DECODING THE JIGSAW PUZZLE OF HEALTHCARE

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1 DECODING THE JIGSAW PUZZLE OF HEALTHCARE HPCANYS Leadership Institute November 6, 2015 Carla R. Williams, MPA Director, O Connell & Aronowitz Healthcare Consulting Group

2 WHAT IS GOING ON?

3 ENVIRONMENT ACA ACOs Medicare Advantage Medicaid Managed Care: MMC, MLTC, FIDA, HARP, DISCO DSRIP Medicare/Medicaid Alignment: Bundling, VBP Consolidation

4 ACA: EXCHANGE GROWTH Exchange marketplace enrollment is projected to reach 10.5 million by the end of Retention rates from 2014 appear to be strong. Increase in maternal and child market Increase Medicaid population This market will become more competitive for Plans. Decision support tools to impact consumer choices Highlight benefit design challenges such as narrow networks or high cost-sharing arrangements.

5 ACO Serving 7.8 million beneficiaries in 2014, Accountable Care Organizations (ACOs) represent a growing model by which providers can take on increased accountability for population health without restrictive networks. Early results from public and private sector ACOs are somewhat promising in their potential for improving quality and bending the cost curve. Additional years of experience are needed. In 2015, CMS has provided additional flexibilities and opportunities to join the ACO program.

6 ACO RESULTS Some Pioneer ACOs reported significant savings. Banner Health Network accounted for $29 million in total savings. Montefiore ACO saved $18 million. Officials at both organizations said performance was boosted by attention to post-acute care costs and quality. Banner Health's ACO developed a preferred network of skilled-nursing facilities and recommends those facilities to patients. The Montefiore ACO worked with skilled-nursing facilities to avoid hospitalization, where possible, by finding alternatives for services that could be delivered elsewhere, such as blood transfusions. More financial risk the greater the motivation to achieve quality and costcontrol targets.

7 ACO RESULTS CMS announced plans to aggressively increase the share of Medicare spending under accountable care and other alternative payment models through out of 353 ACOs earned bonuses totaling $422 million out of $833 million in savings they produced. Savings are awarded under formulas that account for performance on quality targets after the first year in the program. The ratio of ACOs that earned bonuses to those that did not in 2014 is similar to results at the end of Suggests that ACOs alone likely cannot bend the trajectory of U.S. healthcare spending and deliver the quality improvement

8 MEDICARE ADVANTAGE Medicare Advantage plans continue to increase enrollment even with payment cuts. Enrollment will surpass 16 million this year. Plans need to monitor the risk profile of local populations and the behavior of providers serving those markets to maximize financial results. Medicare Advantage plans that move to more value based contracting arrangements with providers have an advantage to manage the impact of the cost versus quality value equation. As risk shifts, health plans will engage in oversight programs to ensure sustained performance and effective contracting relationships.

9 MEDICAID PLANS Medicaid represents a growing market for health plans, with 10 million new enrollees as a result of the Affordable Care Act in 2014 and additional expansion likely in Medicaid market to further align with the marketplace and Medicare. May create challenges for some plans (limited coverage MLTC) Create opportunities for commercial plans to capture Medicaid lives by leveraging existing platforms.

10 MEDICAID PLANS New York s Alphabet Soup of Plans: MMC Mainstream Managed Care Plan MLTC Managed Long Term Care Plan FIDA Fully Integrated Duals Advantage and FIDA IDD HARP Health and Recovery Plan DISCO - Developmental Disabilities Individual Support and Care Coordination Organization

11 MEDICAID PLANS Medicaid Managed Care (MMC) Health Plans For all adults served in MMC health plans, the qualified plan will provide all Medicaid State Plan covered services for MI, SUDs and PH conditions. Must meet criteria contained in the request for qualification (RFQ) and be approved by the State to qualify to administer the BH benefit. Health and Recovery Plans (HARPs) For adults meeting SMI and/or SUD targeting criteria and risk factors Enhanced benefit package (Home and Community Based Services) meet both targeting and needs-based criteria for functional limitations in addition. Help maintain participants in home- and community-based settings. Access limited to those living in Adult BH HCBS Residential Settings

12 MEDICAID PLANS Managed Long Term Care (MLTC) Plans: Adults over 21 and Duals requiring more than 120 days of community based long term care services and those who meet the nursing home level of care (for Programs of All-Inclusive Care for the Elderly and Medicaid Advantage Plus). Benefits: State Plan long term care services, including the LTHHCP and nursing home stays, but not any of the physical health services, which are covered by Medicare. Transition began in New York City in 2012 and has continued into Long Island, Westchester and upstate counties; now over 140,000 people are enrolled. All counties are mandatory at this time

13 MEDICAID PLANS Managed Long Term Care (MLTC) Plans: Individuals between the ages of 18 and 20 may voluntarily enroll in a MLTC Plan. The conditions of eligibility are: require more than 120 days of community based long term care services: and meet Nursing Home Level of Care criteria Non-dually eligible individuals, who are not otherwise considered mandatory for Mainstream Managed Care, may voluntarily enroll in a MLTC plan with the same eligibility conditions.

14 MEDICAID PLANS Fully Integrated Duals Advantage (FIDA) State is also participating in the Federal Medicare/Medicaid Demonstration Program that allows for the alignment of Medicare and Medicaid payments under a capitated model. Program is intended to cover all needed services both physical health and behavioral health for the dual population that is either: in need of more than 120 days of community based services or residing in nursing homes. The full range of BH services are included in FIDAs, including Community Residences.

