THE CHANGING MEDICAID HEALTH CARE ENVIRONMENT

Transcription

1 THE CHANGING MEDICAID HEALTH CARE ENVIRONMENT Finger Lakes Parent Network November 28, 2016 John Lee, MBA

2 Topics Why the State is making changes to the Medicaid Program Managed Care 101 Initiatives underway at the State to improve outcomes tied to the Medicaid Program: Transformation of Medicaid Managed Care Program for Adults with Behavioral Health needs Transformation of the Medicaid Managed Care Program for Children Health Homes: adults and children Delivery System Reform Incentive Payment (DSRIP) Program Value Based Payments How these initiatives are linked Provider considerations

3 Setting the Stage: Why changes are being made to the Medicaid Program

4 GOVERNOR S VISION FOR MEDICAID REFORM It is of compelling public importance that the State conduct a fundamental restructuring of its Medicaid program to achieve measurable improvement in health outcomes, sustainable cost control and a more efficient administrative structure. Governor Andrew Cuomo, January 5, 2011 EXPECTED OUTCOMES: Improved health status Improved quality of care Reduced costs Care Management for All..

5 Medicaid Expenditures: FFY 2013 $54.5 billion

6 What did the NYS Medicaid Managed Care Program look like through June 30, 2016?

7 The Publicly Funded Behavioral Health System Medicaid Recipient in Managed Care Services Not Covered by Medicaid Managed Care Recipients Not Covered by Medicaid Managed Care Medicaid Managed Care Organization Medicaid Carve Out Services Fee For Service High Risk/High Need Medicaid Recipients Medicaid Managed Care Services Non-Medicaid Funded Services Who is accountable for the whole person? 7

8 BHO Phase I post-discharge outcomes for Adult Mental Health discharges, CY 2012 Medicaid claims data

9 Integrated Care: In BHO Phase I, how often did behavioral health inpatient providers identify general medical conditions requiring follow-up, and did they arrange aftercare appointments? No physical health condition identified: 64% Physical health condition identified: 36% No physical health appointment made: 82% Physical health appointment made: 18% Based upon 56,167 statewide behavioral health community discharges (all service types) January 2012 June 2013 Data submitted by BHO

10 There are a lot of other remaining system challenges

11 Managed Care 101

12 Managed Care: Definition An integrated system that manages health services for an enrolled population rather than simply providing or paying for the services Services are usually delivered by providers who are under contract to or employed by the plan

13 Managed Care: Key Ingredients Care management Utilization management Disease management Vertical service integration and coordination Financial risk sharing with providers

14 Managed Care: Goals Control costs Health care costs growing faster than GDP Reduce inappropriate use of services Increase competition: focus on value Improve service quality Improve population health Increase preventive services: promote health (not just treat illness)

15 Managed Care: Key Components Network of providers created via contracting Medical home created w/primary care provider functioning as a gatekeeper Prior approval required for inpatient admissions, specialty visits, elective procedures, etc. Benefits package defined set of covered services Contained list of covered pharmaceuticals (Formulary) Utilization review practices to manage inpatient admissions and length of stay

16 How Capitation Works Managed Care Organization receives a fixed payment each month for each member: Per Member Per Month (PMPM) Fixed fee is for a specific time period (typically a month) Covers defined set of services (these are the benefits) Provider accepts risk for delivering services: Agrees to comply with prior authorization and utilization management practices May enter into pay for performance arrangement

17 Adult Medicaid Managed Care Transformation

18 What we know about the changes anticipated for adults

19 Transformation of Medicaid Program for Adults with Behavioral Health Needs

20 Medicaid Managed Care for Adults with Behavioral Health Needs What Changed? All Medicaid recipients to be members of a Managed Care Plan (unless they are dually eligible). Managed Care principles apply: UM, Care Management, risk sharing More services (including outpatient clinic and recovery services) covered by Managed Care Plans Individuals w/significant needs can become a part of a Health and Recovery Plan (HARP) - receive services not available through the standard BH plan, Home and Community Based Services (HCBS) Embeds process / resource changes w/in a specific philosophical model: Person centered, recovery focused practices Reliance on care management for high need individuals Greater reliance on community services rather than inpatient services Service integration Greater accountability for achieving outcomes

21 Health and Recovery Plans (HARPs) Who is eligible? Must either meet the target risk criteria and risk factors or be identified by service system or service provider Target Criteria: Medicaid enrolled 21 and older SMI/SUD diagnoses Eligible for mainstream enrollment Not dually eligible Not participating in OPWDD program 140,000 individuals are estimated to be eligible (60,000 in Upstate NY) All will be expected to have a Health Home Care Manager

22 More about HARPs HARP Members who meet the Targeting Criteria and Risk Factors, as well as Need-based Criteria, will have access to enhanced benefit package of Home & Community Based Services (HCBS).

