Community Care of Wake and Johnston Counties/ Community Care Physician Network (CCPN) Meeting November 1st, 2018 Michelle Bucknor, MD, MBA, FAAP
Agenda Welcome Dr. Michelle Bucknor, CCNC Chief Medical Officer & CCWJC Medical Director DHHS & Medicaid Updates Dr. Michelle Bucknor, CCNC & CCWJC Medical Director CCPN Support of Future Business Solutions Atha Gurganus, Director of QI/Practice Support Virtual Health: Provider Portal Update Patty Myrick, Director of Clinical Operations Atha Gurganus, Director of QI/Practice Support 2
UPDATE 3
Opioid SPARC Safety Prevention Awareness Raising Confidence Project ECHO is a lifelong learning and guided practice model that revolutionizes medical education and exponentially increases workforce capacity to provide bestpractice specialty care and reduce health disparities. Academic Detailing is a peer to peer educational outreach approach that is a hybrid of pharm detailing and evidence based practice improvments goals of academic groups. 4
ADHD Resource guide AAP Guidelines from 2011 and current (2018) update; new AAP mental health textbook; AAP text on psychopharmacology for pediatrics Algorithm aligns general AAP Primary Care Approach to Mental Health Care Algorithm, with application of specific ADHD algorithm steps Focuses on multimodal intervention Resource guide includes guidance for rating scales, pharmacology, communication with the school (forms based on Guilford model)
NC Department of Health and Human Services released the draft statewide Early Childhood Action Plan Shares a bold vision for improving the health, safety and well-being, and developmental and academic readiness for all young children in NC Includes 10 data-informed goals focusing on child-level outcomes Provides a framework to galvanize coordinated action across public and private stakeholders throughout the state Was drafted with the support of over 350 stakeholders from across North Carolina, including the Early Childhood Advisory Council (ECAC). Click here to view the draft Early Childhood Action Plan. Email all feedback on this draft plan to ECAP@dhhs.nc.gov by November 30 th, 2018. 6
Medicaid Transition 7
Transition Timeline NC General Assembly enacted Session Law 2015-245,directing the transition of Medicaid and NC Health Choice from predominantly fee-for-service to managed care.
Section 1115 Waivers: An Overview Federal Medicaid law requires that waivers: o o o Waiver Requirements Further the objectives of the Medicaid program Be authorized for a demonstration purpose, subject to evaluation Affect a section of the federal Medicaid law subject to waiver (e.g., federal match rate is not waivable) By longstanding practice, waivers must be budget neutral to the federal government Public comment periods for new waivers and renewals are required at the state and federal levels; public input requirements more limited for amendments Common Waiver Uses Expand coverage: New populations and new services Delivery System Reform Waivers: Often involve substantial federal investment; 12 states have DSRIPtype waivers Uncompensated Care Pool Waivers: Payments typically for hospitals to reimburse for uncompensated care; 9 states have UCC waivers Expansion-Related Coverage Waivers: Allows states to modify features of Medicaid coverage (e.g., premiums, higher copayments) Source: Social Security Act (SSA) 1115; See SSA 1916(f) for cost sharing waiver limitations. *States may only waive the previsions in SSA 1902.
Waiver Approved!
Demonstration Waiver The North Carolina demonstration allows the state and CMS to test innovative new approaches to address a broader range of issues that can have a direct impact on an individual s health. North Carolina will implement a groundbreaking program in select regions to pilot evidence-based interventions addressing social determinant issues like housing instability, transportation insecurity, food security, and interpersonal violence and toxic stress.
