1. 2 Innovation in Medicaid Stephen Cha, MD, MHS – Keynote Speaker Chief Medical Officer, Center...

2

Innovation in Medicaid

Stephen Cha, MD, MHS – Keynote SpeakerChief Medical Officer, Center in Medicaid and CHIP Services

Housing as HealthcareModerated Panel Discussion

Pascale Leone, Senior Program Manager, Corporation for Supportive Housing (CSH) Richard Cho, Senior Director of Policy, US Interagency Council on Homelessness

John Monahan, CEO, Greater Trenton Behavioral Healthcare

Moderated by Kristin Miller Director, Corporation for Supportive Housing (CSH)

NYS

“It is of compelling public importance that the State conduct a fundamental

restructuring of its Medicaid program to achieve measurable improvement in health

outcomes, sustainable cost control and a more efficient administrative structure.”

- Governor Andrew M. Cuomo,

January 5, 2011

Stakeholders Representing All Sectors of the Health Care

Delivery System

- Hospitals; Hospital Associations- Managed Care Plans- Advocates, Trade Associations,

Unions- Housing Providers, Developers- State & Local Gov’t- Criminal Justice - Medical, Behavioral, Social Services

and Long-term Care Providers

NY’s Medicaid Redesign

Care Management for All

Universal Access to High Quality Primary Care

Global Spending Cap 2% Across the Board

Cut in Services

Health Homes: Multi-disciplinary teams of providers working together to coordinate care for highest utilizers of Medicaid

Targeting the social determinants of health: Medicaid now actively addressing issues such as housing & health disparities through innovative strategies like supportive housing

How We Got Here

Medicaid Redesign Team’s Affordable Housing Workgroup

Charged with making recommendations to Governor for allocating Medicaid savings into SH Co-chaired by DHCR & DOH Members:

NYS OASAS, OTDA, OMH, AIDS Institute, and OPWDD; NYC DOHMH and HPD

SH Providers and intermediaries Supportive Housing Developers Advocacy/member organizations including aging,

persons with disabilities

Collective decisions made on how to allocate monies Financing across agencies

Show Me The Money

Targets capital construction, rental subsidies and service

supports

Outcomes, measures, research and evaluation are key

components

Connects to other health initiatives i.e., Health Homes

Medicaid Redesign Investment Total $388 million

FY 2012-13 $75 million

FY 2013-14 $86 million

FY 2014-15 $100 million

FY 2015-16 $127 million

Focus

Rethinking Care for Medicaid's Highest-Need, Highest-Cost Populations

• Addressing Social Determinants of Health

• Housing is Health Care

• Targeting “high-cost” Medicaid members

• Demonstrating cost-effectiveness of supportive housing

• Delivery System Reform Incentive Payment program

Innovative Pilot Projects to Expand Models of Care

Nursing Home to Independent Living Supportive Housing Pilot

$8,000,000

rental subsidies & support services to enrolled homeless seniors & individuals w/ physical disabilities in NH or at risk of NH placement

Senior Supportive Housing Services Pilot Program

$4,500,000

supportive services & capital $$ to assist low-income seniors remain housed in their current apartments for as long as possible

Supportive Housing Health Home Pilot Project

$4,000,000

rental subsidies and/or on-site or services to house homeless/unstably housed Medicaid Health Home members to identify best practices and procedures for engaging homeless/unstably housed HH members

Homeless Senior and Disabled Placement Supportive Housing

$5,000,000

1-year appropriation to the NYC Dept. of Homeless Svcs for supported subsidized housing for difficult-to-place elderly disabled clients in shelter who are HH-eligible & receive SSD/SSI

Supportive Housing Health Home HIV + Rental Assistance Pilot Project

$1,000,000

$1M annually (2 yrs) for housing placement & rental assistance to extremely low income homeless HH participants with HIV, but medically ineligible for existing HIV-specific rental assistance program for NYers w/ AIDS / advanced HIV

Step-Down/Crisis Residence Capital Conversion

$4,000,000

2-yr pilot that provides recovery-based, person-centered alternatives to existing hospital services (e.g. short-term respite care, clinical monitoring, connection or re-connection to other MH services, & peer support.)

John Monahan, LCSWPresident & CEOGreater Trenton Behavioral [email protected]

REDUCING HEALTH COSTS

BY TARGETING

HIGH-COST USERS WHO ARE HOMELESS AND/OR AT HIGH RISK

Goal: Target the 5% of the population that account for 50% of health costs.• In New York State, 21% of Medicaid enrollees account

for 76% of health costs*• How many in NJ?

