Medicaid Managed Care - Beth Kohler

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

2

.Reaching across Arizona to provide comprehensive

quality health care for those in need

Spending by Provider Type

3Reaching across Arizona to provide comprehensive quality health care for those in need

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


Medicaid Other Health Income Security

Transportation EducationEverything

Else

5

Medicaid Portion of General Fund

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

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%


7

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


8

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


9

Vision - Integration at all 3 Levels


10

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


11

Integration Efforts


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

12

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


13

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


14

• 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


FY 2011

FY 2012

FY 2013

FY 2014

FY 2015

FY 2015

0

5

10

15

20

25

15

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


16

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


17

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%


18

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


LAN Payment Reform Framework

19

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


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


DSRIP Emphasis over 5 Year Period


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


24

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


25

Transformation Measures


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)

26

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%


27

Proposed Funding


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


https://www.azahcccs.gov/AHCCCS/Initiatives/DSRIP/



http://kff.org/report-section/an-overview-of-delivery-system-reform-incentive-payment-waivers-issue-brief/




https://www.azahcccs.gov/shared/fiveyear.html



Date post:	15-Apr-2017
Category:	Government & Nonprofit
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Medicaid Managed Care - Beth Kohler

Government & Nonprofit