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Re-Shaping Virginia Public and Private Health and Human Services Delivery System
Re-shaping Virginia Public and Private Healthand Human Services Delivery SystemPresentation to Fairfax County Human ServicesCouncilSecretary of Health and Human ResourcesDr. Bill HazelMay 18, 2013
2Health and Human ResourcesJobs andEconomicDevelopmentHomelessnessAdoptionChildren’sServicesCommunityIntegrationDOJVeteran’s andActive DutyMilitaryServicesCoordinationPrisonerReentryeHHREffective andEfficientGovernmentHealthHealth SystemReformMental HealthState ManagedShelters
31. Requires Most U.S. Citizens and Legal Residents to Have Health Insurance;– Offers enhanced federal dollars for states that choose to Expand Medicaid (atstate option) for all individuals with income under 133 percent of poverty. (plusa 5% income disregard).– Reconfigures insurance industry requiring a larger pool of insured individuals tocover the cost of eliminating insurance underwriting (i.e., pre-existingconditions) while standardizing insurance benefits and pricing.2. Creates Health Benefits Exchanges for Individuals and Small Businesses tocompare and purchase health insurance;– Offers subsidies to low-income individuals with income between 100 and 400percent of poverty to purchase insurance3. Encourages InnovationThe Patient Protection and Affordable Care Act3 Major Components
4The Supreme Court’s decision leaves it to state policymakers todecide whether or not to expand Medicaid’s incomeeligibility levels to cover all individuals up to 138% of thepoverty levelWhat does Medicaid Expansion Include?
MandatoryProvisions($142m)OptionalExpansion$280mEstimated Costs of the Affordable Care Act for Virginia: 2014-2022These costsand savingsare alreadyreflected intheGovernor’sIntroducedBudgetThese costsand savings areidentified inthe FiscalImpactStatement forthe ACAExpansionAnnual Impact of Mandatory ProvisionsAnnual Impact of Optional Expansion (only)5SFY 14:($36,673,715)SFY 14:($52,050,282)
6Federal Match for Expansion PopulationThe big question…will it remain?* Per the PPACA, federal financial participation will continue at a 90% rate beyond 2022.• Expansion must include individuals up to 133% (plus a 5%income disregard) of the Federal Poverty Level (FPL).• Savings highlights:– Community Behavioral Health Services (shift from local and state funds toenhanced federal funds)– Inmate Inpatient Hospital Savings (shift from local and state funds toenhanced federal funds)– Indigent Care Savings (shift from state funds to enhanced federal funds)Estimated Cost of Expansion in Virginia
—No consideration of expansion until significantreforms are underway within the Medicaidprogram.—2013 Legislative Session—concluded with budget language authorizingthree phases of Medicaid Reform—created the Medicaid Innovation and ReformCommission8Virginia’s Legislative Approach to Medicaid Expansion
9ImproveService Delivery:Improve Quality, PredictCosts, and Innovate whenNeededImproveAdministration:Streamline Administrationand Minimize Waste,Fraud, and Abuse.IncreaseBeneficiaryEngagement:Showcase Wellness andCost SharingObjectives of Medicaid Reform
All Medicaid PopulationsIncluding LTC inCoordinated SystemContinued StakeholderEngagement(Phase III)Value Based Purchasing inManaged Care for MedicalServices, AdministrativeSimplification andFlexibility and Innovation(Phase II)Ongoing Reforms(Phase I)Three Phases of Medicaid Reform10
11Phase II: Improvements in Current ManagedCare and Fee For Service programs– Commercial like benefit packages and service limits– Cost sharing and wellness– Coordinate Behavioral Health Services– Limited Provider Networks and Medical Homes– Quality Payment Incentives– Data Improvements– Standardization of Administrative Processes– Health Information Exchange– Agency Administration Simplification– Parameters to Test PilotsThree Phases of Medicaid Reform
Phase II (Process)New Medallion II (Managed Care) Contracts– Total reformat based on review of 13 state contracts – focus onlife cycle– Technical manual – reporting, automation, encounter data, scoring– Quality incentive– Medallion Care System Partnership – focus on models– All Payer Claims Database (APCD)– Program Integrity collaborative incentives– Improved chronic care section– Maternity care– Foster care language– WellnessThree Phases of Medicaid Reform12
Phase II (Process)Three Phases of Medicaid ReformMedicaid Managed Care “Breakfast Club”–Six Targeted Conversations–What You Get For The [Medicaid Managed Care] Dollar–Early Periodic Screening, Diagnosis, and Treatment(EPSDT)–Emergency Room Utilization–Personal Responsibility and Co-pays–Administrative Simplification–Innovation Models13
14Phase III: Coordinated Long Term Care– Move remaining populations and waiverrecipients into cost effective and coordinateddelivery models– Report due to 2014 General Assembly ondesign and implementation plansThree Phases of Medicaid Reform
