Washington State Indian Health Care Legislation for 2018 American Indian Health Commission for Washington State Presented By: Vicki Lowe, AIHC Executive Director
AMERICAN INDIAN HEALTH COMMISSION FOR WASHINGTON STATE Mission: Improve the health of American Indians and Alaska Natives (AI/AN) through tribal-state collaboration on health policies and programs that will help decrease disparities Work on behalf of the 29 federally-recognized Tribes and 2 Urban Indian Health Organizations in the state Key: Tribal Councils and UIHP appoint delegates to represent the I/T/U through resolution
BACKGROUND ON AIHC: WORK WITH STATE AGENCIES The Commission provides many health policy-related services under contracts with: Washington State Department of Health Washington State Health Care Authority Washington Health Benefit Exchange Office of the Insurance Commissioner
GOVERNMENT TO GOVERNMENT RELATIONSHIPS: STATE AND FEDERAL - Federal Trust responsibility to protect Tribal sovereignty/lands legal obligation - Federal Executive Order 13175 - WA Centennial Accord 1989 - RCW 43.376.020 codified the Accord The government-to-government relationship respects the sovereign status of the parties, enhances and improves communications between them, and facilitates the resolution of issues.
INDIAN HEALTH SERVICE (IHS) Congressional Budget Office (CBO) estimates that IHS2018 budget is funded at less than 32% of the need The chronic underfunding of I.H.S. programs has made the use of alternate resources vital to these programs The U.S. spends more dollars per capita on federal prisoners than on AI/AN people RESULT: AI/ANs have the worst overall health outcomes of any other population in Washington State
URBAN INDIAN HEALTH PROGRAM INCLUSION Section 1902(a)(73) of the Social Security ACT Section 4 of the Indian Health Care Improvement Act 25U.S.C. 1603 Indian Health Care Provider (IHCP) means a health care program operated by the Indian Health Services (IHS), Tribal Organization or Urban Indian Health Program (otherwise know as the ITU) State Plan Amendment #TN11-25 CMS Dear Tribal Leaders Letter January 22, 2010
Types of Health Care Services Provided by I/T/Us I/T/U Facility Dental Medical Behavioral Referral & Coordination Specialty Care Inpatient Care
I/T/U CHALLENGES Provider Recruitment and Retention For one Tribe recently, it took 15 months to fill a vacant provider slot Specific gaps: Oral Health, Maternal- Infant Health, Long- Term Care Remote Areas with few health care options Lack of providers in rural communities Transportation, Child Care Cultural Barriers Discrimination & Distrust Communication Challenges Lack of understanding of the Indian Health Care Delivery system in mainstream AI/AN Health Literacy used to IHS/Tribal clinics; don t know how to advocate for own health
TRIBAL RESILIENCY Best Practices Holistic Health Care Wrap Around Services Integrated Care Addressing Population Health through Public Health Strengths Economic Growth: Health is a priority of Tribal Leaders Community Connectedness Culture Creative Solutions with Limited Funding
CURRENT CHANGES BEING MADE AT THE STATE LEVEL: 1115 Global Waiver Integration of Medical & Behavioral Health Services Healthier Washington/ Medicaid Transformation State Law SB 6312 1915(b) Waiver Transition from Fee-For- Service to Value-Based Purchasing Creation of Accountable Communities of Health
THE HEALTHIER WASHINGTON INITIATIVE Initiative brings over $1 billion to Washington State s healthcare system over the next five years; Funds are paid against expected savings to the Medicaid system; the plan did not appropriately take into consideration the Indian health care delivery system in our state; The State of Washington plans to use managed care entities (MCEs) to assume financial risk for Medicaid enrollees and create a value based payment system for contracted Medicaid providers.
IMPACTS OF STATE LEVEL DECISIONS: HEALTHIER WASHINGTON INITIATIVE I.H.S. All Inclusive rate not paid through MCOs The use of MCOs for Medicaid has degraded the fee for services (FFS) network Additional layers of MCO authorizations and rules make specialty care difficult to access No determination of how value based payments will work with encounter payments There is no government to government relationship between Tribes and MCOs.
ACTION NEEDED AIHC has taken the legislative issues to create one piece of legislation that would accomplish the following: Address the outstanding issues created by the integration of Medicaid payment systems into managed care; Protect the Indian health care delivery system in Washington State from future legislation that could negatively impact the system; Address other key Indian health legislative issues.
