Home Care Association of New York State Managed Care Reforms and - - PowerPoint PPT Presentation
Home Care Association of New York State Managed Care Reforms and Strategic Home Care Provider Positioning in a DSRIP / PPS Structure September 9, 2016 Gerald J. Archibald, CPA, Partner Tax-Exempt Practice Leader, The Bonadio Group 315.748.0939
Gerald J. Archibald, CPA, Partner Tax-Exempt Practice Leader, The Bonadio Group 315.748.0939 / garchibald@bonadio.com
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dsrip/docs/vbp_roadmap_final.pdf
viable payment reform
function from the consumer/patient’s perspective?
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Functioning Delivery System through Value-Based Payments: A Variety of Options
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1) Since the Medicaid Redesign Team issued its 79 recommendations in 2012, the NYS DOH has been implementing those recommendations. 2) Almost all of the recommendations being implemented are being characterized under the matter of Medicaid Managed Care Reform Initiatives (MMCRI). 3) Almost all reforms initiated to date have involved paying providers at their published Medicaid rate, subject to future negotiated rates. 4) MLTC implementation, through a state-wide effort, has created service delivery, access, and payment issues. 5) As you know, most of the MLTC / Home Care reforms are being dictated / driven by the Federal Government in the name
6) Medicaid is approaching $60 billion annually in New York State, and Medicare is approaching $50 billion annually in New York State.
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7) The primary objective of NYS DOH is to transfer its financial risk for Medicaid spending growth from NYS to both for-profit and not-for-profit Mainstream Insurance Companies. 8) The transfer of financial risk is accomplished by Capitation, Sub-Capitation, Bundled Payments, Value Based Payments, Service Carve-Outs, and More! 9) The one constant in Home Care, as well as Long Term Care, continues to be maximizing your private pay revenue to close the gap resulting from inadequate MLTC / MCO reimbursement amounts. 10) Fee For Service reimbursement is now perceived by government regulators and some healthcare industry experts to be an archaic and dying methodology that emphasizes Volume over Value. That is, volume of services provided is less important than the value / outcomes derived. 11) The primary goal of an insurance company is to generate profits and/or additional reserves while paying providers the least amount they will contractually agree to. The insurance industry also has to remain fiscally viable.
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Homes / Home Care
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between you, the provider, and the State of New York funding sources. Now referred to as “mainstream insurance companies”.
through shared services.
company benefit offering.
shown significant promise!
(Delivery System Reform Incentive Program) – 25 regional health system networks in New York State.
requiring collaboration and compromise among providers who are accustomed to competing with one another as opposed to collaborating.
with integration of provider networks across multiple counties with primary focus on mental health and substance abuse populations.
(e.g., Beacon, Magellan, etc.) – many people see the BHO as the predecessor to the Health Home model.
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Behavioral Health services available from an MCO) - in order to qualify as a Behavioral Health MCO, it must have the availability of these intensive BH services in its provider network with adequate access.
Act (Obamacare) – based on the concept of “population health” and taking full capitation risk for a population of enrolled individuals.
for purposes of contracting with the Federal Government based on “population health” principles.
Universal American, Blue Cross of Western New York, MVP, AmeriHealth, Emblem Health, United Health Care, etc. – further consolidation will occur in response to health system reforms.
discussed by NYS DOH / OPWDD for more than five years, but never fully
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plans involved the development of a fiscal intermediary. A fiscal intermediary can take a variety of forms and structures, as follows:
the insurance company acts as the fiscal intermediary between your employer and you as the individual or family insured and enrolled in a Managed Care plan.
Care (excluding vulnerable populations) where the State or Federal Government has contracted with a variety of insurance companies to create, enroll, and manage various Medicare and Medicaid populations.
fiscal intermediaries (e.g., IPAs, partnerships between insurance companies and providers, Health Homes, etc.).
Health may require either hospital system integration or “carve out” by fiscal intermediaries that are responsible for managing the cost and service quality related to specific types of services required by this population.
demand for Conflict Free Case Management has changed and will continue to change service referral relationships.
