Transcript Community Based Organization Role In Managed Care

Doug Wirth, President/CEO
NYC AIDS Fund
Learning Lab: Session 1
The Emerging Managed
Care Environment …
Choosing a Survival Path
Today’s Discussion:
 Review
State Goals -- MRT, MMC & DSRIP
 Explore Key Questions:
 What do plans want now (need in the future)?
 How to position the missions/services of smaller
HIV/AIDS CBOs?
 Survey Options for Meaningful
in the emerging environment
Participation
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Founded in 1999 by 7 CBOs that offered HIV/AIDS Services (+)
Started serving HIV+ members in 2003 & HIV- homeless in 2014
6,100 Members (w/ multiple & complex needs)
Key Outcomes:
Measure
2008-2011
Emergency Room Use
Decreased 63%
Admissions
Decreased 74%
Hospital Length of Stay
Decreased 35%
(Voluntary) Member Retention
Inpatient Medical Expense
Btw 97% - 98%
Decreased 35%
Retention in Outpt Care
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Expansions: MLTC & Medicare (2014); BH HARP (2015)
94% (2012)
Managed Care Models
Serving Medicaid/M-care Recipients
Current Models*
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Medicaid Managed Care – 8 General Plans
HIV SNP – 3 Plans
MLTC – 23 Plans (and expanding)
* NCQA found that NYS ranked 2nd only to MA in Medicaid Managed Care quality.
Emerging Models
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FIDA/NYS Duals Demo – 23 Plans; Oct 2014 (v); Jan 2015
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BH HARPs – Jan 2015 (NYC); 80,000 eligible
(p); 120,000 eligible
Key NYS Medicaid Managed Care
Population & Service Expansions
Populations
Services **
2005
SSI
2011
2010
HIV/AIDS
2012
Homeless *
Pharmacy
Personal Care
2012
Health Homes
2013
AADHC
2014
Long Term Care
2015
Behavioral Health
* The State allowed HIV- homeless individuals to join HSNPs in 2014.
** The 2012-13 State Budget gave authority to SDOH Commission and Medicaid Director, by 2015, to eliminate all
Medicaid FFS carve-outs and any population exemptions.
Key Reasons for NYS Medicaid
Redesign, MMC & DSRIP
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Medicaid Spending Increases
Overall Quality of Care – “Average”
20% Enrollees (1 million) w/ High Need/High Cost
Reduce Avoidable Admissions
Desired “Care Management for All”
Hospital System Collapses & Consolidations
System Transformation
Clinical Improvements (Evidence-based)
Integrated Care Delivery
Shift to Quality Based Payments & Other Reforms
Sources: Medicaid Redesign Team Update and Next Steps Presentation: Jason Helgerson, SDOH, July 2013; NYS
BHO 2012 Reviews and Implementing Medicaid BH Reform in New York: Bob Meyers, SOMH, Sept 2013.
NYS Health Home SPA for Individuals w/ Chronic Behavioral & Medical Health Conditions - SPA # 11-56.
If managed care is the content for the future …
What do Plans need to demonstrate/do:
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Improved Quality
Reduce Health Disparities
Create models to serve High Need/Cost
Individuals
Increase Outpatient Connectivity (PC, MH & SUD)
Reduce Costs (e.g. ERs, Admits, LTC)
Find/contract with Providers that:
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Provide integrated care (PC, MH & SUD)
Can take risk
Can share data
Q: What do you have to offer to achieve these
goals … and can you prove/show it
(outcomes)?
Things needed by
MMC & PPS/DSRIPs:
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Evidence-based Interventions
for Chronic Conditions
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HIV/AIDS
Serious Mental Illness
Substance Use/Addictions
Long-term Care Alternatives
Social Determinants of Health
Housing Stability & Food Security
Job Training/Supported
Employment
Integrated Care (PC, MH & SA)
Crisis Beds (hospital diversion)
Proactive management of
patients w/ higher risk scores
Care transition models
C-B Navigation Services
C-B Ambulatory Detox/Rehab
Strategic Opportunities for CBOs:
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“NICHE” PROVIDER (go it alone)
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STRATEGIC PARTNERSHIPS (collaborate)
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e.g. Case Findings or Housing Placements or
Training/Supported Employment
e.g. Health Homes or IPAs
MERGER/ASSET Consolidation (build integration)
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Vertical – Integrated Service Delivery System
Horizontal – Expanded Service Capacity
It starts w/ Executive Leadership doing a reality-based
INTERNAL ASSESSMENT:
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Identify services of value, including contributions to achieving desired outcomes
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Identify and collect data
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Determine costs & risk tolerance … readiness to change
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Decide whether to “go it alone” or Partner
(i.e. prevented admissions, stably housed, diversions, harm reduction, etc.)?
 Negotiate & partner effectively
(vertical or horizontal integration?)
(change mgmt.)
 Create an ACTION PLAN (to innovate, build capacity, align staff/resources, deliver services & monitor
results)
The time to ACT is NOW!