Savings accrued during the first five years ofthe expansion should be protected andreinvested to improve the health deliverysystem.—Reinvestment and Savings Strategies Include:– The flexibility to invest in high quality, cost saving healthcare innovation models– Improved analytical and oversight capability at DMAS• Requirement of timely and accurate encounter data fromcontracted Medicaid managed care plans• Creation of Data and Analytics Unit at DMAS– Need to identify structure to protect savings and ensurereinvestmentReinvestment of Medicaid Funding15
Cost and Value Problems in the Healthcare Arena can’t beSolved without Significant Innovation―Innovation opportunities within PPACA are lost in theuncertainties associated with the law.―Virginia is already making progress in key innovation areas―Virginia has created the Virginia Center for Health Innovation(501 (c)3) housed out of the Chamber of CommerceSystem Wide Innovation16
Virginia HealthInnovation PlanImprovingTransparency andAvailability of DataImproving EarlyChildhoodOutcomesPayment and DeliveryReform: ImprovingCare Integrationfor Physical andMental HealthEducating andEngagingConsumers toPurchase ValueImproving theEffectiveness,Efficiency, andAppropriate Mix ofthe Health CareWorkforcePayment and DeliveryReform: ImprovingChronic DiseaseCareEach priority has adedicated workgroupassigned to explorepilot programs and toreach consensus ona recommendedthree-yearimplementation plan.Workgroups includemembers of theVHRI AdvisoryCouncil, the VCHIBoard of Directors,as well as keythought leaders ineach particularpriority area.Virginia Center for Health Innovation Priorities17
MIRCPurpose: To review, recommend and approve innovation andreform proposals affecting the Virginia Medicaid and FamilyAccess to Medical Insurance Security (FAMIS) programs, includingeligibility and financing for proposals set out in Item 307 (VirginiaBudget) in the Department of Medical Assistance Services.Specifically, the Commission shall review:(i) the development of reform proposals;(ii) progress in obtaining federal approval for reforms such asbenefit design, service delivery, payment reform, and qualityand cost containment outcomes; and(iii) implementation of reform measures.The Medicaid Innovation and Reform Commission18
Chair of Senate Finance, or hisdesignee & 4 members ofSenate FinanceChair of House Committee onAppropriations, or hisdesignee, & 4 members ofHouse Appropriations—Walter A. Stosch—Janet D. Howell—Emmett W. Hanger, Jr.—John C. Watkins—L. Louise Lucas—R. Steven Landes—James P. Massie, III—John M. OBannon, II—Beverly J. Sherwood—Johnny S. JoannouMIRC MembershipEx Officio Members:Secretary of Health and Human ResourcesSecretary of Finance 19
• Evolve Analytics Discipline across agencies• eHHR Modernization of Eligibility Services– Comply with PPACA– HHR services integrated across agencies– Build operational efficiency into social services– Fight Fraud and AbuseeHHR Effort
—CommonHelp Portal—Case Management System—Enterprise Data Management (EDM)—Business Rules Engine—Document Management System—Enterprise Service Bus (ESB)21eHHR Core Elements
Some call it the “new Medicaid” because of all the changes.Affordable Care Act requires:• Complete replacement of Medicaid eligibility criteria• Eligibility criteria must be checked real-time with Social SecurityAdministration, IRS, Homeland Security• Income must be computed using IRS Modified Adjustable Gross Incomemethodology• Applications must be accepted on paper, on-line, by phone and by fax• New coverage for Foster Children• Changes to Notifications (letters), Appeals and Complaints processing• New Presumptive Eligibility workflow for hospitals• Cases must be coordinated real-time with the Federal Exchange;electronic transfer between Medicaid and subsidized coveragePreparing to comply with ACA
eHHR Core Elements• CommonHelp Portal• Enterprise Service Bus (ESB)• Enterprise Data Management (EDM)• Business Rules Engine• Case Management System• Document Management System• Connection to the Federal FacilitatedExchange (FFE)
Department of Social Services• Leader on Eligibility Systemmodernization• Interface with Local DSS networkDepartment of Medical Assistance• MAGI Call Center Operations• Interface with Center for Medicareand Medicaid Services• Affordable Care Act policy experts• Federal Exchange expertseHHR TeamVITA• IT Hosting• Enterprise Data Management• Enterprise Service BusmentorshipDepartment of Motor Vehicles• National leadership with on-linecitizen authenticationVirginia Department of Health• Birth/death registry services
eHHR - progress to date• 11 projects on schedule (Initiation or Execution phase)• Launched the statewide CommonHelp Eligibility Services portal.• Reached agreement with the OAG on Citizen Consent languageneeded to empower the modernized eligibility system• IT system infrastructure to support Development and Testing securedand deployed on-schedule by VITA; includes new Service OrientedArchitecture/Enterprise Service Bus (SOA/ESB) modularizedarchitecture• DSS Enterprise Delivery System Program Contract solicited andawarded, signed with Deloitte Consulting on 12/19/12 25
Making Government work smarterVDSS winning the “Innovation inUtilization Award” at RichTech this monthThis award recognizes “the company ororganization whose creative use oftechnology enhances processes,methodologies, and /or services for theirsor others’ benefit.”