15 MEDICAID PLANS Fully Integrated Duals Advantage (FIDA) Status Original region (NYC, Nassau, Suffolk, Westchester) currently only in NYC and Nassau Only 9,000 people enrolled mostly from MLTC Plans + 45,000 people opted out Ongoing passive enrollments : Addition notices will be sent Ongoing programmatic updates Marketing Provider Training Ombudsman:

16 MEDICAID PLANS Health and Recovery Plan (HARP) Eligibility for enrollment is dependent on the Medicaid beneficiaries status related to BH needs: Individuals who are Medicaid eligible under the following categories and who previously received FFS BH services: Temporary Assistance to Needy, Safety Net Adults, Supplemental Security Income (SSI) and Basically all Medicaid-only individuals with BH needs living in the community will enroll in MMC; they will then be directed to HARP based on the significance of their BH needs. A single Health Plan could be both a BH qualified plan and a HARP qualified plan serving both BH populations

17 MEDICAID PLANS FIDA IDD In May, CMS approved FIDA IDD demonstration voluntary program. Work is progressing toward an implementation date of January 1, 2016 in a nine-county area Including the five NYC boroughs, Nassau, Suffolk, Rockland, and Westchester Counties. This demonstration is only for: dual eligible age 21and older.

18 MEDICAID PLANS Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs) Specialized managed care organizations certified through OPWDD and the Department of Health (DOH) Partially capitated to include LTSS and OPWDD HCBS waiver services for those enrolled in the OPWDD 1915(c) HCBS Waiver Comprehensive case management services to ensure coordination and continuity expertise in the provision of services under the auspice of OPWDD controlled by one or more non profit organizations with a history of providing or coordinating health and long term care services to persons with developmental disabilities

19 MEDICAID PLANS Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs) Goals each individual receives services, consistent with his or her known wishes, designed to achieve person centered outcomes, to enable living in the most integrated setting appropriate to his or her needs, and Enable interaction with nondisabled to the fullest extent possible in social, workplace and other community settings.

20 DSRIP Delivery System Reform Incentive Payment Program - allow the state to reinvest $8 billion in federal savings generated by Medicaid Redesign Team (MRT) reforms Promote community-level collaborations and focus on system reform Goal to achieve a 25 percent reduction in avoidable hospital use over five years. Safety net providers will be required to collaborate to implement innovative projects focusing on system transformation, clinical improvement and population health improvement.

21 DSRIP $8 billion reinvestment will be allocated in the following ways: $500M for the Interim Access Assurance Fund temporary, time limited funding to Medicaid safety net providers to support participation without disruption $6.42B for DSRIP Planning Grants, DSRIP Provider Incentive Payments, and DSRIP Administrative costs $1.08B for other Medicaid Redesign purposes support Health Home development, and investments in long term care, workforce and enhanced behavioral health services (HCBS) Comprehensive payment reform Value Based Payments (VBP) and continuing to manage Medicaid within the confines of the Global Spending Cap.

22 DSRIP Implementation via Performing Provider Systems Funding to emerging PPSs to develop comprehensive DSRIP Project Plans. 42 of the 49 applicants received resulted in 25 approved PPSs. Statewide presence of PPSs - each required to participate in BH project (all selected at least BH/PH integration) Expectation is that these new hospital or physician lead organizations will result in integrated systems of PH and BH care for Medicaid ACO over 5 year period. Shift of payments for providers to Value Based rather than FFS this means sharing risk at some level with MCOs.

23 MEDICAID/MEDICARE ALIGNMENT Part of NYS Value Based Payments Road Map (Draft August 2015) 4 Strategies: Allow providers and Managed Care Organizations to include Medicaid beneficiaries in CMS innovative payment models (Bundling, Primary Care, ACO, Cardiovascular Risk Reduction Model) Allow providers to include Medicare FFS beneficiaries in the VBP Arrangements outlined in the NYS Payment Reform Roadmap. State will work with its Medicare Advantage plans to realize a complimentary alignment Allow Montefiore Health System to be the first Accountable Care Organization in the country that seamlessly encompasses both duals and Medicaid- and Medicare-only beneficiaries, managing population health and assuming financial risk across the entire spectrum.

24 PROVIDER RISK Providers must test their ability to bear risk in CMS has set concrete goals and a specific timeline to tie an increasing proportion of Medicare fee-for-service (FFS) payments to quality or value across the next four years. This will spur increased activity among Medicaid and commercial plans toward increased value-based models. Health plans need oversight programs to ensure contracted providers manage risk appropriately. Develop mechanisms to pursue performance-based contracting. Providers continue to vary in their readiness and willingness to participate and accept risk in alternative payment models.

25 POST ACUTE CARE In 2014, post-acute care (PAC) represented 16.5 percent of Medicare spending and included skilled nursing facility (SNF) care, home health, inpatient rehabilitation and long-term care hospital services. There will be continued expansion of managed care and alternative payment models. These trends will likely lead to lower SNF utilization on an absolute and per capita basis. Bundled payment models will continue to place an emphasis on clinical efficiency and discipline, this increases and strengthens PAC partnerships as health plans and hospitals develop narrow, highperforming PAC networks.

26 CONSOLIDATION Consolidation is occurring in the provider marketplace. Systems are integrating and maximizing the providers they have acquired to date. Mergers and acquisitions both of other hospitals and medical practices create challenges to health plan negotiating positions. Leads to upward pressure on provider reimbursement and member premiums. In concentrated markets, consolidation could threaten health plans efforts to narrow networks.

27 ANALYSIS NEEDED Making the business case to potential clients/partners for services involves three steps: 1. What can you add that aligns with partners needs? 2. Providing evidence that proposal will result in outcome (can t just be good provider anymore); and 3. Pricing the service so that there is economic value exceeds the fees paid.

28 DISCUSSION/QUESTIONS Carla R. Williams x 3413