medicaid managed care - beth kohler
TRANSCRIPT
AHCCCS UpdateBeth Kohler Deputy Director
AHCCCS Population as of July 1, 1985 – 2016
19851986
19871988
19891990
19911992
19931994
19951996
19971998
19992000
20012002
20032004
20052006
20072008
20092010
20112012
20132014
20152016
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
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quality health care for those in need
Spending by Provider Type
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20%
16%
15%15%
14%
9%
6%
3% 2%
PhysicianHospital IPHospital OPBehavioral HealthHCBSPharmacyNursing FacilitiesTransportationDental
Percentage Change in Federal Funding (2008-2014)
-20
-10
0
10
20
30
40
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Medicaid Other Health Income Security
Transportation EducationEverything
Else
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Medicaid Portion of General Fund
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FY 1990 FY 2000 FY 2010 FY 2016 FY 2017$367.9 $639.7
$1,926.2 $2,016.3 $2,155.5
$2,651.8
$5,306.8
$5,798.4
$7,517.8 $7,389.0
12.2%
10.8%
24.9%
21.1% 22.6%
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AHCCCS Delivery SystemRegional Behavioral Health Authorities
Acute Care Plans
Individuals with Serious Mental Illness – Integrated
Dual eligible members not in ALTCS – Integrated
Non-SMI/Non-dual adults – behavioral health services
Most adults – physical health services
Children – behavioral health services
Children – physical health services
Crisis Services, Housing and Employment, and distributes SAMHSA funds
Children with special health care needs - Integrated
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GAO - Conditions of Members (%)
Condition Asthma Diabetes HIV/AIDS MH SUD Delivery LTC None
Asthma 24.5 3.9 65.1 29.1 6.5 7.3 17
Diabetes 18.5 2.6 52.4 23.9 3.1 12.7 29.7
HIV/AIDS 17.9 15.6 48.1 39.4 2.1 7.2 29
MH 17.6 18.7 2.8 26.7 4.0 11.9 42.9
SUD 20.8 22.6 6.0 70.8 4.5 10.2 15.6
Delivery 9.3 5.9 0.7 21.3 9.0 0.5 66
LTC 12.5 28.6 2.8 74.7 24.4 0.6 14.1
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Vision - Integration at all 3 Levels
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Integration Efforts to Date1. Ongoing – Duals – >40% alignment DSNP2. 2013 – 17,000 Kids with special needs3. 2014 – 20,000 Individuals with SMI – Maricopa4. 2015 – 19,000 Individuals with SMI – Greater AZ5. 2015 – 80,000 dual eligible members – Integrate
BH6. 2016 – Administrative Merger – 80,000 AIHP
members7. Future Possibilities
1. 2017 – 29,000 members with DD – BH & PH2. 2018 – 34,000 Children with Autism or at risk3. 2018 or future date – Non-SMI adults – BH
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Integration Efforts
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10/1/2012 10/1/2013 4/1/2014 10/1/2015 10/1/2015 7/1/2016 10/1/2017 10/1/2018 4/1/20190.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
ChildrenGMH/SA AdultsALTCS DDAIHP FFSGMH/SA DualsSMI - GAZSMI - MMICCRSALTCS EPD
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Managed Care – Things to Consider1. State Regulatory Oversight Design and Capacity 2. System Design – State Funding Streams
o Medicaid - PH – BH - SAMHSA Funds - State Only Funds
3. Integrated Plan Infrastructure Requirements4. Crisis System Design5. Justice System Transitions6. Value Based Purchasing7. Health Information Technology – HIE8. Duals
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Integrated Plan RequirementsMCOs cannot delegate critical functions1. Grievance System2. Quality Management/Medical
Management3. Provider Relations4. Network and Provider contracting and
oversight5. Member Services 6. Corporate ComplianceReaching across Arizona to provide comprehensive
quality health care for those in need
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• Multiple Plans have partnered to create and support community social service centers
• MCO pilot to invest in low-income housing subsidy
• AHCCCS has dedicated staff resources focused on housing – employment – peer services
• State only investments made through RBHAs
State Housing Funding for Individuals with SMI
Social/Economic Determinant Efforts
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FY 2011
FY 2012
FY 2013
FY 2014
FY 2015
FY 2015
0
5
10
15
20
25
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Justice System Transition Efforts• Daily feeds with DOC/Jails +>90% pop.• Member suspense – reinstatement• Daily feed to plans - $30m cap savings• Pre-release apps processed• 1,100 care coordination efforts with MCOs• Extensive work done by RBHAs in jails• New reach-in requirements for MCOs• Working on HIE connectivity
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Value Based Purchasing and Alternative Payment Models -
Efforts to Date1. AHCCCS role – establish broad goals for system 2. Overall progress is incremental3. System Design Matters - True VBP requires
