Washington State Indian Health Care Delivery System American Indian Health Commission for Washington State Presented By: Vicki Lowe, AIHC Executive Director
A MERICAN I NDIAN H EALTH C OMMISSION FOR W ASHINGTON S TATE Mission: Improve the health of American Indians and Alaska Natives (AI/AN) through tribal-state collaboration on health policies and programs that will help decrease disparities Work on behalf of the 29 federally-recognized Tribes and 2 Urban Indian Health Organizations in the state Key: Tribal Councils and UIHP appoint delegates to represent the I/T/U through resolution
G OVERNMENT TO G OVERNMENT R ELATIONSHIPS : S TATE AND F EDERAL Federal Trust responsibility to protect Tribal sovereignty/lands – legal obligation Federal Executive Order 13175 WA Centennial Accord 1989 RCW 43.376.020 codified the Accord The government-to- government relationship “respects the sovereign status of the parties, enhances and improves communications between them, and facilitates the resolution of issues.”
U RBAN I NDIAN H EALTH P ROGRAM I NCLUSION Section State Plan 1902(a)(73) of Amendment the Social #TN11-25 Indian Health Care Security ACT Provider (IHCP) means a health care program operated by the Indian Health Services (IHS), Tribal Organization or Urban Indian Health Program (otherwise know as the ITU)… Section 4 of the CMS Dear Indian Health Tribal Leaders Care Letter Improvement January 22, Act – 25U.S.C. § 2010 1603
I NDIAN H EALTH S ERVICE (IHS) The chronic underfunding of I.H.S. Congressional Budget The U.S. spends more programs has made Office (CBO) estimates dollars per capita on the use of alternate that IHS2018 budget is resources vital to these federal prisoners than on funded at less than programs AI/AN people 32% of the need RESULT: AI/ANs have the worst overall health outcomes of any other population in Washington State
I NDIAN H EALTH C ARE D ELIVERY S YSTEM (IHDS) I/T/U Facility Referral & Coordination Dental Medical Behavioral Specialty Care Inpatient Care
I N W ASHINGTON S TATE • 29 federally recognized Tribes • 2 Urban Indian Health Programs (UIHPs) • Total of 37 clinics: – 4 are operated by the Indian Health Service – 31 are operated by Tribes – 2 UIHP serving major metropolitan areas of Seattle and Spokane – 3 Tribes do not have primary care clinics and provide care through PRC funds.
P ORTLAND A REA I NDIAN H EALTH S ERVICES (PAIHS) Hospital PRC funds have Reducing funds Services not to be used for available for available in our this expensive specialty care area care Medicaid coverage helps save limited PRC funds
M EDICAID AND THE I NDIAN H EALTH D ELIVERY S YSTEM CMS established 100% FMAP payments to Indian Health Care providers for AI/AN claims to maintain the Federal Trust responsibility. I.H.S is payor of last resort, even with Medicare and Medicaid. Alternate Resources rules require AI/AN to sign up for and use Medicaid (and other coverages) before PRC funds can be expended on care.
T HIRD P ARTY R EVENUE – As much a part of budget as federally appropriated funds – State federal Medicaid program is one of the largest sources of third-party reimbursement – Stability of this revenue-generating source vital to clinic operations – Reduction in funding = cuts to basic Tribal health services – Tribes, UIHPs and AIHC work with the HCA to identify and implement improvements to the Medicaid system: • for AI/AN access and • Tribal provider reimbursement.
O THER C HALLENGES IN THE D ELIVERY S YSTEM Provider Remote Recruitment Areas with Cultural and few health Barriers Retention care options
T RIBAL R ESILIENCY • Holistic Health Care Best • Wrap Around Services • Integrated Care Practices • Addressing Population Health through Public Health • Economic Growth: Health is a priority of Tribal Leaders Strengths • Community Connectedness • Culture • Creative Solutions with Limited Funding
C HANGES AT THE S TATE L EVEL : Integration of Medical & State Law Behavioral Health Services SB 6312 1115 Global Healthier Waiver- Washington 1915(b) Medicaid Transformation Waiver Creation of Behavioral Health Medicaid Organizations Transition from Creation of Accountable Fee-For-Service to Communities of Health Value-Based Purchasing
I MPACTS OF S TATE L EVEL D ECISIONS : H EALTHIER W ASHINGTON I NITIATIVE I.H.S. All Inclusive rate not paid through MCOs The use of No determination of MCOs for Too many how value based Medicaid has payments will impact degraded the changes, our delivery system fee for services meetings, (FFS) network entities to follow There is no government to Additional layers of government MCO authorizations relationship and rules make between Tribes specialty care difficult and MCOs and to access AHCs.
U TILIZING 100% FMAP IN FFS M EDICAID TO F UND T RIBAL R EINVESTMENT P OOLS CMS-I.H.S . Tribal Operated Clinic Tribal Federally Qualified Health Center Contracted Specialty Providers Care Coordination Agreements Purchased and Referred Care Contracts I.H. S. Encounter Rate paid to IHCP Contracted Provider paid PRC rate Difference between encounter rate and PRC rate Becomes Tribal reinvestment funds
100%FMAP Utilization Under Current Managed Care System Specialty Provider receives contracted • Medicaid Eligible AI/AN receives Medicaid covered rate from MCO service from IHCP • No additional FMAP savings • IHCP bills Managed Care Plan • AI/AN patients sees for Specialty care payments, and receives payment MCO funded by MCO through specialty provider from the contracted rate. premium they receive from • IHCP bills Provider One for MCO network the state. balance of AIR • Specialist bills Managed • Patient Referred To specialty Care Organizations (MCO) care Provider Paid IHS Savings on FMAP All- Inclusive Rate underutilized
100%FMAP U TILIZATION E NHANCED FFS S PECIALTY N ETWORK Specialty provider receives contracted rate from TPA • Medicaid Eligible AI/AN See IHCP • IHCP then bills through • AI/AN patients sees specialty provider Enhanced FFS • IHCP payments Network* and receives with care coordination agreement in made at 100% FMAP, encounter rate place no state share • Patient Referred to • TPA bills and receives encounter rate • Specialty providers specialty care for IHCP payments paid at • TPA ensures care • Specialist paid contracted rate, either 100% FMAP, no state coordination based on Medicare payment agreement is in place share methodology or value based with specialty provider payments. • The difference between encounter rate and payment to provider goes to Provider Paid IHS All- reinvestment account. State savings on FMAP Inclusive Rate maximized * requires utilization of third party administrator (TPA)
Questions? E-mail- vicki.lowe.aihc@outlook.com or AIHC.General.Delivery@outlook.com Website: www.aihc-wa.com Phone: 360-460-3580
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