Who are the High-cost Users?Behavioral health problems• 75% of high cost users of ERs and IP have diagnosed

behavioral health problems**

Housing instability and homelessness• 45% are homeless per one study*• % with housing instability much higher

Chronic Illnesses• 76% have chronic illnesses per one study****Cited in Frequent Users of Public Services, Corporation for Supportive Housinghttp://www.csh.org/wp-content/uploads/2011/12/Report_FUFReport.pdf**Role of Behavioral Health in Avoidable Hospital Use & Cost, Rutgers Center for Health Policy, 2014, http://www.cshp.rutgers.edu/Downloads/10530.pdf

http://www.csh.org/wp-content/uploads/2011/12/Report_FUFReport.pdf

http://www.csh.org/wp-content/uploads/2011/12/Report_FUFReport.pdf

http://www.cshp.rutgers.edu/Downloads/10530.pdf



Housing 1st SH + Integrated Care Saves $$$ Strategy to reduce costs for high-cost users with co-occurring MI/SA/chronic diseases.• Numerous integrated care studies (e.g., Kaiser Permanente,

Georgia, etc.) show reduced costs.• 100+ Housing 1st studies found savings per person of $4K-10K

in health/emergency costs.• GTBHC’s Housing 1st Program

• Reduced ER & IP costs by 79% for tenants averaging $24K/year in costs

• Increased # with no ER & IP costs 85%

Supportive Housing & Housing 1st

• Housing is the “best pill”• Help tenants learn new skills

• dependency choice health• “reactive” vs proactive choosing• illness management/healthy lifestyles

• Help staff monitor risk of high cost problems• emergency and inpatient care• household problems eviction• safety problems due to gangs, drugs, etc.

Develop equivalent of Kennedy’s “Moon Launch Program” to reduce health costs: Focus everyone on integrated care and reducing health costs – i.e., all government levels/departments, MCOs/MBHOs,

providers, and consumers. Make it easy to get monitor success in real time via access to good data:

• Track ER visits via “Syndrome Surveillance ER Data” in DOH.• Track reductions in health costs via the Medicaid database.• Create provider portals into Medicaid and other health databases.

Ensure state-wide integrated care for all high-cost users and those at-risk. Pay for the full cost of success to save big $$$: rent subsidies, case management, treatment. Eliminate unnecessary, conflicting, complicated regulations avoid compliance problems Make it easy to get paid: provide cash advances + timely payment case rates vs fee-for-service

What’s keeping us from taking off?• Nothing. We’re ready.• BH providers – like ACOs – focus on reducing health

costs. – reduced state psychiatric hospital admissions 90% – 24,000 in 1955 to 2,400 in 2013 = $4 billion/yr saved.– state-wide BH provider network spanning 21 counties.

The IDS Gamecoming together with

data

So, here’s the hypothetical….

Each table is a research team working closely with the state to promote and evaluate state health initiatives.

Each table is a research team working closely with the state to promote and evaluate state health initiatives.

The Department of Human Services (DHS) is interested in understanding the linkages between housing and health.

DHS has asked your team

DHS has asked your team (and 9 other teams)

DHS has asked your team (and 9 other teams) to evaluate a recent Housing First initiative.

DHS is specifically interested in:• Has hospital utilization decreased as a

result of program participation?

?


result of program participation?• Have participant’s overall health

improved?

?



improved?• Have Medicaid dollars been saved?

?



improved?• Have Medicaid dollars been saved?And beyond health,• How many public dollars have been

saved?

?



improved?• Have Medicaid dollars been saved?And beyond health,• How many public dollars have been

saved?• How has utilization of other social

services and public institutions changed as a result of the Housing First initiative. ?

L e t ’s

L e t ’s P L A Y

Part 1:Survey the data

landscape

(4 minutes)

Your first task is to survey the data out there.


Each team has been given a game board that has county, state, and federal data in blue envelopes on the sides of the board.


Each team has been given a game board that has county, state, and federal data in envelopes on the sides of the board.

Each of these blue envelopes has a list of what data it contains.

After I say “GO”

Take some time as a team to figure out what data at the county, state, and federal level would be useful to this evaluation and why.

Discuss (4 minutes)

Take some time as a team to figure out what data at the county, state, and federal level would be useful to this evaluation and why.

(Do not open any of these envelopes).

Just Discuss (4 minutes).

Discuss (4 minutes)

Part 2:Gather existing

data!

(4 minutes)

Your second task is to gather the data.

Your second task is to gather data.

