Earlier this year, we covered the January 5, 2016 Centers for Medicare & Medicaid Services (CMS) approval of New Hampshire’s Medicaid waiver for a “sustainable integrated care system” (for a complete waiver timeline, see New Hampshire Medicaid Waiver Project To Focus On Integrated Delivery Of Behavioral Health Care). The big questions – what does this mean for consumers with the most complex needs and the provider organizations that serve them?
The waiver allows New Hampshire to implement a Delivery System Reform Incentive Payments (DSRIP) program (see What Is DSRIP & What Organizations Receive DSRIP Funding For Behavioral Health Projects?: An OPEN MINDS Market Intelligence Report for more on DSRIP programs), and provides up to $30 million per year for the five-year, “Building Capacity for Transformation” demonstration. As part of the demonstration, New Hampshire will contract with seven regionally-based Integrated Delivery Networks (IDNs), which are coalitions of behavioral health and other health care and community provider organizations. Applications from IDNs are due on May 31, 2016 (see New Hampshire Seeks Integrated Delivery Network Services); followed by IDN approval by June 30, 2016. IDN project plan applications are due September 1, 2016, and approved projects are slated to launch after January 2017 (see 10 Things You Need to Know About NH’s “Building Capacity for Transformation” Waiver).
The IDNs will serve all Medicaid beneficiaries, whether they are enrolled in a Medicaid managed care plan or remain in the Medicaid fee-for-service (FFS) system. The demonstration excludes individuals in the Medicaid expansion population served under the New Hampshire Health Protection Program (NHHPP); this population will continue to receive Medicaid benefits through qualified health plans (QHPs). The IDNs are also not designed to replace current providers or Medicaid managed care organizations, but instead to offer new resources to providers; and the state’s current proposed attribution method (how Medicaid beneficiaries are assigned to an IDN) would be based on a beneficiary’s long-term care facility residence, community mental health center (CMHC) affiliation, primary care physician (PCP) of record, behavioral health/substance use providers, and, if necessary, place of residence (see NH’s “Building Capacity for Transformation” Waiver Frequently Asked Questions).
The INDs will be paid through the DSRIP capacity building and design fund pool. The state will move the distribution of IDN Fund payments to more outcome-based measures each year of the demonstration. In total, New Hampshire can spend up to $150 million on “Building Capacity for Transformation” between 2016 and 2020, including incentive payments to IDNs and the costs that the state will incur overseeing and operating the waiver. New Hampshire will distribute incentive payments only to IDNs that demonstrate “high performance” – New Hampshire must meet statewide targets or lose some DSRIP funding. Starting in 2018, up to five percent of the DSRIP funds are at risk for the state, and this percentage will increase to 15% in 2020 (see Manatt on Medicaid: New Hampshire’s Building Capacity for Transformation Initiative: Putting a New Stamp on DSRIP Waivers). The program evaluation will focus on the following five performance measures:
- The quality of care delivered to individuals with co-occurring physical and behavioral health issues; the state anticipates that the quality will be higher after the IDNs are operating.
- The total cost of care for Medicaid beneficiaries with co-occurring physical and behavioral health issues; the state anticipates that costs will be lower after the IDNs are operating.
- The rate of avoidable re-hospitalizations for individuals with co-occurring physical and behavioral health issues; the state anticipates that the rate will be lower for this population at the end of the demonstration compared to before the demonstration.
- The percentage of Medicaid beneficiaries waiting for inpatient psychiatric care; the state anticipates that the percentage will be lower at the end of the demonstration than prior to the demonstration.
- Average wait times for outpatient appointments at community mental health centers; the state anticipates that wait times will be lower at the end of the demonstration than prior to the demonstration.
How will this effect provider organizations? To gauge how this waiver will bring change to provider organizations operating in the state, I reached out to Vic Topo, the Chief Executive Officer for Center for Life Management in New Hampshire, and OPEN MINDS advisory board member.
What do you see as potential benefits (or not) for consumers in this change?
