ORGANIZING NORTH CAROLINA S SAFETY-NET SITES INTO A HEALTH SYSTEM. A Healthy Neighbors Assurance Plan. January 26, 2017

Transcription

1 ORGANIZING NORTH CAROLINA S SAFETY-NET SITES INTO A HEALTH SYSTEM A Healthy Neighbors Assurance Plan January 26, 2017

2 TABLE OF CONTENTS Background: Our Changing Policy Landscape and its Impact on the Safety-Net Quick Look at the Safety-Net by Affiliation, Funding Sources and Geography Strengths, Weaknesses, Opportunities and Threats Facing the NC Safety-Net Proposed Solution: The Healthy Neighbors Assurance Plan Overview Operational Details Missing Pieces Building Blocks for a Way Forward: Program Leadership and Alignment Timeline to Achieve Operational Success Program Funding Needs Page 2

3 Our Changing Policy Landscape Background New Presidential administration and Congressional majorities are promising big changes to healthcare Large portions of the Affordable Care Act (ACA) are likely to be repealed and the details of any replacement is at present unknown Block grants are expected for state Medicaid programs The future of Medicaid expansion is uncertain in NC North Carolina Medicaid reform may proceed faster with or without a federal waiver Some NC Medicaid managed care consolidation efforts went into effect March 2016 Page 3

4 The Impact on the Safety-Net Background Repeal of the Affordable Care Act could jeopardize health insurance for >500,000 North Carolinians currently covered under the ACA >1,000,000 North Carolina have no or ineffective levels of health insurance No Medicaid expansion means 500,000+ North Carolinians will be without healthcare except for safety-net providers and/or hospital emergency rooms Medicaid managed care reform in North Carolina is likely to proceed quickly The numbers of uninsured will likely grow in the near term Changes to cost sharing models and the prevalence of high deductible insurance plans have exacerbated problems for populations of underinsured The Safety-Net is needed now, more than ever Page 4

5 Quick Look: Safety-Net Affiliations Background Service Sites Offered via a Network of Affiliations North Carolina Association of Free & Charitable Clinics (NCAFCC) an association of 70 free and charitable clinics 75 clinic sites North Carolina Community Health Center Association (NCCHCA) an association of 38 Federally Qualified Health Centers 202 clinic sites North Carolina Association of Local Health Directors (NCALHD) an association of primary care clinics operated by local Public Health Units 66 clinics Rural Health Centers and Clinics (RHCC) supported by state and federal funds, but not currently represented by an association 79 clinic sites School-Based Health Clinics (SBHC) supported by county funds and currently without identified leadership 25 clinics Page 5

6 Quick Look: Funding Sources Background Funding Source NCAFCC (75 Sites) NCCHCA (202 Sites) NCPHA (66 Sites) RHCC (77 Sites) SBHC (25 Sites) Other (TBD Sites) Charitable Donations Yes Yes Yes Some Yes - Government and Institutional Grants Yes Yes Yes Yes 13 ORH RHCs Yes - Medicaid 1 No 2 Yes Yes Yes Yes - Medicare 1 No Yes No Yes No - Private Insurance 1 No Yes No Yes Yes - Federal Supplemental Funding No Yes No No No - County Funding No 2 No Yes No No - State Supplemental Funding No No No Yes 13 ORH RHCs No - County/School Districts No No No No Yes - 1 Denotes minimal essential ability to file insurance in order to meet NC HIE Requirements in terms of providing encounter level data by July In rare instances, counties may provide some funding Page 6

7 Quick Look: Geographic Coverage Background Page 7 Page 7

8 Strengths, Weaknesses, Opportunities and Threats (SWOT 1 ) Facing the NC Safety-Net STRENGTHS History of innovation and leadership Recognized by regional healthcare system partners for high quality, cost effective outcomes Broad statewide coverage OPPORTUNITIES Capacity-building readiness activities for value-based contracting and value added shared services A common health gains outcomes strategy and plan for assessing progress North Carolina s Safety Net WEAKNESSES Shared purpose, management and/or administration for safety-net network Limited collective experience in VBC 2 Vulnerable to changes in state and federal funding models THREATS Meeting HIE requirements (July 2018) Moving NC safety-net towards selfdetermination requires leadership Changes to existing funding models Legal and administrative challenges 1 Expanded details of our SWOT analysis are available 2 VBC = Value Based Care Page 8