integration to align incentives4. Pursuing VBP requires resources and leadership 5. Creating a culture of learning is critical6. Commitment to keep VBP $ in system 7. Requires improved access to actionable data8. Defining measures is challenging
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Value Based Purchasing GoalsProgram CYE 15 CYE 16 CYE 17 CYE 18 CYE 19
Acute 10% 20% 35% 50% 50%
ALTCS EPD
5% 15% 25% 35% 50%
RBHA 5% 15% 25% 35%
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AHCCCS VBP Fee Schedule Changes• 2014 – Hospital IP – APR-DRG• 2015 - MCOs pay FQHC full rate• 2016 - Hospitals bump for sharing data with
HIE and meeting MU2• 2016 - SNFs – increase for those above avg
with pneumococcal vaccine• 2016 - Integrated Clinics- physical health • 2016 – stand alone ED – new provider type• 2016 – Treat and Refer
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LAN Payment Reform Framework
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What is DSRIP?• Federal funds administered by the
Centers for Medicare & Medicaid Services (CMS)
• DSRIP initiatives provide states with funding to support providers in changing how they provide care to Medicaid beneficiaries
• DSRIP initiatives are part of broader Section 1115 Waiver programs
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DSRIP Initiatives • Five years • No official federal criteria for DSRIP
program qualification• States have taken varying approaches• Payment incentives distributed for
meeting performance outcomes Providers can use funds to develop systems, infrastructure, and/or processes
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DSRIP Emphasis over 5 Year Period
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Arizona’s DSRIP Focus Areas• Adults with Behavioral Health Needs• Children with Behavioral Health Needs
o Children with and At-Risk for ASDo Children Engaged in the Child Welfare
System• Members Transitioning from the
Justice System• *Individuals enrolled in the American
Indian Health Program (AIHP)23Reaching across Arizona to provide comprehensive
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Role of Managed Care Organizations• DSRIP accelerates Arizona’s efforts to integrate at payer
and provider level.• DSRIP looks to build on Value Based Payment efforts by
requiring MCOs and providers to continue increased Alternative Payment Models that drive to greater risk alignment
• DSRIP leverages important roles for MCOs in justice system initiative by having RBHAs serve as DSRIP lead while partnering providers and other managed care organizations
• DSRIP leverages MCO structure by allowing MCOs to be DSRIP lead for Integration strategic focus areas
• Provider organizations may form DSRIP entities but must collaborate with MCOs that have specific roles around data aggregation and sharing
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Transformation Measures
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DSRIP Strategic Focus Candidate Measure #1 Candidate Measure #2 Candidate Measure #3Justice transition: Individuals released from Incarceration
Adults access to preventive/ambulatory health services (HEDIS)
Follow-up after emergency department visit for alcohol and other drug dependence (HEDIS)
Adult body mass index assessment, (HEDIS)
Children: behavioral/physical health integration
Well-child visits in the third, fourth, fifth and sixth years of life for children with a behavioral health diagnosis (HEDIS, modified)
Follow-up after emergency department visit for mental illness (HEDIS)
Mental health utilization (HEDIS)
Adults: behavioral/physical health integration
Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications (HEDIS)
Follow-up after emergency department visit for mental illness (HEDIS)
HbA1c poor control >9% for adults with diabetes and a behavioral health diagnosis (HEDIS measure component, modified requiring chart review)
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APM Proposed TargetsDSRIP Year Percent Spend LAN 2-4 Percent Spend LAN 3 & 4
Year 1 30% NA
Year 2 40% 5%
Year 3 50% 10%
Year 4 60% 20%
Year 5 70% 40%
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Proposed Funding
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Programs DY 1 DY 2 DY 3 DY 4 DY 5 Totals
Justice $22 m. $22 m. $22 m. $18 m. $16 m. $100 m.
Adult BH Integration $156.99 m. $156.99 m. $156.99 m. $116 m. $92 m. $678.97 m.
Pediatric BH Integration $156.99 m. $156.99 m. $156.99 m. $116 m. $92 m. $678.97 m.
Totals $335.98 m. $335.98 m. $335.98 m. $250 m. $200 m. $1,457.94 m.
Arizona DSRIP-Additional Information• https://www.azahcccs.gov/AHCCCS/Ini
tiatives/DSRIP/
• http://kff.org/report-section/an-overview-of-delivery-system-reform-incentive-payment-waivers-issue-brief/
• https://www.azahcccs.gov/shared/fiveyear.html
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