Transcript The Family Opportunity Act

An Overview of Potential 1115 Waiver
Program Options for
California Children’s Services
Sally Bachman, Ph.D.
617-353-1415
[email protected]
www.catalystctr.org
March 1, 2010
Lucile Packard Foundation
for Children’s Health
The Catalyst Center
• The national center dedicated to improving health care
insurance and financing for Children and Youth with
Special Health Care Needs (CYSHCN)
• Funded by the Maternal and Child Health Bureau within
the Health Resources and Services Administration,
USDHHS
• Provide technical assistance
• Conduct research and evaluation
Why am I here?
• Provide basic information about potential 1115
waiver program options for California Children’s
Services (CCS)
• Frame the discussion that will follow
Potential 1115 Waiver program options
• Medicaid Managed Care
• Specialty Health Care Plan
• Provider Based Accountable Care Organization
• Enhanced Primary Care Case Management
• Implementation option: Administrative Services
Organization
Within each option many program decisions
are negotiable
Such as:
• Breadth of provider networks
• Locus of program administration
• Degree of coordination for services covered or not
covered by the option
• Sources of financing
• Provider reimbursement strategies
• Geography
More examples of negotiable
program decisions
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Enrollment: voluntary or mandatory
Quality assurance methods
Characteristics of eligible children
Extent of use of medical home model
Extent of family involvement
Nature and extent of performance measures
Use of pay for performance strategies
Program elements can be combined
• The program options identified here are not mutually
exclusive
• California can select one program option and
“customize” it with components of other models
• There are many state examples of combination models
Medicaid Managed Care
• Key characteristics
– A mainstream managed care plan that provides
services to children eligible for Medi-Cal would enroll
children eligible for CCS
– The plan would be reimbursed through a capitated
payment
– The plan would be responsible for providing all
services enrolled children need
– The plan would handle most administrative functions
– Performance measures needed to ensure quality and
access
Medicaid Managed Care
• California’s COHS plans have experience that could be
leveraged
• Key issues:
– Whether to use mandatory or voluntary enrollment
– How to risk adjust payment systems
• Examples:
– Arizona AHCCS/ALTCS
– Rhode Island RITE CARE
Specialty Health Care Plan
• Key characteristics
– All services for children eligible for CCS included in
the plan
– The plan determines the provider network
– Greater emphasis on including specialty providers
– The plan receives capitated, risk adjusted payment
from the state
– The plan pays providers, possibly using different
types of reimbursement strategies
Specialty Health Care Plan
• The plan would manage most programmatic decisions
• Key issues:
– Whether to use mandatory or voluntary enrollment
– How to risk adjust payment systems
• Examples:
– CMS of Florida
– Star Health of Texas
Provider Based Accountable Care Organization
• Key characteristics
– State contracts with a provider network that has
primary and specialty physicians and at least one
hospital
– Children served could be identified by condition
specific criteria
– Reimbursement through global payment
– Greater emphasis on quality accountability and
metrics
– The accountable organization would handle most
administrative functions
Provider Based Accountable Care Organization
• Current conversation about Accountable Health
Organizations focuses on Medicare
• Model emerging from integrated delivery systems
• Examples
– Geisinger Health System
– Mayo Clinic
Enhanced Primary Care Case Management
• Key characteristics
– Each child is linked to a Primary Care Provider (PCP)
who manages care across specialties
– Broad provider network
– Fee for service reimbursement
– PCP receives a care management fee, enhanced for
CSHCN
Other ways to promote care management:
a critical need for CSHCN
• Subtle language differences are important:
– Care vs. Case Management;
– Care Coordination
• Can be promoted outside of a managed care framework
• A key element of a medical home
• Functions should be carefully conceptualized to achieve
balance between access and gatekeeper functions
• Examples
– Oklahoma Medicaid’s care management unit and
medical home tiers
– New Mexico’s statewide care coordination program
An implementation option:
Administrative Services Organization
• Key characteristics
– The state contracts with a private vendor to serve as
the Administrative Services Organization (ASO)
– The ASO would perform a broad range of
administrative activities
– The ASO could provide some clinical services such
as disease management
– The ASO may address some of the system
fragmentation issues that currently exist
Administrative Services Organization
• Range of activities provided by ASO is negotiable
• ASOs are used by many Medicaid programs
• Multiple examples of the practice can be found
– Carve outs
– Eligibility determination
– Provider network development
– Claims processing
CCS may need a hybrid model
• Potential program options do not need to be mutually
exclusive
• For example
– An ASO can be used to implement a PCCM program
– Care coordination will be a cornerstone of a specialty
health plan
• Multiple combinations can be conceptualized