9 Proposed Solution Healthy Neighbors Assurance Plan (H-NAP) Page 914

10 Healthy Neighbors Assurance Plan A Mechanism for Engaging Essential Community Providers Under Proposed State Medicaid Reform a) A plan designed to assure health services for vulnerable populations in North Carolina through a statewide network of safety-net providers b) An opportunity to continue North Carolina s leadership in healthcare for this vulnerable population c) Mirrored after managed care and health insurance principles, but not regulated as a health insurance company d) There will be no insurance contracts with patients; however, for data collection purposes, patients will carry an H-NAP identification card e) A patient-centered approach to providing a medical home for all patients f) A statewide network of Safety-Net clinics with experience in successfully treating vulnerable populations g) Implement managed care principles, while minimizing administrative activities that are not proven to contribute to improved quality of care Page 10

11 Operational Details Healthy Neighbors Assurance Plan i) All financial revenues, irrespective of source, will be distributed on a per patient basis (similar to capitation) j) Similarly, expense data will be subject to actuarial analysis to provide applesto-apples comparisons with health insurance cost data k) All Safety-Net providers will be compliant with the state s Health Information Exchange (HIE) and submitting encounter level data by the July 2018 Deadline l) HIE data will serve as the basis for reporting unduplicated health gains outcomes for a challenging at risk population m) Safety-Net providers will serve as the initial foundation for the plan with other healthcare and social service providers engaged as appropriate n) In risk-bearing arrangements, adequate stop-loss coverage (reinsurance) will protect against catastrophic and/or outlier medical events Page 11

12 Missing Pieces Healthy Neighbors Assurance Plan o) An appropriate entity to conduct the business of the Healthy Neighbors Assurance Plan p) An appropriately experienced management team for the plan q) Consensus and support from internal and external stakeholders r) Consideration of the Healthy Neighbors Assurance Plan as an alternative to providing health insurance to vulnerable populations not covered by Medicaid Page 12

13 Program Leadership and Alignment Building Blocks Safety-Net Stakeholders Supporting Foundations Safety-Net Advocates State Health Policy Leaders Community Leaders Collective Actions Across the Safety-Net to Become Reimbursement Ready NCAFCC Randy Jordan CEO Staff and Board Expertise Point of Contact(s) NCCHCA Ben Money CEO Proposed Working Group Point of Contact(s) Staff and Board Expertise NCALHD Lynette Tolson, CEO Point of Contact(s) Staff and Board Expertise Point of Contact(s) RHCC CEO Staff and Board Expertise Business Leaders Opportunities for Shared Services Page 13

14 Leveraging All Collective Assets Targeting Social Determinants of Health NC Rural Health Leadership Alliance Demonstrated quality of care through health gains outcomes Page 14 Social Determinants of Health: 1. Economic Stability 2. Education 3. Social and Community Context 4. Health and Health Care 5. Neighborhood and Built Page Environment 14

15 Timeline of Initiatives Building Blocks Self-Determination Defining Phase 1 Propose Solution Refine and Socialize Approach Secure Funding Assessing Phase 2 Harmonize goals and define language Validate compliance with HIE requirement Evaluate current state capabilities Assurance Phase 3 Provide Targeted Support in order to meet HIE Deadline Establish Meaningful Pilot /Proof of Concept Stabilize Leadership Build Out Value- Based Capabilities Harmonize Policies and Procedures Develop Shared Services Reimbursement Ready Network of NC Safety-Net Clinics - Stable Leadership - Capable of Value- Based Contracting - Responsive to Member Clinics - National Leader in Uninsured Care Present ~6 Month Effort 6 9 Month Effort On-Going Concern Efforts July 2018 HIE Compliance Deadline 18 Month Effort Page 15

16 Sustainability of the NC Safety-Net Diversification of Revenue Sources Defining, Assessing and Assurance (Phases 1-3) Per Patient Disbursements to NC Safety-Net Sites Reimbursement Ready NC Safety-Net Pilot Self-Determination Revenue from Premiums and At-Risk Arrangements State /County Funds for Health Care Grants from Local Agencies and Businesses Foundations Focused on Health Outcomes NC Safety-Net Stewards, Vision Casters and Earliest Stakeholders Jan-2017 ~18 Month Effort Contracting and Pre-Enrollment Activities Contract Administration and PMPM Revenue Page 16

17 Program Funding Needs Building Blocks for a Sustainable Safety-Net Health System # Funding Partner Healthy Neighbor Assurance Plan Discrete Implementation Steps Phase 1 - Defining Phase 2 - Assessing Phase 3 - Assurance Self - Determination 1 - Leadership of the Initiative Funded annually over several years 2 FHLI Manpower Contributions Annual Fellowships with Mentoring 3 - Groundwork for Program Success Policy and Procedure Harmonization Across Safety-Net Stakeholders HIE Readiness and Value Based Care (VBC) Contracting Capabilities Establish Meaningful Pilot and Validate Proof of Concept(s) 7 - Implementation of Shared Services 8 - Disbursement of Funds on PMPM Basis and Establish Sources of Sustainment Page 17