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combines the functions of health insurance, delivery of care, and administration.
you, the provider, and the State of New York traditional funding source (i.e., DOH)
formed by multiple providers to share and combine administrative functions for purposes of achieving operating / cost efficiencies
Human Resources Fundraising and Development Information Technology Managed Care Provider Contracting Finance Facilities/Occupancy/Maintenance Compliance/QA Access to Capital Financing/Credit Facilities Transportation Strategic Planning Marketing, Public Relations & Communications Administrative Functions Supporting Provider Network (e.g., IPAs)
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physicians and / or other healthcare providers that are under contract to provide services to members / enrollees of different MCOs, as well as other insurance plans, incorporating a fixed fee per enrollee (capitation) or based on a Pay-For- Performance model (P4P) (partial capitation), service carve-
the early 1970s has been on reducing the utilization of emergency rooms and hospital inpatient admissions.
member of the IPA, and the MCO.
integrated system of healthcare service delivery covering all sectors of healthcare needs for a defined population of Plan members / enrollees.
at least 10,000 lives in order to properly spread the risk associated with high cost / high need individuals.
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Contracting Team for your organization.
“template contracts” from MCO Plans, Health Homes, etc.
some modifications / addenda will be required.
based financial risk model – AKA insurance for a population of enrollees who you, the provider, does not control. 21
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MVP, VNA, United Healthcare, Aetna/Humana, etc. are the most active in the Upstate Market.
Sixteen (16) MLTC plans are currently licensed.
financial risk.
providers related to existing published Medicaid rates has been provided for in the Managed Care transition process.
provider with an MCO will be jointly contracting through an IPA entity formed by multiple providers as a Regional Provider Network.
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your organization to sign a “Participating Provider Agreement” in their Provider Service Network.
developed and presented by NYS DOH.
that in the initial contracting process (1-3 years), it is unlikely that individual providers will be subject to assuming any major degree
individual provider basis.
may be beneficial to your organization. Really depends upon the role of the PPS.
violations in both the existing system and the new requirements of negotiated MCO contracts. 23
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Source: COPE Health Solutions, February 2016 presentation – DSRIP and Value-Based Payments
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Source: COPE Health Solutions, February 2016 presentation – DSRIP and Value-Based Payments
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Source: COPE Health Solutions, February 2016 presentation – DSRIP and Value-Based Payments
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Source: COPE Health Solutions, February 2016 presentation – DSRIP and Value-Based Payments
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portion of what was Fee For Service rate reimbursement, which will then be based on service quality, cost efficiency, and desirable outcomes (VBP).
DOH and the MCOs, are anticipated to be used as the “Bible”.
Intermediaries for purposes of paying individual providers or the IPA entity.
spread across multiple providers who are IPA members. Providers must be careful in assessing the quality and cost of
rate reimbursement towards P4P-targeted payment methodologies.
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flexibility than a Worker’s Comp Self Insurance Trust -- specifically, variable withholds for individual provider members of the IPA.
continue to be reimbursed in the short-term based on either Medicaid rates or negotiated rates including the Federal Wrap Payment.
individual providers or provider networks to develop creative / innovative alternatives to traditional service delivery modalities.
Fee For Service, 2-10% = performance-based compensation in a VBP model.
funded by a provider withhold / financial risk pool based on claims submitted during each year. 30
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regulations, as long as…clinical and financial integration processes are implemented.
creative solutions from providers that address the Triple Aim for the State’s Managed Care Reform Initiatives.
billion of Federal funds for the Delivery System Reform Incentive Program (DSRIP).
been allocated to the 25 PPSs over a five-year period (ending March 31, 2020).
Implementation Plans and received a financial award that will reimburse them tens of millions of dollars if they achieve their implementation goals. 31
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Panel meetings made it quite clear that their intention is to integrate the DSRIP / PPS initiative in its yet to be negotiated contracts between the State and the traditional MCOs.
in a dominant and controlling decision-making position related to Medicaid eligibles
heard from
with the MCOs / Mainstream Insurance Plans
guidance from DOH as to how their implementation plans and DSRIP awards will be balanced with the terms of these MCO contracts 32
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delivery is still unknown in the following areas, among others:
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York State will continue to have increasing role and responsibilities, IF they are successful in their objectives. Children’s Health Homes are in process of implementation.
whether a patient receives an MRI vs. CT Scan vs. PET Scan or who is entitled to joint replacement surgery.
implementation for the employed population, the focus for the Medicaid vulnerable populations is still on avoiding emergency room visits and inpatient admissions / re-admissions. As you all know, these facility-based services are typically higher cost and not viewed as cost effective in relation to community-based services. 34
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effectiveness, and appropriate need for frequency of service delivery.
interest and ethical issues for providers and particularly clinicians and administrators.
increase your risk management and compliance program initiatives.
training and education related to the revised approaches to individual resident service delivery and service modalities.