Each team has been given a game board that has county, state, and federal data in blue envelopes on the sides of the board.

Your first task is to assemble your existing data.

Each team has been given a game board that has county, state, and federal data in envelopes on the sides of the board.

Each of these blue envelopes has gray e n v e l o p e s from different entities.

These gray e n v e l o p e s contain smaller envelopes.

Some of which are empty.

Some of which contain a folded sheet of paper.

Some of these sheets of paper

may contain D A T A (= puzzle piece).

Some of these sheets of paper may contain

DATA (= puzzle piece).

After I say “GO” (4 minutes)

(1) Go through these envelopes and determine what data your team has.

(2) Check off what you have on the blue envelopes as you find the data.

Part 2:Integrate your

data!

(8 minutes)

You’ve now inventoried your existing data,

You’ve now inventoried your existing data, conducted a preliminary analysis of the data,

You’ve now inventoried your existing data, conducted a preliminary analysis of the data, done a thorough lit review,

You’ve now inventoried your existing data, conducted a preliminary analysis, done a thorough lit review, and realize that you will need additional data to tell the full story.

You’ve now inventoried your existing data, conducted a preliminary analysis, done a thorough lit review, and realize that you will need additional data to tell the full story.

You REALIZE that linking 8 particular datasets would yield the most illuminating results

Medica id data

9 - 1 - 1 c a l l d a t aMedica id data


Uni

form

Bill

ing

data


Uni

form

Bill

ing

data

Psych

iatric data


Uni

form

Bill

ing

data

Psych

iatric data

Substance Abus e Moni tor ing data


Uni

form

Bill

ing

data

Psych

iatric data


Co

rrec

tio

ns

dat

a


Uni

form

Bill

ing

data

Psych

iatric data


Co

rrec

tio

ns

dat

a HU

D voucher data


Uni

form

Bill

ing

data

Psych

iatric data


Co

rrec

tio

ns

dat

a

Homeless Management Information Systems

HU

D voucher data

It just so happens that you have IRB approval and pre-existing data agreements with the other academic teams in the room.

These data agreements comply with all relevant privacy and security standards that are applicable to the receipt, maintenance, and transmission of data that includes individually identifiable information that is protected health information as defined under relevant privacy and security standards, including HIPAA.

And under the very special circumstances of today, you can exchange data with these other teams to get the magic 8 datasets.

1.Survey what data your team has.

• You should have 4 of the magic 8 & 2 copies of each puzzle pieces (=8).

• Keep 1 copy of each, and set aside the others to trade.

2. Figure out what you still need.

• Based on the list of magic 8 , figure out what 4 datasets you still need. I will show you the magic 8 list again.

3. Pick Roles! Pick 4 people in your team to be integrators. The rest will of your team will be assemblers.

Pick 4 people in your team to be integrators.

The rest will of your team will be assemblers.

• Integrators will integrate your team’s data with other team’s data by trading your extra pieces with pieces you need.

Each integrator will trade 1 puzzle piece.

• Assemblers will assemble the puzzle while integrators trade their data around the room.

• with pieces you need. Each integrator will trade 1 puzzle piece.


3. Pick Roles! Pick 4 people in your team to be integrators. The rest will of your team will be assemblers.

Pick 4 people on your team to be integrators.

The rest will of your team will be assemblers.

• Integrators will integrate your team’s data with other team’s data by trading your extra pieces with pieces you need.

Each integrator will trade 1 puzzle piece.


• with pieces you need. Each integrator will trade 1 puzzle piece.


4. Raise your hand when your team assembles the puzzle.

Whoever assembles the puzzle first wins!!

en your team assembles the puzzle.

t h e m a g i c 8

• Figure out what you have• Figure out what you need• Pick integrators &

assemblers• Integrators trade• Assemblers assemble

Whoever assembles the puzzle first wins!!

1. Medicaid data (state)2. Uniform Hospital Billing data (state)3. 9-1-1 call data (county)4. Psychiatric data (state)5. Substance Abuse Monitoring data

(state)6. Corrections data (state)7. Homeless Management

Information Systems data (state)8. HUD- housing voucher data (state)

i n s t r u c t i o n s

I n S u m . . .

IDS RoundtableDiscussion

R e f l e c t i o n

1. How do you think an IDS could benefit your work?2. What data would you like to see in it?3. Can you contribute any data to it?4. What safeguards would you like to see in place to preserve

security and privacy of the data?