23 Services to be covered by HARPs (These services will be paid for by MCOs if person is shown to be eligible for a HARP) Referred to as Home and Community Based Services (HCBS) for Adults Meeting Targeted and Functional Needs. Rehabilitation (Psychosocial Rehab, Community Psychiatric Support and Treatment (CPST)) Empowerment Services- Peer Supports Habilitation (Habilitation, Residential Supports in Community Settings) Respite (Short Term Crisis Respite, Intensive Crisis Respite) Non-medical transportation Family Support and Training Employment Supports (Pre-voc, Transitional Employment, Intensive Supported Employment, Ongoing Supported Employment) Education Support Services

24 Effective Date of Changes for Our Area July 1, 2016 Has already begun

25 Expected System Outcomes Placed upon the Managed Care Companies Improved individual health and behavioral health life outcomes Improved social/recovery outcomes including employment Improved member s experience of care Reduced rates of unnecessary or inappropriate emergency room use Reduced need for repeated hospitalization and re-hospitalization Reduction or elimination of duplicative health care services and associated costs, and Transformation to a more community-based, recovery-oriented, person-centered service system. Question: With the Managed Care Organizations as a new potential customer, what role will our services play in achieving the above outcomes?

26 What does this initiative mean to the work of FLPN?

27 Transformation of the Medicaid Managed Care Program for Children: What do we know?

28 The State is not far along in their planning for Children s Medicaid Managed Care transformation... The transformation will not go into effect in Upstate NY until January 2018.

29 Challenges in Helping Children We wait too long to identify and treat kids Well intended, yet maladaptive responses All child-serving systems work extremely hard to help children with an emotional disturbance, but it is not enough Children and youth can only achieve their full potential if together we operate at ours.

30 The Scope and Impact of Serious Emotional Disturbance (SED) 1 out of 10 children have a serious emotional disturbance; more children suffer from psychiatric illness than from cancer, blindness, autism, intellectual disabilities, and AIDS combined. Only 20% of children with an emotional disturbance receive specialty mental health treatment. Children with mental health problems are much more likely to appear in pediatric offices and in schools than in clinics or therapist s offices. Emotional disturbance is associated with the highest rate of school failure. Only 30% of children identified with an emotional disturbance graduate with a standard high school diploma. Suicide is the third leading cause of death for 15 to 24-year olds.

31 Could someone help me with these? I m late for math class. Scott Spencer

32 An opportunity presents itself

33 Anticipated Changes to Support Children s Mental Health Needs Target Population Children and youth younger than 21 Children with Serious Emotional Disturbance (SED) Children in Foster Care who have SED, are Developmentally Disabled or Medically Fragile, or have experienced trauma Children who are physically disabled and require significant medical or technological health supports Youth with Substance Use Disorders Additional Medicaid Fee For Service (FFS) services to be covered by managed care organizations Additional services to be covered by Medicaid Managed Care Additional services (HCBS) to be covered for high need children and their families

34 Proposed New State Plan Services (SPA services)- January 2017 Crisis Intervention Community Psychiatric Supports and Treatment (CPST) Other Licensed Practitioner Psychosocial Rehabilitation Services Family Peer Support Services Youth Peer Support and Training

35 Proposed Home & Community Based Services (HCBS) Array 35 Habilitative Skill Building Caregiver/Family Supports and Services Prevocational Services Supported Employment Community Advocacy and Training Non-Medical Transportation Habilitation Respite (Crisis & Planned) Adaptive and Assistive Equipment Accessibility Modifications Palliative Care (includes Family Palliative Care Education, Bereavement, Massage and Expressive Therapy, and Pain and Symptom Management) Care Coordination (for children ineligible for, or opting out, of Health Home)

36 GOALS Get children back on their developmental trajectory: Identify needs early Maintain the child at home with support and services Maintain the child in the community (least restrictive) Children and their families to receive the right services, at the right time, in the right amount. Focus on recovery and building resilience! Prevent unnecessary suffering Reduce cost of care for adults

37 Children s BH Team Themes & Priorities Intervening early in the progression of behavioral health disorders is effective and reduces cost. Accountability for outcomes across all payers is needed for children s behavioral health. Solutions should address unique needs of children in a unified, integrated approach. The current behavioral healthcare system for children and their families is underfunded. Children in other public or private health plans should have access to a reasonable range of behavioral health benefits.

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39 What does this initiative mean to the work of FLPN?