Collaboration, Competition, Compensation, Care coordination, Convergence, Contracting 35
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Member Per Month (PMPM) to the MCO will determine the amount of “pain or pleasure” that providers will experience from a financial perspective.
State’s or the provider’s reference point for determining PMPM amounts.
bear no relationship to the actual cost of the service being delivered.
formation of a Regional Network (i.e., either an IPA or a joint contracting LLC).
should be to achieve a strategic position that:
negotiating leverage. 36
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provided to MCOs.
provider will agree to with the most favorable MCO terms and conditions.
targeted return on their investment (profit / capital reserves)!
needs to determine whether it wants to negotiate individually or in collaboration with a provider network through an IPA structure 37
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changes will be required.
and answering the following questions:
in the next 3-5 years or is it more feasible to merge with or be acquired by another organization? (That is, is your service niche exceptional or is your organization already too big to ignore as a provider?)
Compliance Program?
contracting decisions regarding network participation (e.g., IPA) and negotiating favorable payment rates / incentives will be of paramount importance. 38
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These software applications may not yet exist at the level of sophistication necessary to truly “Manage Care”.
all program service components.
accommodate revised contract payment methodologies (e.g., incentive payments for achieving performance goals, P4P).
bundle payment methodology? 39
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affiliation and merger options with other providers.
formation of and participation in a regional IPA. 40
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lowest cost of care
clients needs vs. wants
Budget ($$$)
result in more Palliative vs. Curative service delivery (e.g., reduced Emergency Room utilization and inpatient admissions)
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1.
Under Managed Care principles, New York State is "transforming” the health and human service delivery system from providing services that individuals / families / guardians “want” to a system based on an assessment of what the individual “needs”. How does your organization evaluate the impact of this transformational change from a service delivery perspective?
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What strategies has the Home Care provider developed to plan for and address the impact of this transformational change resulting from Medicaid Managed Care reforms? (Medicare as well)
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New York State has selected a traditional Care Coordinator / Manager “model” to serve as the “gatekeeper” for determining what services are needed by each individual being served. How does the Home Care provider assess the impact of this shift in the referral of service role from the current referral sources to the Care Coordinators / Managers? (There are a variety of Managed Care Organizations – MCOs – that will become the primary referral sources.)
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NYS has acknowledged its objective very clearly in its Medicaid Waiver application. The State’s “Triple Aim” is to achieve:
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Better service quality
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Better health outcomes
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Reduced / more efficient costs of delivery
This “Triple Aim” is filled with inherent conflicts for providers. How will the Home Care provider achieve each of the goals specified in the State’s “Triple Aim” mantra while maintaining fiscal viability?
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NYS has made it quite clear, with the Department of Health (NYS DOH) now driving the bus, that fewer health and human service providers with reduced administrative costs will be one
address its administrative cost efficiency and, more broadly, the State’s desire for mergers, affiliations, and shared service
system?
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6.
Traditional managed care principles will affect all aspects of health and human service provider programs in the following areas:
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Restricted access, A/K/A challenges to service eligibility
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Relocation of service delivery sites
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Rationing of services through care coordination
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Redistribution of the health and human services fiscal budget ($$$)
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Reduced end of life care – Palliative v. Curative (e.g., reduced emergency room utilization)
How does the Home Care provider intend to proactively address the potential impact of the areas listed above to address and achieve the State’s “Triple Aim” referred to above?
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NYS and the federal government are expecting cost efficiencies together with health and service outcomes. What structural and operational changes will the Home Care provider require to compete in this changing environment?
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The following areas are of highest priority in evaluating the question above:
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Partnering/merger/affiliation with other service providers
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Participation in regional provider networks
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More sophisticated cost accounting and electronic records for all program components
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Restructuring your billing and accounts receivables systems to accommodate revised contract payment methodologies (e.g. incentive payments for achieving performance goals, P4P)
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Incremental cost structures on administrative infrastructure (technology, compliance, etc.) will be a significant challenge in assessing your
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How is the Home Care provider communicating with its patients for purposes of informing them of the potential massive changes in program service delivery?
the “Wal-Marting” of the community based health and human service providers?
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