An Overview of Potential 1115 Waiver Program Options for California Children’s Services Sally Bachman, Ph.D March 1, 2010 Lucile Packard Foundation for Children’s Health

The Catalyst Center The national center dedicated to improving health care insurance and financing for Children and Youth with Special Health Care Needs (CYSHCN) Funded by the Maternal and Child Health Bureau within the Health Resources and Services Administration, USDHHS Provide technical assistance Conduct research and evaluation

Why am I here? Provide basic information about potential 1115 waiver program options for California Children’s Services (CCS) Frame the discussion that will follow

Potential 1115 Waiver program options Medicaid Managed Care Specialty Health Care Plan Provider Based Accountable Care Organization Enhanced Primary Care Case Management Implementation option: Administrative Services Organization

Within each option many program decisions are negotiable Such as: Breadth of provider networks Locus of program administration Degree of coordination for services covered or not covered by the option Sources of financing Provider reimbursement strategies Geography

More examples of negotiable program decisions Enrollment: voluntary or mandatory Quality assurance methods Characteristics of eligible children Extent of use of medical home model Extent of family involvement Nature and extent of performance measures Use of pay for performance strategies

Program elements can be combined The program options identified here are not mutually exclusive California can select one program option and “customize” it with components of other models There are many state examples of combination models

Medicaid Managed Care Key characteristics –A mainstream managed care plan that provides services to children eligible for Medi-Cal would enroll children eligible for CCS –The plan would be reimbursed through a capitated payment –The plan would be responsible for providing all services enrolled children need –The plan would handle most administrative functions –Performance measures needed to ensure quality and access

Medicaid Managed Care California’s COHS plans have experience that could be leveraged Key issues: –Whether to use mandatory or voluntary enrollment –How to risk adjust payment systems Examples: –Arizona AHCCS/ALTCS –Rhode Island RITE CARE

Specialty Health Care Plan Key characteristics –All services for children eligible for CCS included in the plan –The plan determines the provider network –Greater emphasis on including specialty providers –The plan receives capitated, risk adjusted payment from the state –The plan pays providers, possibly using different types of reimbursement strategies

Specialty Health Care Plan The plan would manage most programmatic decisions Key issues: –Whether to use mandatory or voluntary enrollment –How to risk adjust payment systems Examples: –CMS of Florida –Star Health of Texas

Provider Based Accountable Care Organization Key characteristics –State contracts with a provider network that has primary and specialty physicians and at least one hospital –Children served could be identified by condition specific criteria –Reimbursement through global payment –Greater emphasis on quality accountability and metrics –The accountable organization would handle most administrative functions

Provider Based Accountable Care Organization Current conversation about Accountable Health Organizations focuses on Medicare Model emerging from integrated delivery systems Examples –Geisinger Health System –Mayo Clinic

Enhanced Primary Care Case Management Key characteristics –Each child is linked to a Primary Care Provider (PCP) who manages care across specialties –Broad provider network –Fee for service reimbursement –PCP receives a care management fee, enhanced for CSHCN

Other ways to promote care management: a critical need for CSHCN Subtle language differences are important: –Care vs. Case Management; –Care Coordination Can be promoted outside of a managed care framework A key element of a medical home Functions should be carefully conceptualized to achieve balance between access and gatekeeper functions Examples –Oklahoma Medicaid’s care management unit and medical home tiers –New Mexico’s statewide care coordination program

An implementation option: Administrative Services Organization Key characteristics –The state contracts with a private vendor to serve as the Administrative Services Organization (ASO) –The ASO would perform a broad range of administrative activities –The ASO could provide some clinical services such as disease management –The ASO may address some of the system fragmentation issues that currently exist

Administrative Services Organization Range of activities provided by ASO is negotiable ASOs are used by many Medicaid programs Multiple examples of the practice can be found –Carve outs –Eligibility determination –Provider network development –Claims processing

CCS may need a hybrid model Potential program options do not need to be mutually exclusive For example –An ASO can be used to implement a PCCM program –Care coordination will be a cornerstone of a specialty health plan Multiple combinations can be conceptualized