NYC AIDS Fund Learning Lab: Session 1 The Emerging Managed Care Environment … Choosing a Survival...
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Transcript of NYC AIDS Fund Learning Lab: Session 1 The Emerging Managed Care Environment … Choosing a Survival...
NYC AIDS Fund
Learning Lab: Session 1
The Emerging Managed Care Environment …
Choosing a Survival Path
Doug Wirth, President/CEO
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 Participation in the emerging environment
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:
Expansions: MLTC & Medicare (2014); BH HARP (2015)
Measure 2008-2011Emergency Room Use Decreased 63%
Admissions Decreased 74%
Hospital Length of Stay Decreased 35%
(Voluntary) Member Retention
Btw 97% - 98%
Inpatient Medical Expense Decreased 35%
Retention in Outpt Care 94% (2012)
Managed Care Models Serving Medicaid/M-care Recipients
Current Models* 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 FIDA/NYS Duals Demo – 23 Plans; Oct 2014 (v);
Jan 2015 (p); 120,000 eligible
BH HARPs – Jan 2015 (NYC); 80,000 eligible
Populations
2005 SSI
2010 HIV/AIDS
2012 Homeless *
Services **
2011 Pharmacy
Personal Care
2012 Health Homes
2013 AADHC
2014 Long Term Care
2015 Behavioral Health
Key NYS Medicaid Managed Care Population & Service Expansions
* 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
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:
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:
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:
Evidence-based Interventions for Chronic Conditions
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:
“NICHE” PROVIDER (go it alone)
e.g. Case Findings or Housing Placements or Training/Supported Employment
STRATEGIC PARTNERSHIPS (collaborate)
e.g. Health Homes or IPAs
MERGER/ASSET Consolidation (build integration)
Vertical – Integrated Service Delivery System Horizontal – Expanded Service Capacity
How Do You Choose?It starts w/ Executive Leadership doing a reality-based
INTERNAL ASSESSMENT:
Identify services of value, including contributions to achieving desired outcomes
Identify and collect data (i.e. prevented admissions, stably housed, diversions, harm reduction, etc.)?
Determine costs & risk tolerance … readiness to change
Decide whether to “go it alone” or Partner (vertical or horizontal integration?)
Negotiate & partner effectively (change mgmt.)
Create an ACTION PLAN (to innovate, build capacity, align staff/resources, deliver services & monitor results)
The time to ACT is NOW!