals must meet financial criteria (income level, asset test) AND also be categorically eligible: Families with children Pregnancy Disability Seniors Children in foster care People with specific diseases (i.e., breast cancer and HIV) After Affordable Care Act Higher income threshold No longer need to be categorically eligible, although categories will remain to qualify others Elimination of asset test 20

21 Medi-Cal Benefit Package ACA defines certain categories of benefits as Essential Health Benefits Essential Health Benefits Ambulatory patient services (doctor visits) Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care 21

22 Income Guidelines for ACA Programs IF YOU ARE AN INDIVIDUAL making less than $15,415 YOU QUALIFY FOR Medi-Cal making $15,415 to $27,935 Help in paying out-of-pocket costs like deductibles and co-pays. You also qualify for a tax credit that will lower the amount of your monthly premium making $27,935 to $44,680 A tax credit that will lower the amount of your monthly premium making over $44,680 A FAMILY OF FOUR making less than $31,810 No government assistance but are eligible to buy health insurance through Covered California Medi-Cal making $31,810 to $57,635 Help in paying out-of-pocket costs like deductibles and co-pays. You also qualify for a tax credit that will lower the amount of your monthly premium making $57,635 to $92,200 A tax credit that will lower the amount of your monthly premium making over $92,200 No government assistance but are eligible to buy health insurance through Covered California 22

23 MSI Program Overview Anthony Rose Administrator, Medical Services Initiative Orange County Health Care Agency 23

24 About the MSI Program Mandated under California s Welfare and Institutions Code Serves as the county s safety-net program for the uninsured Expanded under 1115 Medicaid Waiver Low-Income Health Plan (LIHP) November 2010 to December 2013 Approximately $50 million each year to continue primary and preventive care, and expand membership for ACA implementation in January

25 Who Qualifies for MSI Now? Ages 19 to 64 Income at or below 200% Federal Poverty Level $1,915/month for individual U.S. citizen or legal permanent resident Orange County resident Not eligible for Medi-Cal 25

26 LIHP Population Demographics Diverse population Slight majority of females (52.7%) More than half are age 50+ Slight majority of Asian/Pacific Islanders, with Latinos as the next largest group English is preferred language among members who stated a preference (66.7%) More complex needs than current Medi-Cal population Half have a chronic disease, with hypertension as the top condition Nearly 5% are homeless Approximately 500 have HIV 26

27 MSI Membership Trends Steady growth from 2010 to present 27

28 MSI Transition Member Income: 0% to 138% of FPL Will be transferred to Medi-Cal expansion under CalOptima 45,650* MSI members, or 83% of existing group MSI began to pre-enroll members into Medi-Cal expansion starting May 1, 2013 DHCS to notify members of their eligibility in October 2013 Member Income: 138.1% to 200% of FPL Eligible to purchase subsidized coverage from Covered California 9,350* MSI members, or 17% of existing group Includes legal residents of less than 5 years, regardless of income level Open enrollment period: October 1, 2013, to March 31, 2014 *Membership figures as of July

29 MSI Post Transition MSI to resume its role as the county s safety net program Serving people with incomes of 138.1% to 200% of FPL who have not enrolled in a plan through Covered California Will need urgent or emergent condition to enroll Reduced scope of benefits and smaller network of providers Co-pays similar to the Bronze Plans in Covered California All enrollees will be encouraged to apply for coverage during Covered California s open enrollment period Smaller network of providers Estimated annual enrollment less than 6,000 29

30 Newly Eligible Ilia Rolon Director, Strategic Development 30

31 31 Medi-Cal Expansion Population Mix

32 Newly Eligible Population Eligibility determinations remain with the Social Services Agency CalOptima is collaborating with the community on outreach and education Covered OC Town Halls CalOptima Community Alliances Forum (September 18) CalOptima Informational Series (September 27) 32

33 Expected Enrollment Patterns Young and healthy newly eligible are one of the most difficult populations to reach May not be motivated to enroll due to good health status May not be aware that they qualify for free or low-cost coverage Many young adults under age 26 can be covered under their parents plan CalOptima expects about 8,600 newly eligible to enroll in FY14 33

