An Overview of Potential 1115 Waiver Program Options for California Children’s Services

1. An Overview of Potential 1115 Waiver Program Options for California Children’s Services Sally Bachman, Ph.D. 617-353-1415 sbachman@bu.edu www.catalystctr.org March 1, 2010 Lucile Packard Foundation for Children’s Health

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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