This week, our In Focus section provides a recap of the third annual HMA Conference, The Rapidly Changing World of Medicaid: Opportunities and Pitfalls for Payers, Providers and States, held this Monday, October 1, and Tuesday, October 2, in Chicago, Illinois. More than 450 leading executives representing managed care organizations, providers, state and federal government, community-based organizations, and other stakeholders in the health care field gathered to address the opportunities and challenges facing health plans, states, and providers as they strive to provide the best possible care to Medicaid beneficiaries and other vulnerable populations at a time of significant uncertainty and change. Conference participants heard from keynote speakers, engaged in panel discussions and connected during informal networking opportunities. Below is a summary of highlights from this year’s conference.
“Medicaid in an Era of Community Engagement and Shared Responsibility”
Michael Leavitt, General Partner of Leavitt Partners, former governor of Utah, and former Secretary of the U.S. Department of Health and Human Services spoke about how the nation is 25 years into a 40-year health care transformation, with the 2018 election representing another phase in the journey toward value-based care. While the 2018 election will see a reemergence of various ideas – including Medicare-for-all among Democrats and market-based solutions among Republicans – a middle ground suggests support for the key components of the Affordable Care Act, continued expansion of Medicaid, and stabilization of the ACA Exchanges. “The ACA lives on,” Leavitt said adding, “This is how Democracy works.” According to Leavitt, Democrats and Republicans agree that the need for cost control is driving efforts towards value-based health care; however, they remain divided on the structure of an integrated, value-based care model. He also noted that health care stakeholders need a shared definition of “value” and its metrics, information systems capable of supporting population health management, and a willingness to go beyond a “lukewarm defense” of the value-based concept.
State Medicaid Director Keynote Q&A Session
“How States Are Fostering Community Engagement and Innovation in Medicaid”
Next up, HMA convened five state Medicaid directors to discuss how they are using waivers to restructure Medicaid programs to meet the unique needs and priorities of their states, with an emphasis on member engagement, payer and provider accountability, and innovation. Speakers highlighted the impact of Medicaid work requirements and community engagement, including the challenges of alerting members to their responsibilities under these new requirements. Justin Senior, Secretary, Florida Agency for Health Care Administration, cited the unique challenges facing non-expansion states that might be considering the implementation of Medicaid work requirements, including the administrative level of effort related to managing such a program that will impact a very small number of current Medicaid beneficiaries. Other topics included efforts by Medicaid to change how providers practice, setting specific value-based payment targets for managed care plans, and efforts to address the opioid epidemic. Other speakers included Stephanie Muth, Associate Commissioner, Medicaid/CHIP Medical and Social Services Division, Texas Health and Human Services Commission; Allison Taylor, Director of Medicaid, Indiana Family and Social Services Administration; and Matt Wimmer, Administrator, Division of Medicaid, Idaho Department of Health and Welfare.
Medicaid Managed Care Keynote Q&A Session
“The Next Wave: How Medicaid Plans are Positioning Themselves for Success”
Executives from leading Medicaid health plans discussed what’s next for Medicaid managed care, including a look at the types of investments, partnerships, and initiatives that will best position the industry for success. A key theme surrounded the challenges of the request for proposal (RFP) process states use to award contracts to Medicaid managed care plans. One speaker noted, for example, that the RFP process does not invite effective partnership with states, but rather sets rules and limitations. Another noted RFPs are full of unfunded mandates, including requirements to provide a variety of social services. While a third pointed to considerable amounts of time, energy, and money spent on the RFP process that takes away from the focus on identifying areas where plans can have the most positive impact on Medicaid. Another key area of concern was the impact of social determinants of health. “Social determinants of health are real and we must acknowledge them,” stated Jack Stephenson, President and Chief Executive of Empire BCBS HealthPlus. John Baackes, Chief Executive of L.A. Care Health Plan, added that income inequality must be addressed. Other speakers included Janet Grant, Head, Aetna Medicaid, Great Plains Region; and Catherine Anderson, Senior Vice President, Policy and Strategy, UnitedHealth Community and State.
“Medicare-Medicaid Integration: Emerging Models and Opportunities”
Speakers during this session highlighted the complexity of the current Medicare and Medicaid systems for dual eligible beneficiaries and the status of current and future state and federal efforts to implement integrated managed care models. These efforts include comprehensive Medicare and Medicaid services delivered by Medicare-Medicaid plans (MMPs), Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs), Fully Integrated Dual Eligible Special Needs plans (FIDE SNPs), and the Program of All-Inclusive Care for the Elderly (PACE). Dually eligible beneficiaries need choice of a continuum of integrated care options that reflect their diverse needs, speakers noted. Consumer education is crucial, with a need for clear, understandable information on program options and benefits, particularly care coordination and care management. There have been successes in improved access to care and more appropriate use of services for individuals through these models. Continued efforts to extend, build on and further streamline models must be done with the beneficiary at the center of policy planning and program design. Speakers included Bernadette Di Re, Chief Executive, UnitedHealthcare Community Plan of Massachusetts; Peter Fitzgerald, Executive Vice President, Policy and Strategy, National PACE Association; Michael Monson, Senior Vice President, Medicaid and Complex Care, Centene Corp.; and Cheryl Phillips, MD, President, Chief Executive, SNP Alliance, Inc.