Valerie J. Harr, Director

Good Care Collaborative ConferenceJanuary 30, 2015

NJ FamilyCare/Medicaid Update

Overall Enrollment

Source: Monthly eligibility statistics released by NJ DMAHS Office of Research available at http://www.nj.gov/humanservices/dmahs/news/reports/index.html

Notes: Includes all recipients eligible for NJ DMAHS programs at any point during the month

1,100,000

1,200,000

1,300,000

1,400,000

1,500,000

1,600,000

1,700,000

Dec-091,231,314

Dec-101,278,773

Dec-111,285,963

Dec-121,301,287 Dec-13

1,284,481

Dec-141,680,938

Total NJ FamilyCare Recipients, Dec. 2009 – Dec. 2014

http://www.nj.gov/humanservices/dmahs/news/reports/index.html

1,680,938 Total NJ FamilyCare Enrollees(December 2014)

18.8% % of New Jersey pop. enrolled(December 2014)

93% NJ FamilyCare Recipients Enrolled in Managed Care

NJ Total Population: 8,938,175

Sources: Total New Jersey Population from U.S. Census Bureau 2014 population estimate at http://www.census.gov/popest/data/state/totals/2014/index.html

“Enrolled in NJ FamilyCare” from monthly eligibility statistics released by NJ DMAHS Office of Research available at http://www.nj.gov/humanservices/dmahs/news/reports/index.html

“NJ FamilyCare Recipients Enrolled in Managed Care” based on those enrolled with an NJ FamilyCare managed care organization at any point in December 2014

http://www.census.gov/popest/data/state/totals/2014/index.html


NJ FamilyCare Net Enrollment Increase(Since Dec. 2013)

Source: Monthly eligibility statistics released by NJ DMAHS Office of Research available at http://www.nj.gov/humanservices/dmahs/news/reports/index.html; December eligibility recast to reflect new public statistical report categories established in January 2014Notes: Net change since Dec. 2013; a small number of “Newly Eligible Adults Enrolled in NJ FamilyCare” were eligible for the former “General Assistance Medicaid Waiver” prior to 1/1/14; “Adults Transitioned to Exchange” includes individuals disenrolled in Dec. 2013 and not subsequently found eligible by the federally facilitated marketplace

2014 Expansion Detail

396,457

Adults Transitioned to Exchange -3,537

Medicaid Adults: 7,344Aged: 2,907Blind: -14Disabled: -2,219Children’s Services: 344CHIP Children - 142% - 150% FPL: -1,189CHIP Children - 150% - 200% FPL: 4,593CHIP Children - 200% - 350% FPL: 2,352M-CHIP Children - 107% - 142% FPL: 2,960Medicaid Children: 67,323

ABP Other Adults Up To 133% FPL: 245,451ABP Parent Up To 133% FPL: 70,142

84,401

315,593

Previously Eligible Children & Parents (Woodwork)

Newly Eligible Adults (Expansion)


NJ FamilyCare 2006-2013 Spending GrowthBelow National Trend and 2nd Lowest in the Region

Source: CMS-64 and 21 Quarterly Expense Reports from www.medicaid.gov accessed February 2014

Notes: All data shown by federal fiscal year, which runs October – September. Spending for Medicaid administrative costs not included.National and other states’ CMS-64 Information only available through federal fiscal year 2012. 111

R.I. N.J. N.Y. Pa. Mass. Md. Conn. Del.0%

10%

20%

30%

40%

50%

60%

70%

12.1%

19.7%21.3%

36.5%38.6%

55.0%57.2%

65.4%

Total Medicaid/NJ FamilyCare Spending Growth 2006-2013, Select States

2006 2007 2008 2009 2010 2011 2012 2013-10%

0%

10%

20%

30%

40%

50%

0.0%-2.1%

3.9%7.2%

16.3%

20.8%18.2% 19.7%

0.0%

5.8%

12.2%

20.8%

28.7%

36.7% 37.2%

45.4%

Total Medicaid/NJ FamilyCare Spending Growth 2006-2013, New Jersey vs. US

New Jersey

USA

Federal Fiscal Year

Expansion Population Service Cost Detail

Claim Type Claim Count Paid AmountInpatient Hospital 27,504 $190,776,705Outpatient Hospitals 1,651,334 $179,457,622Physician and Professional Services 4,323,607 $142,903,255Dental Services 654,293 $37,376,661Transportation 125,855 $2,394,905Home Health Services 7,828 $819,203Vision Services 96,539 $587,851Long Term Care 107 $357,006Pharmacy 2,267,368 $247,428Crossover Claims for Dual-Eligibles 3,906 $19,826Total Service Payments $554,940,462Average Enrollment 392,556