Utilizing 100% FMAP* in Fee for Service (FFS) Medicaid to Fund Statewide Tribal Strategic Plan Indian Health Care Provider (IHCP) provides care to Medicaid eligible patient Bills Provider One (P1) Fee for Services; P1 pays Indian Health Services, I.H.S., All Inclusive Rate, the encounter rate, currently $391 per encounter ; Such payments are eligible for the enhanced federal matching authorized under section 1905(b) of the Social Security Act at a rate of 100 percent; Washington State realizes a saving to the Medicaid program each time a Medicaid eligible client is seen by an IHCP in the FFS payment system; These saving should be reinvested back into the Indian Health/Tribal/Urban (I/T/U) Health System. *FMAP= Federal Medicaid Assistance Percentage or the % of reimbursement provided by the federal government to State for Medicaid claims.
UTILIZING 100% FMAP IN FFS MEDICAID TO FUND TRIBAL REINVESTMENT POOLS CMS-I.H.S. Tribal Operated Clinic Tribal Federally Qualified Health Center Contracted Specialty Providers Care Coordination Agreements Purchased and Referred Care Contracts I.H. S. Encounter Rate paid to IHCP Contracted Provider paid PRC rate Difference between encounter rate and PRC rate Becomes Tribal reinvestment funds
LEGISLATION NEEDED TO CREATE A SUSTAINABLE FFS SYSTEM FOR MEDICAID 1. Creation of I/T/U Reinvestment Pool from 100% FMAP Savings achieved by the State 2. Create a Tribal Entity with a Governing Board to receive, manage and utilize funds to acheive agreed upon goals within Strategic Plan. 3. Prioritize how funds are spent in this order: 1. Data/population health management 2. TPA Administration costs 3. CDR sponsor 4. Regional Needs 5. Individual Tribes
CREATION OF A THIRD PARTY ADMINISTRATOR FOR THE FFS NETWORK Use existing Purchased and Referred Care, PRC, contracts where possible Partner with existing Third Party Administrator or Administrative Services Organization or 'Rent-a- Network" Needs to be able to: Process Medicaid claims Process PRC or Medicare "like" rates claims Provide Coordination of benefits or repricing for PRC programs Support I/T/U Staff Report to I/T/U and State
CREATION OF TRIBAL MANAGED CARE ORGANIZATION Separate Rating for I.H.S. Eligible enrollees Actuarial amounts for FMAP Savings Network Adequacy tied to TPA networks
LEGISLATION TO ADDRESS ISSUES OUTSIDE OF THE SCOPE OF MEDICAID Involuntary Treatment Admissions Legal designation of Tribal Designated Mental Health Provider Legal acknowledgement of Tribal Court Orders Full Faith and Credit for assessments by IHCP
LEGISLATION TO ADDRESS ISSUES OUTSIDE OF THE SCOPE OF MEDICAID Government to Government relationships between Tribes and Regional and County Entities: Local Health Jurisdictions = LHJs Accountable Communities of Health = ACH Behavioral Health Organizations = BHO AND any new entity yet to be created: There needs to be a process to deal with Tribal implications at the local level. Appropriate conferral relationship Required agreement for outcomes
LEGISLATION TO ADDRESS ISSUES OUTSIDE OF THE SCOPE OF MEDICAID Funding for reporting: Efficacy of inpatient Mental Health and Evaluate & Treat Services for AI/AN Best Practices/cultural protective practices Support for feasibility of Tribal Inpatient Facilities Comparison of Tribal and non-tribal SUD Provide culturally appropriate care; Involve family in the care planning process; Utilize cultural protective factors within inpatient treatment plan and home treatment plan.
August to October 2017 September 8, 2017 WIHCIA TIMELINE Draft language completed and shared with Tribal and Urban Leaders and AIHC delegates Consultation with Governor Inslee s office to review outline and request support of the bill October to November 2017 Finalize language and work with Tribes for approval and support of the newly proposed bill September - November 2017 Indian Health Care 101 with legislative committees Winter 2017-2018 Washington Indian Health Care Improvement Act will be Introduced
Questions? E-mail- vicki.lowe.aihc@outlook.com or AIHC.General.Delivery@outlook.com Website: www.aihc-wa.com Phone: 360-477-4522