“Behavioral Health: How Value-Based Contracting Is Driving Payer-Provider Partnerships”
Speakers discussed how value-based payments can be a market-based solution for behavioral health, helping to address the high cost of treating serious mental illness and substance use disorders. Ann Sullivan, Commissioner, New York State Office of Mental Health stated that under the value-based payment structure, Medicaid managed care organizations must aim to improve quality, reduce costs, focus on patient experience, and build care team well-being. Value must be go beyond staying out of the hospital and focusing on recovery, including employment, housing, and community stability. Other speakers included Lou Dierking, Senior Vice President, Behavioral Health Payer Channel Lead, Optum; David Guth, Chief Executive, Centerstone America; Jim Spink, Former President, Mid-Atlantic Region, Beacon Health Options.
“Addressing Social Determinants of Health: Emerging Payer-Provider Partnerships”
Using the Centers for Medicare & Medicaid Services Innovation Center’s Accountable Health Communities framework to define social determinants of health, this panel discussion focused on efforts to improve outcomes by addressing health-related social needs such as housing and employment. Kathye Gorosh, Senior Vice President, Strategic Initiatives, AIDS Foundation of Chicago (AFC), discussed how social determinants of health play a key role in improving health equity for individuals with HIV or are vulnerable to contracting the virus. She outlined a partnership between AFC’s Center for Health and Housing and University of Illinois Hospital & Health Sciences System, which resulted in significant reductions in ER visits, inpatient days and hospital costs by bridging housing and supportive services to health care. Karin VanZant, Vice President, Executive Director, Life Services, CareSource, discussed efforts to connect with non-traditional partners, such as major employers, to address members’ most pressing needs. By hosting job fairs and linking members to high-quality employment opportunities, CareSource is creating a pathway to improve health outcomes and encourage self-sufficiency for their members, she said. James Kiamos, Chief Executive, CountyCare Health Plan, Cook County Health and Hospitals System, discussed CountyCare’s role as a vehicle for engagement and stability in the public delivery system. As Cook County’s largest Medicaid plan, CountyCare has partnered with Medical Home Network to address social determinants of health and improve health outcomes through care coordination. Cheryl Lulias, President, Medical Home Network and Chief Executive, MHN ACO, reviewed the practice-level care management her team provides to CountyCare members and the power of technology and data sharing in screening, risk stratifying and predicting rising risk in the member population.
“How Health Plans and Providers Are Joining Forces to Improve Patient Care”
Speakers discussed some of the challenges and solutions to creating successful partnerships, while noting that the move toward value-based payment models has resulted in alliances that were once considered unlikely between payers and providers. Panelists emphasized the need for transparency, establishing a single mission and vision with aligned goals, emphasizing member communication, and focusing on improving care while reducing costs. Only after this initial foundation is built can these partnerships develop new models of care that improve patient outcomes and lower costs. Speakers included Edward Fishman, Managing Director, Cain Brothers; Brent Layton, Executive Vice President, Chief Business Development Officer, Centene Corp.; Pete November, Senior Vice President, Chief Administrative Officer, Ochsner Health System; James Schroeder, Vice President, Safety Net Transformation, Kaiser Permanente; and Ed Stellon, Executive Director, Heartland Alliance Health.
“Beyond the Basics: The Future in Medicaid Pharmacy Management and Pharmaceutical Care”
Speakers discussed new pharmacy programs and initiatives aimed at improving patient care and controlling costs, with themes including how Medicaid drug rebates and waste act as barriers to controlling Medicaid pharmacy costs. Other highlights included the emerging role of ACOs, new clinical programs, State Innovation Model (SIM) grants, partnerships with community pharmacies to improve treatment adherence, new models that bring value to specialty drug spending, and a discussion of the need to engage pharmacists in patient care. Speakers included Paul Jeffery, Director of Pharmacy for MassHealth; John Stancil, Director of Pharmacy, North Carolina Department of Health and Human Services; Scott Streator, Managing Principal, Government Program Services, MedImpact; Jim Gartner, VP Pharmacy and Retail Strategy, CareSource; Krista Ward, Senior Director, Medicaid, Express Scripts; and Andrew Fox, Director, Healthcare Segment Development, Walgreens.
