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Doug Wirth, President/CEO

NYC AIDS Fund Learning Lab: Session 1 The Emerging Managed Care Environment … Choosing a Survival Path. Doug Wirth, President/CEO. Today’s Discussion:. Review State Goals -- MRT, MMC & DSRIP Explore Key Questions: What do plans want now (need in the future)?

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Doug Wirth, President/CEO

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  1. NYC AIDS FundLearning Lab: Session 1The Emerging Managed Care Environment …Choosing a Survival Path Doug Wirth, President/CEO

  2. Today’s Discussion: • Review State Goals -- MRT, MMC & DSRIP • Explore Key Questions: • What do plans want now (need in the future)? • How to position the missions/services of smaller HIV/AIDS CBOs? • Survey Options for Meaningful Participation in the emerging environment

  3. Founded in 1999 by 7 CBOs that offered HIV/AIDS Services (+) • Started serving HIV+ members in 2003 & HIV- homeless in 2014 • 6,100 Members (w/ multiple & complex needs) • Key Outcomes: • Expansions: MLTC & Medicare (2014); BH HARP (2015)

  4. Managed Care Models Serving Medicaid/M-care Recipients Current Models* • Medicaid Managed Care – 8 General Plans • HIV SNP – 3 Plans • MLTC– 23 Plans (and expanding) * NCQA found that NYS ranked 2nd only to MA in Medicaid Managed Care quality. Emerging Models • FIDA/NYS Duals Demo – 23 Plans; Oct 2014 (v); Jan 2015 (p); 120,000 eligible • BH HARPs – Jan 2015 (NYC); 80,000 eligible

  5. Key NYS Medicaid Managed Care Population & Service Expansions Populations 2005SSI 2010HIV/AIDS 2012Homeless * Services ** 2011Pharmacy Personal Care 2012 Health Homes 2013AADHC 2014Long Term Care 2015Behavioral Health * The State allowed HIV- homeless individuals to join HSNPs in 2014. ** The 2012-13 State Budget gave authority to SDOH Commission and Medicaid Director, by 2015, to eliminate all Medicaid FFS carve-outs and any population exemptions.

  6. Key Reasons for NYSMedicaid Redesign, MMC & DSRIP • Medicaid Spending Increases • Overall Quality of Care – “Average” • 20% Enrollees (1 million) w/ High Need/High Cost • Reduce Avoidable Admissions • Desired “Care Management for All” • Hospital System Collapses & Consolidations • System Transformation • Clinical Improvements (Evidence-based) • Integrated Care Delivery • Shift to Quality Based Payments & Other Reforms Sources: Medicaid Redesign Team Update and Next Steps Presentation: Jason Helgerson, SDOH, July 2013; NYS BHO 2012 Reviews and Implementing Medicaid BH Reform in New York: Bob Meyers, SOMH, Sept 2013. NYS Health Home SPA for Individuals w/ Chronic Behavioral & Medical Health Conditions - SPA # 11-56.

  7. If managed care is the content for the future … What do Plans need to demonstrate/do: • Improved Quality • Reduce Health Disparities • Create models to serve High Need/Cost Individuals • Increase Outpatient Connectivity (PC, MH & SUD) • Reduce Costs (e.g. ERs, Admits, LTC) • Find/contract with Providers that: • Provide integrated care (PC, MH & SUD) • Can take risk • Can share data Q: What do you have to offer to achieve these goals … and can you prove/show it (outcomes)?

  8. Things needed by MMC & PPS/DSRIPs: Evidence-based Interventions for Chronic Conditions HIV/AIDS Serious Mental Illness Substance Use/Addictions Long-term Care Alternatives Social Determinants of Health Housing Stability & Food Security Job Training/Supported Employment Integrated Care (PC, MH & SA) Crisis Beds (hospital diversion) Proactive management of patients w/ higher risk scores Care transition models C-B Navigation Services C-B Ambulatory Detox/Rehab

  9. Strategic Opportunities for CBOs: • “NICHE” PROVIDER (go it alone) • e.g. Case Findings or Housing Placements or Training/Supported Employment • STRATEGIC PARTNERSHIPS (collaborate) • e.g. Health Homes or IPAs • MERGER/ASSET Consolidation (build integration) • Vertical – Integrated Service Delivery System • Horizontal – Expanded Service Capacity

  10. How Do You Choose? • It starts w/ Executive Leadership doing a reality-based INTERNAL ASSESSMENT: • Identify services of value, including contributions to achieving desired outcomes • Identify and collect data (i.e. prevented admissions, stably housed, diversions, harm reduction, etc.)? • Determine costs & risk tolerance … readiness to change • Decide whether to “go it alone” or Partner(vertical or horizontal integration?) • Negotiate & partner effectively (change mgmt.) • Create an ACTION PLAN (to innovate, build capacity, align staff/resources, deliver services & monitor results) • The time to ACT is NOW!

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