40 Health Homes

41 What is a Health Home? Outgrowth of the Affordable Care Act Designed to expand on the traditional medical home model to build linkages to other community and social supports, and to enhance coordination of medical and behavioral health care for individuals with multiple chronic illnesses

42 What is a Health Home? It is a program that provides Care Management to High Need Medicaid Recipients All of the professionals involved in a member s care communicate with one another so that all needs are addressed in a comprehensive manner. Medical, behavioral health and social service needs are to be addressed

43 What is a Health Home? Work done: Work is done through a care manager who oversees and coordinates access to all of the services a member requires, including those being covered by Managed Care Organizations Care manager ensures that the member receives everything necessary to stay healthy. All the services and partners are considered collectively as the Health Home.

44 Health Home System Health Care Providers Community Resources Individual & Care Manager Education Vocational Services Services Agencies Housing

45 What is a Health Home? Desired Outcomes: Improve health care and health outcomes Lower Medicaid costs Reduce preventable hospitalizations and ER visits Avoid unnecessary care for Medicaid members

46 Health Homes for Children Unique elements of Health Home care management for children: Requesting that complex trauma be added to the list of eligibility requirements Use of CANS NY to determine acuity and rates Engagement of families with child Consent Involvement of Foster Care Agencies in CM Embedding of children s system of care principles Resilience

47 Health Home Dates Health Homes that serve adults began providing services in July Health Homes for Children are scheduled to begin providing services in December 2016.

48 What does this initiative mean to the work of FLPN?

49 Delivery System Reform Incentive Payment (DSRIP) Plan

50 Delivery System Reform Incentive Payment (DSRIP) Plan $7.567 Billion over 5 years Theme: Communities of providers encouraged to work together to develop DSRIP project proposals Focus on reducing in appropriate hospitalizations Open to a wide array of safety net providers Payments are performance based Must choose from a menu of 25 CMS-approved programs Goal: Reduce avoidable hospitalizations by 25% over five years.

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53 What does this initiative mean to the work of FLPN?

54 What is the NYS Value Based Payment Road Map?

55 Value Based Payment (VBP) VBP is a strategy used by purchasers to promote quality and value of health care services. The goal of any VBP program is to shift from pure volume-based payment, as exemplified by fee-forservice payments, to payments that are more closely related to outcomes.

56 Value Based Payment (VBP) Why Are We Moving Towards Value Based Payments? The State is required to submit a multi-year roadmap for comprehensive Medicaid payment reform, including how the State will amend its contracts with MCOs, in order to ensure the long term sustainability of the improvements made possible by the DSRIP investments

57 Value Based Payment (VBP) Desired Outcomes: Reduce avoidable (re)admissions, ED visits and other potentially avoidable complications thru more effective clinical and service models that partner primary care, acute, home and community based care Value Based Payment (VBP) is an approach to align the financial incentives to achieve the above outcomes.

58 Value Based Payment (VBP) Target: Benchmark Date Notes 80-90% of the State s total MCO-PPS payments (payments to providers) (in dollars) will use value based payment methodologies at least at Level 1 VBPs End of DY 5 (2019) State aims to have more than 50-70% of these costs contracted at Level 2 VBPs or higher by this time. Levels are described below

59 Value Based Payment (VBP) What Are The Value Based Principles? Be transparent and fair, increase access to high quality health care services in the appropriate setting and create opportunities for both payers and providers to share savings generated if benchmarks are achieved. Be scalable and flexible to allow all providers and communities to participate, reinforce health system planning and preserve an efficient essential community provider network. Allow for flexible multi-year phase in to recognize administrative complexities including system requirements Align payment policy with quality goals Reward improved performance as well as continued high performance Incorporate a strong evaluation component and TA to assure successful implementation Engage in strategic planning to avoid unintended consequences of price inflation, particularly in the commercial market. Financially reward rather than penalize providers and plans that deliver high value care through emphasizing prevention, coordination, and optimal patient outcomes.

60 Value Based Payment (VBP) Range of VBP Payment Options: Total care for total population Integrated Primary Care Selected care bundles o Acute Care bundles o Chronic Care bundles Special needs subpopulations

61 Range of Value Based Payment (VBP) Options Total care for total population: MCO contracts with a DSRIP Performing Provider System (PPS)... PPS receives a PMPM to meet all needs of member. Accountable Care Organization (ACO) Model. One payment provided monthly to cover the cost of all services. Included in the payment bundle would be the providers needed to meet all the needs of the members: Inpatient: Medical, Surgical, Behavioral Health Outpatient Primary Care Care Management Testing (lab services, X-Ray, etc.) Health and Wellness Services Other The dollars in the bundle would be shared among all participating providers

62 Range of Value Based Payment (VBP) Options Integrated Primary Care: MCO contracts with a Patient Centered Medical Home or Advance Primary Care arrangement with the PPS (or the PCMHs or APCs in PPS) to reimburse based on the savings and quality outcomes they achieved. Continuous in nature, strongly population focused, based in the community, and culturally sensitive. One payment provided to cover the cost of relevant services required as the primary source of care for the majority of everyday needs. Included in the payment bundle would be the providers needed to meet the member s needs tied to primary and secondary prevention: Primary Care Chronic Disease management Medication Management Community based prevention activities Alignment with community based home and social services Other Care Management Health and Wellness Services Other