34 CalOptima Preparations Ilia Rolon, MPH Director, Strategic Development 34

35 Preparations Gearing up for increased volume Assessing resources Budget Staffing Workspace Participating with the state Developing communications strategy Preparing for the transition of LIHP members to Medi-Cal 35

36 LIHP Transition Planning MSI to CalOptima transition planning began in 2011 Analysis of MSI and CalOptima networks Over 98% of MSI primary care providers are CalOptima providers CalOptima actively recruiting MSI providers not already affiliated with Medi-Cal 36

37 LIHP Transition Overview State-mandated and state-led transition process Department of Health Care Services is lead agency Monthly DHCS teleconferences with LIHP plans Draft transition plan released in August Transition requirements Continuity of care Member/PCP assignment Special populations requiring additional assistance Beneficiaries receiving mental health services Ryan White beneficiaries Homeless beneficiaries Beneficiaries with open treatment authorizations 37

38 LIHP Transition Timeline October 2013 CalOptima prepares systems, develops policies and procedures November 2013 CalOptima receives utilization management data LIHP members begin to receive DHCS notices December 2013 By December 30, CalOptima receives enrollment data from DHCS CalOptima receives PCP companion files for continuity of care January 2014 CalOptima sends welcome packet to new Medi-Cal members by January 10 LIHP still enrolling through the end of the year 38

39 LIHP Impact on CalOptima Provider Network Capacity Strong likelihood of continuity of care Increased demand for behavioral health services due to needs of population and new legislation Increased Volume Call center, claims, utilization management and case management New member packets, provider directories and standard communications Fiscal Considerations Full-scope benefits Rate for expansion population pending 39

40 Benefits and Contracting Benefits for Medi-Cal expansion population Requires 10 essential benefits May be different than existing Medi-Cal population Excludes Long-Term Services and Supports, unless the state gets permission from CMS to apply the asset test Contracting is CalOptima Medi-Cal CalOptima is not taking over MSI contracts Provider outreach efforts Will provide education and information 40

41 Upcoming Events CalOptima Informational Series: Affordable Care Act and Its Impact on Vulnerable Populations in OC Friday, September 27, Noon to 2:30 p.m. 41

42 MAKING THE ACA WORK FOR CLIENTS AND COMMUNITIES LESSONS LEARNED RELATED TO THE DELIVERY OF CARE AND ACCESS TO SERVICES Mary Anne Foo, MPH Orange County Asian and Pacific Islander Community Alliance

43 Challenges Accessing Care for Diverse Communities As a small business owner I m scared that I will lose my business because this new insurance will cost too much. I m going to reduce my employees time and the number of employees so I don t have to pay for this. I m very excited I can now have health insurance but I don t know where to go, who to choose, and how to find the right hospital or clinic. I want to choose the clinic and hospital near me, but they don t have anyone that speaks my language or have anything in my language. I want to go to a provider or place that looks like me, speaks like me, and understands me. Even if I get the insurance I ll still go through emergency because I will be seen faster instead of waiting weeks to see a doctor.

44 Partnering with community organizations and providers Ethnic Chambers of Commerce can reach out to all the small business owners Ethnic media and community leadership can give tours of the facility, introduce them to your leadership, help them understand how your health system will be improving access to care and addressing an increase in patients Can partner with community organizations who can help on patient navigation medical interpreting, making appointments, navigation through the health system, improving patient-provider communications, building trust for the health care system will lead to improved patient compliance and increase HEDIS scores for managed care institutions and cost effectiveness Can partner with community organizations, churches, temples, school districts to reach homeless community members to have services in the community or more accessible

45 Partnering with community organizations and providers Language and cultural competency work with a small group of community organizations and leaders on translations and cultural competency Community competency work with community resources to understand how to increase access in the health care system for special populations Color code or use visuals for community members with higher illiteracy Work with community organizations and leaders on helping patients to understand all the paperwork, HIPAA, patient rights and responsibilities, etc. Work with community partners and leaders in teams or through Advisory Committees tumor board, going on rounds, trainings for providers and administrators, ACOs, CCEs, case management, etc.

46 Translations Don t send to Asia to be done Don t use google translate Don t do literal word for word translations Do check for regional, generational, and gender differences When is the best time to have relations (sex) with you?