“Best Practices in Medicaid IT and Business Process Transformation”
Speakers outlined strategies for addressing the numerous challenges faced by states, managed care plans, and providers in the design and implementation of Medicaid information technology systems. A theme of the discussion was how Medicaid IT efforts are hindered by regulatory changes, insufficient focus, and resource constraints – despite billions of dollars of investment. Speakers cited realistic expectations, access to data, clearly defined projects and staff responsibilities, communication, use of pilots, investigating problems at an early stage, and recognizing built-in support structures as critical success factors for Medicaid IT initiatives. Luis Sylvester, Executive Account Manager, U.S. Virgin Islands, Molina Medicaid Solutions, discussed a partnership between West Virginia and the U.S. Virgin Islands that led to the first Medicaid Management Information System (MMIS) for a U.S. territory. By utilizing the existing MMIS platform West Virginia had created, the U.S. Virgin Islands implemented a certified MMIS within 10 months, allowing the territory to expand Medicaid and restore CHIP funding. This initiative resulted in successful completion of CMS annual audits, accurate and timely CMS reporting and payment of provider incentives. Other speakers included Jared Linder, CIO, Indiana Family and Social Services Administration and Jennifer Harp, Deputy Executive Director, Office of Administrative and Technology Services, Kentucky Cabinet for Health and Family Services.
“What’s Next for Integrated Care: A Status Report and Forecast”
John Jay Shannon, M.D., Chief Executive of Cook County Health & Hospitals System (CCHHS), highlighted the glaring health inequities among Cook County residents, including differences in life expectancy of up to 15 years depending on a person’s neighborhood. While charity care has decreased across the country since the introduction of the Affordable Care Act, Shannon said, CCHHS’s payer mix still consists of 80 percent Medicaid or uninsured/self-pay patients who rely on the system as a safety net system. With a diminishing tax-payer allocation to its budget in recent years, CCHHS has emphasized the importance of adapting services and programs to meet the needs of its target population while continuing to operate at a high level of efficiency. In 2012, for example, CCHHS introduced CountyCare, its Medicaid Managed Care health plan, which now serves one in three Medicaid enrollees in Cook County. CCHHS also formed the Behavioral Health Consortium with 15 community-based organizations, creating a single behavioral health referral line that can immediately link individuals to appropriate care. CCHHS has established partnerships to divert individuals from jail through triage centers that provide transitional care and wrap-around services. Shannon also emphasized the importance of social determinants of health and partnering to address these needs at the community level.
Integrated Care for High-Cost Populations Keynote Session
“Managing Chronically Ill Medicaid Patients – Emerging Payer-Provider Models”
Speakers addressed emerging models for serving chronically ill Medicaid populations. “Complex patients are high cost because they are not getting the right care,” said Susan Mende, Senior Program Manager with the Robert Wood Johnson Foundation. High cost populations often have underlying social needs, yet health care and social services are often fragmented and do not address social determinants of health, she said. Leanne Berge, Chief Executive, Community Health Plan of Washington, outlined the state’s collaborative care model, which integrated mental health services in primary care settings to reduce inpatient medical admissions, inpatient psychiatric cost increases, and hospital days. Rebecca Kavoussi, President, West Landmark Health, which contracts with health plans in value-based arrangements to manage complex, chronically-ill members, sends physicians, nurses, case managers, and other providers to a patient’s home – an effort that has reduced inpatient admissions, ER visits, and SNF days. Preston Cody, Division Director, Medicaid Program Operations & Integrity, Washington State Health Care Authority also contributed to the discussion as a panelist.
“The Role of Value-Based Payments in Fostering Delivery System Reform”
Speakers discussed the role of value-based payment models in improving population health and outcomes of Medicaid beneficiaries, including how their organizations are positioning themselves to participate in emerging value-based models. Mandy Cohen, M.D., Secretary, North Carolina Department of Health and Human Services, revealed how North Carolina structured its 1115 waiver application to integrate value-based payments, with a goal of increasing value-based payment arrangements by 20 percent in its second year. By integrating best practices from other 1115 waivers and establishing regional pilots to test non-medical interventions, North Carolina will be able to align payment incentives and social determinants of health to improve health outcomes, she said. Lisa Trumble, Senior Vice President of Accountable Care Performance, Cambridge Health Alliance (CHA), said that 45 percent of the health system’s business is now in value-based models. She outlined current strategies, including payer-provider relationships, health screenings and assessments, investment in community partnerships, and the utilization of evidence-based guidelines. James Sinkoff, Deputy Executive Officer, HRHCare Community Health, highlighted the internal infrastructure needed for a delivery system to properly implement value-based payments, including departments focused on analytics and informatics, clinical quality, care management, and credentialing. He also stressed the importance of building trust, especially in payer-provider relationships, and aligning with payers to save money, improve quality, enhance the patient experience, and simplify systems. Emily Stewart, Vice President of Policy, Planned Parenthood Federation of America, demonstrated how Planned Parenthood has looked to improve the health of women of a reproductive age through value-based mechanisms. Through innovative partnerships and programs, Planned Parenthood has challenged the traditional value-based models to respond to the needs of women, including offering behavioral health co-location in offices and shifting current policy and culture to address the health crisis women are facing in the United States.