Obviously we are still at a preliminary stage of knowing how the everyday Medicaid enrollee will benefit from this, but the way the grant is written, there were certain results and outcomes that would be of consequence, such as better health outcomes, better access to care, and increased of provider capacity.
And part of the reason this is yet to be determined is because the design of the waiver is more of a planning tool and we probably won’t see changes to the service delivery system for quite some time. The IDNs are at the heart of this, and it has yet to be decided how the money will flow into those various networks. I really want to know how much of the money – and in essence we are talking about $150 million over five years – will go into services and how much will go into planning and development. When we know, the consumer would absolutely be said to derive a certain benefit. In the first year, 65% of the dollars will go into the planning and infrastructure phase for IDNs, and 35% into actually building provider capacity. And “capacity” is their word – a key semantic that I believe means increasing the number of providers.
What are the challenges for you as the CEO of specialty provider organization?
What we need to know is to what extent we can attract the professionals we need to serve this population. There continues to be a severe shortage of professionals to deliver our services, and when I and others on the ground read “provider capacity,” we have obvious questions about how to do that considering the shortage. This waiver proposal puts a lot of weight on increasing provider capacity at the same time we struggle to find staff. And we’re not just talking about psychiatry. It’s a shortage of master’s level social workers with experience, who are also hard to get. This is a very unique type of business and I think the “war for talent” will continue.
Another thing listed as an outcome that remains unclear is the elimination of gaps in service to provide a “smoother” process for people going from one provider to another. When you have an array of providers who have other competing priorities beyond just the Medicaid population, there will be a challenge to coordinate care.
What do state policymakers need to do to make sure this change is successful?
There needs to be a recognition that the IDNs can’t “just happen” because the waiver says they need to happen. They could change all the Medicaid contract business to be one in the same, which would make sense. Instead, we will have two parallel contract processes – one for waiver dollars and one for non-waiver dollars. At the end of the day, it’s the same Medicaid enrollees who we are talking about, but the fact that the exact same consumer may have two separate, different networks could potentially be confusing.
There also needs to be more of a recognition that there are a lot of local and regional politics that need to be worked through. Some of that has to do with the complexity of financing around Medicaid. Managed care is also a part of this. The Medicaid managed care process is part of the waiver, but the managed care organizations (MCOs) really need to be at the table for the development process. Managed care is relatively immature here, and we are still working out some of the kinks in terms of capitation and the contracting process. This makes it more challenging to try and do both at the same time. State policy makers need to really think this through, both in the short term and long term.
As a sidebar, they basically have taken the map and redesigned this to be more of a public health model and collapsed some of the regions making them much larger than before. It’s too early to tell whether doing so will increase the likelihood of success for providers and/or Medicaid enrollees.
Who do you see as “winners and losers” in this change?
I’d like to be able to tell you that we will all be winners – the consumers and the communities. I wish I had a clear answer on who the winners will be – the plan is to have the actual Medicaid enrollees benefit and to be better off from the time we start the waiver to the time we end it. A scenario that could present itself, and allow this would be an increased proportion of money in the waiver going to actual services and provider capacity. If a significant portion of the $30 million a year went into services and capacity building, we and the recipient themselves would absolutely be winners. Some of the losers could potentially be providers who are used to a steady stream of money coming in during the waiver period, only to have it disappear at the end. The same could hold true for enrollees who can no longer receive a service at the end of the waiver period.
But I think, 1115 Medicaid waiver “nirvana” would be that consumers will transition from a service(s), level of care with no interruption or relapse, and perhaps be saved from death by overdose and/or premature death in case of serious mental illness.
For more on integrated care, be sure to join me on June 9 at The 2016 OPEN MINDS Strategy & Innovation Institute for the session, “Making Integrated Service Delivery A Financial Reality: Key Models For Integration With Primary Care” – featuring James Stewart, Chief Administrative Officer, Grafton Integrated Health Network; Jessie J. Peters, Director of Medical Integration, Spectrum Healthcare Group, Inc.; Peggy DeCarlis, Senior Vice President & Chief Innovation Officer, New Directions Behavioral Health; and David E. Cook, Chief Executive Officer, Zumbro Valley Health Center.