Orientation to DCH Navigant Report Wendy White Tiegreen, M.S.W. Deputy Chief of Staff Department of Behavioral Health & Developmental Disabilities

DCH Medicaid Redesign Initiative Georgia Department of Community Health (DCH)=State Medicaid Authority Summer to Fall 2011: comprehensive assessment and recommended redesign of Georgia's Medicaid Program and Children's Health Insurance Program (CHIP/PeachCare for Kids®) Navigant Consulting retained to conduct this review.  Goal: “to help us look at various strategic options geared toward achieving long-term program and financial sustainability.” (http://dch.georgia.gov/00/channel_title/0,2094,31446711_175210527,00.html)

DCH Medicaid Redesign Initiative: DBHDD Behavioral Health Context: DBHDD is the policy manager, definition designer, provider network manager, utilization review organization, co-funder for DCH/Medicaid. In other words, DBHDD=Managed Care Organization for DCH for the following populations: Aged, Blind, Disabled (Adults and Youth) Foster Care Youth Managed Care Covered (CMOs) in the “Gap” Over 50,000 “covered lives” ~32,000 Adults ~20,000 Youth

DCH Medicaid Redesign Initiative: DBHDD DBHDD is Partnered with DCH on Leveraging Federal Funds: Legislative Appropriation to DBHDD Leveraged through DCH from CMS

DCH Medicaid Redesign Initiative: Reform Context Medicaid Expansion (2014): Millions of low-income adults without children Many low-income parents Some children now covered through the Children’s Health Insurance Program (CHIP) People who already are eligible for Medicaid under current rules but have not enrolled. In total, Medicaid/CHIP, is expected to cover an additional 16 million people by 2019. SOURCE: Kaiser Family Foundation

DCH Medicaid Redesign Initiative: Reform Context + CMO Contracts already extended, redesign called for Continued growth in Medicaid: DCH forecasted the need for $120.4 million for projected enrollment growth in FY 2013 (gpbi.org) Since the recession began in 2008, total enrollment in Medicaid and PeachCare has increased by more than 200,000 individuals, about 14 percent (DCH, January 2012)

Navigant Recommendations Medicaid and PeachCare for Kids® Design Strategy Report EXECUTIVE SUMMARY, January 23, 2012 DCH should become a “value‐based purchaser” by: Increasing communication among all stakeholders Reducing administrative complexities and burdens for providers and members Standardizing, centralizing or streamlining appropriate processes and forms across the CMOs Increasing patient compliance through incentives and disincentives Increasing focus on health and wellness programs and preventive medicine Other opportunities for improvement include: • Tracking progress over time in achieving quality of care improvements using the(Healthcare Effectiveness Data and Information Set) HEDIS® and HEDIS®‐like measures • Considering an approach to manage care for Georgia’s most expensive Medicaid members: those who are dually eligible and those who are aged, blind and disabled • Considering short‐ and long‐term plans for the use of technology including electronic health records and telemedicine

Navigant Recommendations Narrowed Overall Options to 3: Option 6: Georgia Families Plus; Option 8: “Commercial Style” Managed Care; and Option 9: Free Market Health Insurance Purchasing. Additional Recommendations for Specific Target Populations

Navigant Recommendations Option 6: Georgia Families Plus; (GA Families=Current CMO Model) Expands upon the current Georgia Families program by: • Incorporating extensive value‐based purchasing • Further encouraging use of medical homes, for example, through PCMHs • Reducing administrative complexities and burdens for providers and members • Increasing patient compliance through incentives and disincentives beyond those currently used in Georgia Families • Increasing focus on health and wellness programs and preventive medicine • Continuing to build upon current efforts to focus on quality • Carving in more services (e.g., transportation) and populations (e.g., dual eligibles)

