072616 AHCCCS Update Kohler AzRHC2016...Beth Kohler Deputy Director Reaching across Arizona to...

AHCCCS UpdateBeth KohlerDeputy Director

2Reaching across Arizona to provide comprehensive quality health care for those in need

AHCCCS Population 2006 – 2016

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

3.

Reaching across Arizona to provide comprehensive quality health care for those in need

Average Annual Capitation Growth (%)

1.4

2.8

2.0 1.8

0.00.51.01.52.02.53.03.54.0

CYE'13 CYE'14 CYE15 CYE16


Total AHCCCS System Health Plan Profits

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

2012 2013 2014 2015


Eligibility and Payment Error Rate

0.00%1.00%2.00%3.00%4.00%5.00%6.00%7.00%8.00%9.00%

10.00%

2014 2011

AHCCCSErrorRate:

NationalErrorRate:


Select HEDIS MeasuresMeasure AZ NCQA Mean

AccesstoPCP: 12-24Months 97.72% 96.1

AccesstoPCP: 25Months-6YearsofAge 89.98% 88.3

AccesstoPCP: 7-11YearsofAge 91.91% 90

Accessto PCP: 12-19YearsofAge 89.77% 88.5

Well-Child,15Months(6+visits) 69.96% 61.6

Well-Child,3-6Years 66.68% 71.5

AdolescentWellCare 40.49% 50


FY 2016 Accomplishments• BHS/AHCCCS Merger• Transitions:

o Greater AZ RBHAso Duals BH Integration

• Initiative Expansionso CRN – SMI Determination

statewideo DES Medicaid in HEAPluso Over 80 AIHP members in

care coordination• Avoided 5% provider rate

reductions

• System Improvement Activities – Reports on:o Children with or at risk of

ASDo CMDP

• Federal Submissions:o 1115 Waiver Proposal

§ AHCCCS Care§ DSRIP

o HCBS Plan


FY 2017 Opportunities• Merger:

o 7-1-16 – Complete Formal Transition

o Ongoing activities

• 10-1-16 – New 1115 Waiver• Procurements:

o ALTCS EPD o DD Subcontractors o Begin work on Acute

• Integration 2.0 Planning –Stakeholder Engagement

• Value Based Purchasing • Health Information Exchange• Justice System Initiatives• Clinical initiatives:

o ASDo Substance Use Disorder

• New Federal MCO Regulations – Access Requirements

• Mental Health First Aid Training


Ongoing Opportunities• Sustainability – including VBP• Employee Support• DCS System• Behavioral Health–Physical Health Integration• Social and Economic Determinants• Opioid Crisis


LAN Payment Reform Framework

11

Value Based Purchasing and Alternative Payment Models - Efforts to Date

1. 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


Value Based Purchasing GoalsProgram CYE 15 CYE16 CYE17 CYE18 CYE19

Acute 10% 20% 35% 50% 50%

ALTCSEPD

5% 15% 25% 35% 50%

RBHA 5% 15% 25% 35%


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 – Freestanding ED – new provider type• 2016 – Treat and Refer


VBP Differential Adjusted Rates• Effective for dates of service 10/1/16 - 9/30/17

o Inpatient/outpatient hospital services increased by 0.5%

o Nursing facility services increased by 1%o Select physical health services for Integrated Clinics

increased by 10%

• IC: List of proposed procedure codes on web is still under discussion – more information to be provided ASAP


VBP Differential Adjusted Rates, cont.• Qualifying hospitals and NFs will be

determined prior to 10/1/16• ICs can qualify throughout CYE 2017 for

dates of service that coincide with IC registration

• MCOs will be mandated to pass-through differential adjustments on MCOs’ rates


Free-Standing Emergency Departments (FrEDs)• New Provider Type 10/1/16 – effective 1/1/17• Rate methodology (dates of service on and after)

effective 1/1/17• Reimbursement based on a percentage of OFPS

o 60% for a level 1 emergency department visito 80% for a level 2 emergency department visit o 90% for a level 3 emergency department visit o 100% for a level 4 or 5 emergency department visit


FrEDs, cont.• No PGM except unique circumstance:

o City or town in county less than 500,000 residents

o Only hospital in the city or town operating an emergency department closed on or after January 1, 2015THEN

o PGM associated with nearest hospital with which the FrED shares an ownership interest


Treat and Refer• New Provider Type effective 10/1/16• A0988 – Ambulance Response, No Transport• Modifiers:

o UA – Treat at home, refer to PCP/specialisto UB – Treat at home, refer to Crisis Responseo UC – Treat at home, refer to BH Providero UD – Treat at home, refer to Urgent Care