Expansion Group Fee-for-Service Claims and Managed Care Encounters(Payments to Providers for Services Rendered, January-June 2014)

Source: NJ DMAHS Share Data Warehouse fee-for-service claim and managed care encounter information accessed 1/9/15

Notes: The information includes all fee-for-service claims and managed care encounters paid through 1/9/2015 for services provided in January through June 2014; based on historic trends, this represents approximately 90% of all fee-for-service claims and managed care encounters for this period.- Capitation payments to NJ FamilyCare managed care organizations, “subcapitation” payments made to entities subcontracting with NJ FamilyCare managed care organization for various services, and stand-alone “Media Code 7” lump sum payments to managed care organizations are not included.- Encounters and enrollment for WellCare Health Plans of New Jersey are not included due to incomplete encounter information.- Only paid claims and encounters are included; transactions that are paid at $0.00 are not shown- In additional to traditional “physician services” claims, “Professional Services” includes orthotics, prosthetics, independent clinics, supplies, durable medical equipment, hearing aids and EPSDT, laboratory, chiropractor, podiatry, optometry, psychology, nurse practitioner, and nurse midwifery services.

Greater Access to Benefits & Improved CareMLTSS

Implementation (7/1/14)

Medicaid Expansion

(1/1/14)

20142010 2011 2012

General Assistance

Waiver (2/11)

Managed Care Carve-in

MATI Claiming

(10/12 – 12/13)

Orthodontia Revamp

ACO Legislation

Passed (8/2011)Comprehensive

Waiver Approval (10/2012) Telepsychiatry

(12/13)

EHR Payments

Begin (12/2011)

2013

Behavioral Health Rate

Increase (1/13)

Delivery System Innovation

• 8 initial applicants; 1 application withdrawn

• Proposals are under review following a public comment period

Accountable Care Organization

Demonstration

Indicators are in alignment with Healthy NJ 2020• Birth Outcomes• Childhood Immunizations• Heart Disease• Obesity

Performance Based

Contracting

Provider-Focused Initiatives

Electronic Health RecordsIncentive Payments(more than $156 million paid to providers and hospitals through 12/31/14)

Telepsychiatry

Behavioral Health Rate Increase

Applicants have a quick and pleasant experience and, once enrolled, receive high quality,

coordinated care in a fiscally sustainable system.

NJ FamilyCare Vision

Medicaid Moving Beyond a Medical Model

Jail-Involved Populations

Managed Behavioral

Health

Transportation RFP

High Utilizer Initiative

Provider Credentialing

Community Support Services

Behavioral Health Home

Medicaid Innovation ChallengeJanuary 30, 2015 2:15-3:15 pm

Background

• Public-private partnership

• $1M - $5M investment over 2 years

• Collective impact – “the commitment of a group of actors from different sectors to a common agenda for solving a complex social problem.”

• Design a project to improve Medicaid delivery system

Project Proposal

Each table will develop the outline of a project that includes:

Project name

Project benefits

Area of need

Brief project summary

Role of each team member

Timetable

1. Select area of need to address (10 min)

2. Discuss each team member’s strengths and capacities (10 min)

3. Brainstorm project ideas (5-10 min)

4. Flesh out project proposal (15-20 min)

5. Reflections by mentors (15 min)

Roles & Responsibilities

• Table captain – facilitate activity• Mentor – listen to process and provide feedback on ideas

• Scribe – document ideas

• Team members – everyone participates

Area of need (10 mins)

1. Brainstorm areas of need

2. Each member writes 2-3 areas most in need (one per post-it)

3. Organize areas of need by theme

4. Group selects 1 area of need for project

Member strengths/capacities (10 mins)

• Have each team member briefly discuss their own strengths and capacities

• Scribe documents discussion – will inform identification of project roles

Brainstorm project ideas (5-10 mins)

• Team members should generate a list of project ideas

• Collectively choose a single project idea

• Can use post-its to document ideas

Flesh out project (15-20 mins)

Consider questions:• What problem(s) is the project trying to address?• What are the primary objectives of the project? • Who is the target population? • What is the role of each stakeholder in the project?• What are the expected benefits of the program?• What are the most significant challenges to the program and how do you

anticipate overcoming them?• How will the program use data? • Is it scalable?

Complete project outline

• Project name

• Area of need

• Brief project description

• Role of each stakeholder

• Project benefits

MENTOR EVALUATION & DISCUSSION

1. 2 Innovation in Medicaid Stephen Cha, MD, MHS – Keynote Speaker Chief Medical Officer, Center...

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