Navigant Recommendations Option 8: “Commercial Style” Managed Care Expands upon Option 6, Georgia Families Plus program, a full risk‐based managed care program with value‐based purchasing: • Employs all levers and innovations typically used in commercial market, including incentives and, for some members, deductibles and copayments, to encourage members to be active participants in their health care and to comply with treatment plans • Establishes HRAs for members where rewards (e.g., incentive payments) are deposited for members who meet goals for healthy behaviors to purchase preapproved health care‐related services or items • Balances in HRAs could be used in a shared savings model whereby members, upon leaving Medicaid or reaching the end of the benefit year, have the option to spend a portion of remaining funds on pre‐approved items such as health club memberships

Navigant Recommendations Option 9: Free Market Health Insurance Purchasing • DCH would provide a credit to members for purchase of insurance through the free market • DCH would not contract directly with health plans and would not process claims • DCH would partner with the Department of Insurance to define the standard Medicaid benefit packages participating health plans must offer and certification requirements specific to Medicaid (e.g., covered benefits, provider network composition and reporting) • DCH would contract with or serve as a choice counselor, helping members to select a healthplan

Navigant Recommendations Overarching Design Long-Term Care Behavioral Health Foster Care Other… Other… Other…

Navigant Recommendations Behavioral Health Options (Navigant Report, Appendix L): Carve in behavioral health services. In this risk‐based managed care delivery Carve out services to be managed by a different vendor or community vendors. Carve out population with physical health to also be managed by behavioral health providers.

Navigant Recommendations Carve in behavioral health services. Navigant: In this risk‐based managed care delivery system, behavioral health services would be included in the benefit package, along with physical health services, and the cost of the benefit would be included in the capitation rate, similar to the current model for Georgia Families. The health plan would be responsible for managing the behavioral health benefit for its enrolled population, either through a subcapitated arrangement or by developing its own behavioral health provider network, payment rates and policies governing the behavioral health benefit.

Navigant Recommendations Carve in behavioral health services, in other words: Integration is an omnibus concept, defined in many ways. There can be financial, structural and/or clinical practice integration. Integration that is financial (benefit packages, “carve-ins”, shared risk pools or other incentives) or structural (services delivered under the umbrella of the same organization, BH specialty services co-located with primary care services) does not necessarily assure clinical integration. (NCCBH, Mauer 2006)

Navigant Recommendations Physical Health Behavioral Health

Navigant Recommendations Faux Carve-Ins Physical Health Behavioral Health

Navigant Recommendations Carve out services to be managed by a different vendor or community vendors. In this risk‐based managed care delivery system, behavioral health services would be carved out to a different vendor specifically focused on managing behavioral health services. The vendor would be responsible for managing the behavioral health benefit for the same population managed through the physical health plan and developing its own behavioral health provider network, payment rates and policies governing the behavioral health benefit.

Navigant Recommendations Behavioral Health Physical Health Dental Other

Navigant Recommendations Carve out population with physical health to also be managed by behavioral health providers. In this model, individuals with specific behavioral health diagnoses would be carved out of the physical health delivery system. Their full needs, both physical health and behavioral health, would be managed and coordinated by behavioral health care providers. NOTE: Not mutually exclusive to other two options!

DCH Plan Feedback Due to DCH by February 29, 2012 (Next Week) http://dch.georgia.gov/00/channel_title/0,2094,31446711 _180745696,00.html 2 Modes for Feedback: Detail feedback submitted through “Feedback Tool” (500 Character Limit) Brief Comment (no attachments) through: MyOpinion@dch.ga.gov

DCH Plan Assessment – Completed Recommendation – Underway August – December 2011, completed. Recommendation – Underway January 2012, posting of Strategy Report. January – April 2012, review and analysis of the Strategy Report. April 2012 – Finalization of the Redesign Model. Procurement – Later in 2012, 2013 April – July/August 2012, procurement planning. July/August 2012, procurement documents to be posted. January 2013, contract award to successful vendor(s). Implementation – Planned for Early 2014 January/February 2014, implementation begins.