18 Appendix

19 A Quick Look at the Safety-Net Its Strengths 1. Broad geographically distribution across all of North Carolina 2. A mature collaborative network of Safety-Net providers 3. A national leader in innovation 4. Proven history of low-cost efficiency in healthcare delivery 5. Demonstrated quality of care through health gains outcomes 6. Recognized benefit by hospital systems (lower ED utilization) 7. Strong history of support from state and federal government and institutional funders Page 19

20 A Quick Look at the Safety-Net Its Weaknesses 1. No central organizational, management or administrative structure 2. Inexperience in negotiating and performing under value-based contracts 3. No overarching philosophy on how to acquire needed financial resources 4. At times and in places, a competitive spirit among clinics 5. Misunderstandings of the ongoing need for funding 6. Vulnerable to political upheaval or changes 7. No uniform practices or commitments to health data collection 8. Little experience at free clinics with electronic health care claims preparation, billing and reconciliation Page 20

21 A Quick Look at the Safety-Net Its Opportunities 1. A leadership structure committed to the Safety-Net, supporting value-based care (VBC) contracts and working with managed care organizations (MCO) 2. A common health gains outcomes strategy and plan for assessing progress 3. Capacity-building in many areas to get ready for value-based contracting % capability to submit encounter level data electronically to the Health Information Exchange (HIE) and to retrieve data for analysis 5. An ability to accept and manage capitated risk payments for the Safety-Net 6. An ability to project clinic operations based on historical utilization patterns 7. Cost savings of more efficient safety-net providers as compared to traditional provider networks 8. Expanded EDI health care claim preparation, quality assurance and processing capabilities as the source of encounter level data and reporting 9. Capability to recruit and contract with Safety-Net, specialty and hospital providers Page 21

22 A Quick Look at the Safety-Net Its Opportunities (con t) 10. An ability to interact with state and federal policymakers with a unified voice 11. A stable playing field for making necessary short and long-term changes 12. An opportunity for pro-active self-determination, instead of reactive responses to an ever-changing political environment 13. An ability to negotiate with payors of all types 14. A uniform way to identify patients and monitor their interactions within the Safety-Net 15. A uniform way to process funding and treat patients irrespective of payment source (e.g., per capita) 16. Adequate stop-loss insurance to cover outlier medical events Page 22

23 A Quick Look at the Safety-Net Its Threats 1. Inaction will lead to a series of reactions rather than any attempt at a proactive plan, i.e. self-determination 2. Lack of effective organizational structure to focus efforts and address most pressing needs 3. Lack of identified skill sets and technology enablement required to administer state HIE requirements 4. Competing priorities with better advocacy groups / louder voices 5. Growing body of research around social-determinants of health are adding new engagement opportunities with at risk populations served by the NC safety-net Page 23

24 Experience in Population Health/VBC Background I. Population Health is an approach to health that aims to improve the health of an entire human population. Some would argue that Safety-Net providers have always followed the principles of Population Health by providing place-based access to care regardless of an ability to pay. Furthermore the healthcare services are often packaged with other much needed social services including faith-based support, food and shelter. Historically the coordination of care and related management processes have been lacking due to resource constraints. II. Value-Based Contracting represents risk-based relationships between insurers and healthcare providers where payments are more closely related to improving health outcomes (value) as opposed to inputs (volume) which has has historically been the pattern under fee for service (FFS) provider arrangements. NCCHCA has established an IPA and ACO in order to be able to contract with payors and accept healthcare risk. All other Safety-Net provider groups are new to value-based contracting. Page 24

25 Looming NC Regulatory Deadline Requirement to Submit Electronic Encounter Data ~450 NC Safety-Net Sites Healthy Neighbors Assurance Plan Future State Expanded Reach % of Existing Sites Do NOT Meet HIE Requirements < 50% Clinic Sites Capable of Value- Based Contracting Targeted Support to Clinic Sites Requiring Assistance Development of Shared Services Building Out Value- Based Contracting Capabilities Reimbursement Ready NC Safety- Net - Clinics meet NC HIE Requirements - Capable of Value- Based Contracting - Clear Benefits achieved through Shared Services Current State July 2018 Deadline Level of Effort Required to Organize and Support Program Led Efforts Page 25

26 Proposed Medicaid Regions

27 Managed Medicaid Regions for Behavorial Health