Leverage Managed Care to Drive New Programs State s Vision for Managed Care Transition All beneficiaries screened for unmet social resource needs Population Health Approach to select conditions Mild-Moderate behavioral health carved in In Lieu of Services Test the Advanced Medical Home Model Value based contracts Funding follows the patient to the practice Care management occurs at practice level 12
Demonstration Waiver DHHS goals: Deliver whole-person care through coordinated physical health, behavioral health, intellectual/developmental disability and pharmacy products, and care models Address the full set of factors that impact health, uniting communities and health care systems Perform localized care management at the site of care, in the home or community Maintain broad provider participation by mitigating provider administrative burden
Medicaid Waiver Approved Move to managed care plans for 1.6 million on Medicaid. Targeted plans for high-needs behavioral health patients, intellectual or developmental disability patients Pilot programs to address housing, transportation, food access, family violence and toxic stress issues that undermine health outcomes Foster care children under specialized plan, including coverage up to age 26 for those who age out of system Funding for opioid and substance abuse treatment in short-term facilities Not approved Behavioral health crisis services for those in nonhospital, inpatient settings Assessment and incentives to address gaps in state s healthcare workforce Endorsement of Carolina Cares, a Medicaid expansion proposal with work requirement that for yet to clear the N.C. legislature Funding for telemedicine initiatives Money to cover uninsured patients treated by the Eastern Band of Cherokee Indians medical system Source: Oct. 19 Letter from CMS to DHHS 14
DHHS FY2019 FY2020 7/18 1/19 7/19 1/20 Waiver Waiver Approved Enrollment begins (7/19) 1-2 regions go live (11/19) All regions go live (12/19) PHPs RFP Release (8/18) RFP Response Due (10/18) MCO contracts awarded (2/19) Implementation (3/19-11/19) 15
Managed Care Transition Behavioral Health Integration and Tailored Plans Integrated physical, behavioral and pharmacy benefits Allows seamless access to coordinated care Opioid Strategy increase access to inpatient and residential substance use disorder treatment by beginning to reimburse for substance use disorder services provided in institutions of mental disease Healthy Opportunities Pilots
North Carolina will implement within its Medicaid managed care program a groundbreaking pilot program in two to four regions of North Carolina to improve health and reduce health care costs. Healthy Opportunities Pilots Working with managed care plans, these pilots will identify cost-effective, evidence-based strategies focused on addressing Medicaid enrollees needs in five priority areas that drive health outcomes and costs: housing, food, transportation, employment and interpersonal safety. The State will increasingly link pilot payments to improvements in health outcomes and efficiency. North Carolina will use a rigorous rapid-cycle assessment strategy to evaluate pilot performance and tailor service offerings to those with demonstrated efficacy.
Prepaid Health Plans (PHP)
DHHS Levers for Improvement in Managed Care Provider Incentive Programs PHP Withholds Value-based Payment Quality Improvement PHP Performance Improvement Plans 19
How Does Care Management Work? Each beneficiary receives a Care Needs Screening Housing, Transportation, Interpersonal Violence, Food Population Health Approach 7 Priority Populations (Infant mortality, low birth weight) Telephonic care management Care gap closure 20
How Does CCWJC Provider Support Work? Data Will need to ingest and operationalize data from multiple sources Value-Based Reimbursement Using CMS LAN framework Advanced Medical Home Attestation for Tier 3 starts October 1st 21
Provider Services and Practice Support 22
Care Management and Care Coordination 23
FAQs 24
Question Under Medicaid Managed Care four health plans will offer statewide coverage. There will also be one to two regional contracts awarded. Does that mean I must sign up to take four or more different Medicaid insurance products? Answer No, there is no requirement to sign up with all offered Medicaid plans. You may sign up with one plan or all plans, depending upon what you think is reasonable. A key consideration is that if your current patients sign up with plans that you don t contract with, they will no longer be able to see you. As a CCPN member you will have access to multiple, favorable contracts with health plans, increasing expand your chances that you will be able to continue seeing your current patients. 25
Question How hard will it be to sign up with participating health plans? Answer It won t be hard. There will be a single, staterun credentialing process. And, you only need to get credentialed once. All health plans will have access to your credentialing information. CCPN provider relations staff will bring contracts to CCPN members as soon as winning plans are selected. 26
Question Why should I become a member of CCPN? It s Time to Think Big Answer CCPN is a physician-led, clinically integrated network of primary care clinicians and supported by CCNC resources. We have negotiated very favorable contracts with almost all health plans hoping to offer a Medicaid managed care program in North Carolina. That means CCPN members won t have to negotiate rates and terms with each plan on their own. 27
