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!