• The capacity to collect and analyze client-specificexpenditure data for the significant fund sources andto integrate that data with demographic andassessment data will enable the Commonwealth toanswer critical questions such as:– Are services available to the children who need them?– Are services being provided in accordance with eachchild’s needs?– Are funds for services being spent wisely?– To what extent is each program meeting the measurablegoals for that program based on the availability of services,each child’s needs, and the funds for those services?CSA Opportunities
Transparency• OCS can identify the unique childrenserved by localities requesting thosefunds.• OCS can review individual charges thatconstitute the aggregate reimbursementrequests.
Accountability• Data are being integrated across programs toidentify the total funding per child over time.• Database under development now includeshistorical child-level data from: OCS CANS score data on child need CSA claim level payment data Title IV-E funding at the claim level VDSS case data on foster care status VDSS VEMAT data on child need Medicaid claim data for child services procedurecodes
Even With CSA to Coordinate payments, Services forChildren Remain Fragmented
Local service provider data, e.g., specific costs for specific services, are notcurrently reported to the Commonwealth. We have shown through abrief, privately funded, proof of value project that these data can beefficiently collected and can be matched to other data sources to enablepowerful analysis. We have documented things such as:1. There is significant variability in the cost of services available to a childreceiving CSA services at the local level, even adjusting for child need.2. A risk-adjusted payment model can be produced to allow for comparableper diem per client estimates which will highlight outliers.3. A linear model of payment per client per day allows us to account for theeffects of the multiple variables simultaneously, e.g., gender, ethnicity,locality, assessment scores (initial and final), age, number of placements,etc. to ensure that differences are statistically significant and indicative of“risk,” i.e., potentially indicative of fraud, waste or abuse.CSA Opportunities
Lessons Learned• Some localities cannot distinguish CSA from Title IV-Efunding– Informally being stored in comment fields• Some localities using non-standard accountingpractices– methods for recording ongoing monthly payments(ex., “Payment for June, July…” recorded only incomment fields)– Inconsistent process for recording re-payments orcancelled payments.
• Recent payment of $48,446 was made to aCSA vendor in error.• Recent CSA payment for 25 shirts @Burlington for the same child.• New analytics process identified both of theseanomalies. Funds were recovered.Results
Virginia’s Movement Towards Community-Based ServicesPrior to1960Late1960s–1970sEarly-mid1970s19911972 TodayLarge trainingcenters (TCs)primary servicesourceTCCensus is5,240Growth of communityservices starts witharrival of communityservices boardsTC Census = 839;Those on Waiver =9943; Waiver WaitingList = 7864First group homesappear, communityvocationalservices beginMedicaid Waiver for Homeand Community-Basedservices and Medicaid StatePlan Option developed
Community Integration/DOJDOJ Settlement Agreement Timeframe• February 2011 – Findings• Jan. 26, 2012 - Negotiation completed andsettlement agreement signed• Aug. 23. 2012 - Judge signs agreement asconsent decree36
Community Integration/DOJVirginia will create 4,170 waiver slots by June 30, 2021:37StateFiscalYearIndividuals in TrainingCenters to Transitionto the CommunityID Waiver Slotsfor Individuals onUrgent Wait ListDD Waiver Slotsfor Individualson Wait List20121 60 275 1502013 160 225* 25**2014 160 225* 25**2015 90 250* 25**2016 85 275 252017 90 300 252018 90 325 252019 35 325 252020 35 355 502021 0 360 75Total 805 2915 450These FY2012 slots have already been funded and assigned to individuals.*25 slots each year are prioritized for individuals less than 22 years who reside in nursing homes or largeICFs.**15 slots each year are prioritized for individuals less than 22 years who reside in homes or large ICFs.
38DOJSummary of Total Cost of theSettlement AgreementTotal 10-Year Cost $2.4 BillionTotal GF cost of services $1.2 BillionTotal GF savings and offsets $ 826.9 MillionTotal estimated newGF required$ 387.7 Million
Improve Waivers toResolve Current ChallengesVirginia must evaluate methods to move toward a moreflexible array of services that support system values andresolves challenges with current waivers:• Flexibility to address the most complex medical andbehavioral needs• Expand the array of residential supports to includesmaller, more integrated environments• Expand group and individual supported employmentoptions
Children’s ServicesVirginia’s behavioral health services for children faces multiple challenges including anincomplete, inconsistent array of services, inadequate early intervention services, a need forworkforce development and inadequate oversight and quality assurance.0510152025303540Crisis StabilizationUnit for ChildrenEmergency RespiteCareIn Home CrisisStabilizationMobile Child CrisisResponsePsychiatric Services Case Management Intensive CareCoordinationIntensive In-HomeServicesAvailability of Base Services by Number of CSBsAdequate Capacity Inadequate Capacity Services Not Provided
Children’s Services• Priority needs in most Virginia communities:– Access to child psychiatry– Crisis stabilization services– Mobile crisis teams• In 2012 and 2013, the Governor and General Assembly providedfunding to provide child psychiatry, crisis stabilization, and mobilecrisis services to children with behavioral health disorders.Fiscal Year GF DollarsFY 2013 $1.5MFY 2014 $3.65MTOTAL $5.15M ($3.65M ongoing)