• Will require CMS approval prior to implementation


Long-Acting Reversible Contraception • Effective 10/1/16 AHCCCS will pay hospitals for

LARC device in addition to DRGo Will be eliminated in future, if and when ICD-10 PCS

code is established and DRG Grouper updated • Billing requirements will direct hospitals to bill the

device on Form 1500• Codes/rates utilized from Physician Fee Schedule

for device


Behavioral Heath Outpatient Rates• Identified a sustainable methodology for

computing and updating rates• Setting 10/1/16 rates at median of RBHAs

FFS rates utilizing this methodology• Will review for potential impacts to cap

rates


AzEIP Speech Therapy Rates• Procedure code 92507

Treatment of Speech, Language, Voice, Communication, and/or Auditory Processingo Place of Service differentiation

§ Clinic setting§ Natural setting

o Group Size Modifier – 1 to 3 clientso Unique rate by County

• AzEIP flagged children only 22Reaching across Arizona to provide comprehensive

quality health care for those in need

340B• Drugs dispensed by 340B covered entities or

administered by 340B providers (including physicians) shall be billed and reimbursed the lesser of: 1) the actual acquisition cost of the drug or 2) the 340B ceiling price

• Does not apply to licensed hospitals and outpatient facilities that are owned or operated by a licensed hospital at this time


340B, cont.• MCOs will be mandated to comply with all

changes to reimbursement methodology for 340B entities

• 10/1/16 effective date for roll-out


Other 10/1/16 Rate Issues• HCBS rates – 2% increase proposed (EPD)• NF rates – 1% increase proposed• Air Ambulance realignment • Dental realignment • DRG – 3rd year of phase-in• FQHC PPS rates rebased


Other 10/1/16 Rate Issues, cont.• ALTCS Adult Dental of $1000 per member

begins – dates of service 10/1/16 forward• Services provided by a licensed podiatrist

covered – dates of service 10/1/16 forward• BCBA Provider Type – BC – begins effective

10/1/16


Public Notice• See the Public Notice regarding all 10/1/16

FFS rates at:https://www.azahcccs.gov/AHCCCS/Downloads/PublicNotices/rates/NOPI_FFS_RateChange07182016.pdf

• See all proposed 10/1/16 rates at:https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/AHCCCSProviderRateAnalysis2016.html


Supplemental Payment Schedule


Fund Source Timing

CAH DecemberandMay

DSH Pool4inJunePools1&2inNov/DecemberPool5thefollowingSpring

GME DependentuponCMSapproval–November/December

RHIF LateApril/EarlyMay

Trauma/EDProp202 Feb/March(Traumaonly)andAug/Sept(TraumaandED)

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


Vision - Integration at all 3 Levels


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 7. 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


AHCCCS Contract Timeline


Health and Social Care Spending as a Percentage of GDP


0

10

20

30

40

FR SWE SWIZ GER NETH US NOR UK NZ CAN AUS

Healthcare Socialcare

Source: E. H. Bradley and L. A. Taylor, The American Health Care Paradox: Why Spending More Is Getting Us Less, Public Affairs, 2013.

34

• 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


0

5

10

15

20

25

FY2011

FY2012

FY2013

FY2014

FY2015

FY2015

Health Information Technology• All MCOs must contract with a non-profit organization

that operates statewide health information exchange• State looking to leverage state only dollars to connect

BH providers to HIE through MCOs• State supports having federal government revisit Part

2 requirements• Blind Spot data – mandates MCOs leverage info • Have contractual requirements to increase use of e-

prescribing


The Network – Growth All Participants

36

-102030405060708090

100

2011YE2012YE

2013YE2014YE

2015YE2016YTD

11 2333 33

7991

Num

bero

fParticipants

88%ofthe2015/2016growthoccurred aftertheimplementationofthenewHIEInfrastructure.

SIM Sustainability - DSRIP Projects 1. American Indian Care Management

Collaborative2. Physical Health - Behavioral Health

Integrationa. Adultsb. Children

3. Justice System Transitions


38

Medical care providers, behavioral health care providers, and social service organizations rarely collaborate in a way that addresses complex needs of members.Due to fragmented funding streams providers have little or no relationship or recognition of critical potential partners.Previous system design really limited ability to drive toward alternative payment models. Because of fragmentation providers do not have the network, capacity or infrastructure to manage risk.

