MEDICAID REFORM PROPOSAL Stakeholder Meeting August 24, 2004

1. MEDICAID REFORM PROPOSAL Stakeholder MeetingAugust 24, 2004

2. Georgia Department of Community Health 2 Medicaid Growth is Unsustainable!

3. Georgia Department of Community Health 3 Percent of All New Revenue Required by the Medicaid Program

4. Georgia Department of Community Health 4 Utilization Management is a Necessity

5. Georgia Department of Community Health 5 Quality Indicators HealthCheck Comparative Data

6. Georgia Department of Community Health 6 Quality Indicators ER Utilization Per 1,000

7. Georgia Department of Community Health 7 Why Medicaid Reform? To focus on system-wide improvements in performance and quality To consolidate fragmented systems of care To control unsustainable trend rate in Medicaid expenditures To adopt a �management of care� approach to achieve the greatest value for the most efficient use of resources

8. Georgia Department of Community Health 8 Goals of Reform Improve health care status of member population Establish contractual accountability for access to and quality of healthcare Lower cost through more effective utilization management Budget predictability and administrative simplicity

9. Georgia Department of Community Health 9 Vision To create a statewide, full-risk organized system of care for Medicaid and PeachCare members that incorporates Georgia-specific initiatives as well as �best practices� for the provision and purchasing of healthcare.

10. Georgia Department of Community Health 10 Strategy A successful model for the �management of care� for Georgia Medicaid involves: An organized system of care Responsibility for case oversight A network of contractually accountable providers to ensure both quality and cost containment Medically based guidelines for appropriate treatment leading to healthy outcomes

11. Georgia Department of Community Health 11 Population-based Strategy

12. Georgia Department of Community Health 12 The Plan � Part I Regionalized approach � 6 geographic regions Competitive procurement for up to 2 care management organizations (CMOs) in each region CMOs will: Be licensed by Georgia Department Of Insurance as risk-bearing entities Be subject to net worth and solvency standards Have demonstrated ability to provide all covered healthcare services and an adequate provider network

13. Georgia Department of Community Health 13

14. Georgia Department of Community Health 14 The Plan � Part I Additional preferred attributes for consideration of CMOs: Incorporate technological advances (i.e. electronic prescribing and telemedicine) Focus on the education and empowerment of the Medicaid member Introduce elements of consumerism to Medicaid members to drive better healthcare choices (i.e. financial incentives and quality information) Incorporate disease and case management functions as part of their medical management strategy Georgia provider-owned/sponsored organizations

15. Georgia Department of Community Health 15 The Plan � Part I Required enrollment for: Low-income Medicaid adults and children PeachCare for Kids Right from the Start Medicaid Refugees CMO enrollment mandatory, but: Enrollees will have 30 days to select one of at least two CMOs Enrollees will have 90 days to change CMO without cause; thereafter, will remain in selected CMO until one-year anniversary

16. Georgia Department of Community Health 16 The Plan � Part I CMOs will be responsible for providing all covered Medicaid services, which include: Physician visits, laboratory and diagnostic testing, and inpatient and outpatient hospitalization Mental health and substance abuse treatment Pregnancy-related services Prescription drugs Dental and vision care services (to eligible populations) Screening and preventive services (to eligible populations) Durable Medical Equipment

17. Georgia Department of Community Health 17 The Plan � Part I CMOs will not be responsible for: ICFMR- Intermediate Care Facility/Mentally Retarded HCBS- Home and Community-based Services under a 1915 (c) waiver Other long-term services

18. Georgia Department of Community Health 18 Healthcare Delivery and Access Standards DCH will protect the patient/provider relationship by contractually requiring CMOs: To have sufficient numbers of providers of both primary and specialty care To include sufficient numbers of safety-net providers and rural and critical access hospitals To have a culturally appropriate mix of providers

19. Georgia Department of Community Health 19 Rights of Members DCH will contractually require CMOs to provide to members: Bi-lingual written materials and oral interpretation services Clear information on grievance and appeal rights Multiple means to access CMO member services

20. Georgia Department of Community Health 20 Rights of Providers DCH will contractually require CMOs to provide healthcare providers with: Prompt payment and adherence to State reimbursement policies Expedited grievance and appeal processes Multiple means to access CMO provider resources

21. Georgia Department of Community Health 21 Quality Management DCH will require CMOs to have an internal program that monitors and assures DCH-mandated: Levels of service quality and efficiency Outcomes and health status targets Contractual obligations will prevent the CMOs from sub-optimal provision of healthcare

22. Georgia Department of Community Health 22 Quality Management DCH will require CMO reporting on: Well child visits and childhood immunizations Rates of breast cancer and cervical cancer screening Rates of diabetic eye exams and HgbA1c testing Early initiation of prenatal care and incidence of C-Sections Appropriateness of emergency room utilization Incidence of avoidable procedures Other possible quality indicators

23. Georgia Department of Community Health 23 Reform Strategy � Part II Who is not included in the CMOs: Elderly and Disabled Medically Fragile Children Foster Children And what is our strategy for them?� An overview of Part II

24. Georgia Department of Community Health 24 Care Management for Elderly and Disabled � Part II An initial strategy of statewide disease management programs focusing on: Congestive Heart Failure Diabetes Chronic Obstructive Pulmonary Disease Programs to reach and manage both Medicaid and SHBP members Programs could be implemented as early as July 1, 2005

25. Georgia Department of Community Health 25 Care Management for Elderly and Disabled � Part II A longer-term, more comprehensive strategy in development for 275,105 Medicaid members in Elderly and Disabled sub-programs Will be consistent with new policy direction of DHR Will be coordinated with the Governor�s Office and DHR Will combine vigorous assessment and case management with traditional fee-for-service reimbursement to providers Vouchers for self-directed care could be made available for those eligible and able to manage Health outcomes improved and utilization reduced through oversight and management by a statewide ASO vendor Vendor incentivized to attain outcomes and cost goals Program could be moved to full risk over time

26. Georgia Department of Community Health 26 Timeframe Development of System of Organized Care Model - September 1 � October 30 Statewide consensus building Development of SPA & RFP/Contract Administrative Functions Submit SPA & RFP/Contract to CMS for review (CMS approval mandatory and can take 90+ days) Release RFP (target is 1st week of January 2005, pending CMS approval) Evaluation of RFP responses Contract decisions made Contracts negotiated and signed Readiness evaluation Implementation � January 1, 2006 Implement CMOs in two/three regions, with remaining two/three regions phased in during the next 6 � 12 months

27. Georgia Department of Community Health 27 Conclusion Current trend for the Medicaid program is unsustainable A more efficient and effective system for appropriate utilization management is necessary This plan will create a more organized and accountable system of care Quality outcomes must be a primary goal

28. Georgia Department of Community Health 28 Questions & Comments