Question What if I already contract with some managed care companies that win the state s Medicaid bid? Answer United Healthcare, Aetna, BCBS and other health plans, for example, already offer commercial and Medicare Advantage plans in North Carolina. If you are in one of these networks, they will still need to have you to sign a contract amendment to cover Medicaid. As a CCPN member you will already have contracts for Medicaid with many of these plans. You may want to compare their contract terms and rates with CCPN contract terms and rates. Their contract terms and rates for commercial or Medicare Advantage plans will be very different than Medicaid terms and rates. 28
Question The state is offering practices an opportunity to attest as a Tier 3 Advanced Medical Home. If I attest to being a Tier 3 AMH, I can contract directly with health plans and get paid a permember/per-month care management fee on top of my fee-for-service payments. In a DHHS meeting I recently attended, speakers said there was $10.86 per-member/permonth available for Tier 3 AMH participants. Should I do this? It seems like a lot of money. Answer That is certainly an option for any practice that is willing and able to provide the associated Tier 3 AMH required services. These include: hiring a care manager, aggregating quality and clinical data, doing risk stratification, identifying specific patients for health screenings, documenting a comprehensive care plan and communicating the details of that plan back to the health plan, and quality reporting including metrics tied to value-based care metrics. The $10.86 per-member/per-month amount is what the state will provide to health plans for all care management functions. A portion of the $10.86 amount would be used to offset a health plan s costs associated with care management and to pay for their costs of managing some high-risk and complex patients. You will want to carefully evaluate the cost of providing or developing these required services in your practice and then compare those costs with what plans are offering you for Tier 3 AMH participation. The state will not dictate the amount of care management payments paid by plans and it is still not known what health plans may be willing to pay. CCPN has negotiated very favorable contracts with almost all health plans hoping to offer a Medicaid managed care program in North Carolina. That means CCPN members won t have to negotiate rates and terms with each plan on their own. 29
Question The state says if I am a currently participating in CCNC, I will automatically become a Tier 2 AMH in the new system. Does this approach have any advantages? Answer Yes, as a Tier 2 AMH, you will continue to get your current fee-for-service payments and the $2.50 or $5.00 per-member/per-month for enrolled patients from all Medicaid health plans. You will be glad to know that CCPN has negotiated contract terms with five of the six health plans bidding on the new Medicaid plan. These terms meet and or exceed your current fee-for-service and per-member/ permonth payments. In addition, the CCPN/health plan agreements include your CCNC care manager, analytics and reporting support, and a generous guaranteed bonus pool for providers meeting quality targets. Most plans have also offered CCPN a significant shared saving bonus pool. If you are a member of CCPN, there is no additional contract negotiation needed on your part to participate in these arrangements. 30
So what are the next steps in Medicaid Transformation? 31
DHHS FY2019 FY2020 7/18 1/19 7/19 1/20 Waiver Waiver Approved Enrollment begins (7/19) 1-2 regions go live (11/19) All regions go live (12/19) PHPs RFP Release (8/18) RFP Response Due (10/18) MCO contracts awarded (2/19) Implementation (3/19-11/19) 32
Next steps in Medicaid Transformation First, look for a visit from our CCWJC practice liaisons. They will meet with you to walk through all the contracts CCPN has negotiated, summarize current and future CCPN offerings, and let you know about important changes coming in the next six months as the state implements commercial managed care. Second, look for regional CCPN meetings we will hold across the state after the health plan contracts are awarded in February of 2019. We want to get your feedback and provide more details on CCPN s quality reporting tools, care management process and contract monitoring procedures. 33
Next steps in Medicaid Transformation Third, we will distribute to CCPN members all the contracts we have negotiated after the health plan awards are announced. You will have a 30-day period to review contact terms and decide to participate. We think you will like what CCPN has negotiated, and won t need to do anything else, because you will be enrolled in each plan through CCPN s single-signature contract. A final point to keep in mind is that many of the Medicaid health plans with other business lines beyond Medicaid have offered contracts to CCPN for commercial business and other populations. So, the system that works for you for Medicaid may soon offer additional benefits with other populations. We expect to see much more expansion of your options in the future. 34
Questions or Comments? 35