Overall Delivery System Limitations and Challenges


Adult Integration DSRIPFocus – Establish comprehensive approach to integrate care for adult Medicaid members that require physical and behavioral health services.Proposal – Establish 4 projects that focus on1. Integration of primary care and behavioral health

(primary care site) 2. Integration of primary care and behavioral health

(behavioral health site)3. Integration at co-located site4. Care coordination for adults being discharged from

inpatient stay39Reaching across Arizona to provide comprehensive


Children Integration DSRIPFocus – comprehensive approach to integrate care in any setting for Medicaid members under the age of 21 with special focus on children with and at risk of autism and children engaged in child welfare system.Proposal – Creates 5 projects1 & 2. Integration of primary care and behavioral health services for children and families (primary care site and BH site)3. Improving treatment for care of children with (or at risk of) Autism Spectrum Disorders (primary care site)4 & 5. Improving treatment of care for children engaged in child welfare system (primary care site and BH. site)


Justice System Efforts to Date• Have 9,000 unique Medicaid members incarcerated at some

point monthly • Daily match with county jails >90% population and DOC to

suspend/reinstate – saved >$30m cap• Make incarceration data available to plans daily• RBHAs staff established in jails – Creating reach in

requirements for other MCOs• Partnering with DOC/Jails resulted in 1,500 pre-release apps

processed • 1,100 transitions included select care coordination efforts

through manual process 41Reaching across Arizona to provide comprehensive


Current System Limitations and Challenges

• 50% of population entering Pima county jail are AHCCCS enrolled – another 30% enrolled in past 2 years

• Need ability to make more scalable• Need data to flow between justice system partners and

Delivery system• Need to be more strategic in delivering services – right service

– right place – right time• Need to ensure greater continuity to address Behavioral Health

needs of population• Continue to improve partnership with Justice System


Justice DSRIP Proposed SolutionObjective: RBHAs organize DSRIP entity to develop an integrated health care setting within the probation and parole offices and improve overall coordination: (i) coordinate eligibility and enrollment activities to maximize access to services,(ii) assist with health care system navigation, (iii) perform health care screenings, (iv) provide physical and behavioral health care services with co-located facility(v) provide care coordination services to assist the individual in scheduling initial

and follow-up appointments with necessary providers within or outside of the integrated setting,

(vi) assist individuals with coordinating/arranging continuing care within the health plan

(vii)Leverage Peer Support services(viii)Establish capacity to share data between systems


44

Staff – added new resources including BH manager and physicianRelationships–Have traveled statewide to visit Tribal providers and stakeholdersData – Sharing data with 14 different organizations on member utilizationModel – Have 130 members in active care management with providers

Care Management Model

American Indian Efforts to Date


Staff Relationships

Data TheModel

Current System Limitations and Challenges• Scale of fragmentation is significant given broad network

American Indians may access for services and geography of Arizona

• Resource limitations of Indian Health Provider Organizations to share or receive actionable data

• Limited resources within AHCCCS to create more scale around care management platform

• Historical limitations of Medicaid and other payers to cover costs of care management infrastructure.

• Significant healthcare disparities of American Indian population


46

Project 1. CMC Formation, Governance, and ManagementProject 2. Care Management and Care Coordination. Develop a care management and coordination system that will support the care delivered to American Indian populations enrolled in AHCCCS.Project 3. Care Management Data Infrastructure. Develop a data infrastructure that can support data analytics for both clinical data and claims data for participating providers through the CMC. Project 4. PCMH Development

•

Care Management Collaborative Framework

American Indian DSRIP Proposed Solution –Care Management Collaborative


Role of Managed Care Organizations• Arizona has extensive history in leveraging managed care for

all populations • DSRIP compliments 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 APM • DSRIP leverages important roles for MCOs in justice system

initiative by having RBHAs partner with other MCOs and justice system to establish DSRIP entities

• DSRIP leverages MCO structure by requiring DSRIP entities pursuing integrated projects to have formal MCO commitment and role


DSHP FundingProgram Amount Source Services Population

SmokingCessation

$18m TobaccoTax Help lineandotherservices

Smokersseekingassistance

PreventionServices

$19m Tobacco Tax Screening andprevention

Childrenages0-5

Trauma Services $25m IndianGaming Providesfunds to6level1traumafacilities

Individuals servedbyfacilities

DDHCBSFunding

$16m General Fund Home andCommunityBasedServices

State onlymemberswithincome>Medicaid

Individuals withSMI

$50m General&County Funds

Prescriptiondrugs–behavioralhealth

Individuals withSMI&income>Medicaid


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