63 Range of Value Based Payment (VBP) Options Selected Care Bundles o Acute Care bundles: MCO contracts for specific, patient focused bundles of care (such as maternity care episodes or stroke) with the PPS or (groups of) providers. The cost of office visits, tests, treatments and hospitalizations associated with the medical event are bundled into a single episode-based total cost. One payment provided to cover the cost of all services to be provided during the acute care episode. Included in the payment bundle would be the providers needed to meet all the needs of the members acute episode such as maternity: OB/GYN Delivery Suite Follow Up Care Care Management Testing such as Ultrasound The dollars in the bundle would be shared among all providers. Offers reward for efficient service delivery as well as risk.

64 Range of Value Based Payment (VBP) Options Selected care bundles o Chronic Care bundles: Focus will be on following internationally emerging best practices to treat chronic conditions as full-year-of-care bundles emphasizing the continuous nature of the care. Population examples include: Bipolar Disorder, Substance Abuse, Chronic Kidney disease. One fixed payment provided to cover the cost of all services needed to care for the chronic condition such as Bi-Polar Disorder. Included in the payment bundle would be the providers needed to meet all the needs of the members: Inpatient: Behavioral Health Outpatient MH, SUD Primary Care Care Management Health and Wellness Services Other The dollars in the bundle would be shared among all providers. Includes both risk and reward.

65 Range of Value Based Payment (VBP) Options Special needs subpopulations: For some populations with severe co-morbidity or disability that require highly specific and costly care, the majority of the care would be included in the full year of care bundles. Example: HARP One fixed payment provided to cover the cost of all services for this special needs population, for example: HARP. Included in the payment bundle would be the providers needed to meet all the needs of the members: Inpatient: Behavioral Health Outpatient: MH and SUD Primary Care Care Management Home & Community Based Services (HCBS) Health and Wellness Services Other The dollars in the bundle would be shared. Includes both risk and reward.

66 Value Based Payment (VBP) VBP Levels: Levels of payment reflecting different degrees of Values Based Philosophy (and risk/reward): Descriptions for Total Care for Total Populations, but themes are similar for other Payment Options Level 0 VBP: Fee For Service payment with bonus and/or withhold based upon quality scores Level 1 VBP: Fee For Service with upside-only when outcome scores are sufficient Level 2 VBP: Fee For Service with risk sharing (upside available when outcome scores are sufficient; downside is reduced when outcomes scores are high) Level 3 VBP: Global capitation (with outcome-based component) PMPM driven.. Need experience with other levels first Requires mature PPS.

67 Value Based Payment (VBP) To What Should We Pay Attention? MCOs and providers can jointly agree to pursue different or off-menu value-based payment arrangements as long as the arrangements reflect the Value-Bases Principles: How Social Determinants of Health fit in: A task force was created to address social determinants of health within the context of Value Based Payments. Key recommendations presented in late 2015 categories include: Assure focus: The overall wellbeing of individuals, families and communities should be the driving purpose of the healthcare system. Recommendations to encourage development of culturally competent Social Determinants initiatives and collaboration with MCOs. Methods to measure the success of the programs implemented Management of Managed Long Term Care (MLTC), Dual Eligible and shared savings. Impact on Medicare and the commercial market over time. The State acknowledged in its Roadmap that there may be providers that require more time and technical assistance to be fully prepared for entering into such agreements. These providers include community and home based organizations who may have challenges related to infrastructure, technology and workforce.

68 What does this initiative mean to the work of FLPN?

69 Pulling It All Together

70 The Aim of The State s Redesign Improved health status Improved quality of care Reduced costs: All initiatives focus on reducing use of inpatient and Emergency Services By way of: Care Management o Managed Care Organization Oversight o Health Home Care Management Accountability for outcomes and quality services o Heightened accountability to demonstrate impact of services on priority outcomes o Value based Payment Integrated approaches to planning and service provision o MCO o DSRIP o Health Home Plans of Care Increasing access by enhancing service array and continuum of care o Payment for services not previously covered by Medicaid Person centered approaches

71 What Do These Changes Mean to Service Delivery? Heightened accountability for demonstrating impact of services provided by agencies. New partners: Managed Care Organizations Need for additional back office services for some providers: Medicaid Managed Care Billing, Corporate Compliance practices, etc. Need for system partnerships to achieve integrated outcomes. Increased focus on social determinants of health as part of the system solution: Meeting the needs of the whole person.

72 What Is FLPN s Role? Discussion: What ought you to consider doing in order to prepare for and to successfully embrace these changes?

73 Q and A