Re-Shaping Virginia Public and Private Health and Human Services Delivery System Presentation to Fairfax County Human Services Council

1. Re-shaping Virginia Public and Private Health
and Human Services Delivery System
Presentation to Fairfax County Human Services
Council
Secretary of Health and Human Resources
Dr. Bill Hazel
May 18, 2013

2. 2
Health and Human Resources
Jobs and
Economic
Development
Homelessness
Adoption
Children’s
Services
Community
Integration
DOJ
Veteran’s and
Active Duty
Military
Services
Coordination
Prisoner
Reentry
eHHR
Effective and
Efficient
Government
Health
Health System
Reform
Mental Health
State Managed
Shelters

3. 3
1. Requires Most U.S. Citizens and Legal Residents to Have Health Insurance;
– Offers enhanced federal dollars for states that choose to Expand Medicaid (at
state option) for all individuals with income under 133 percent of poverty. (plus
a 5% income disregard).
– Reconfigures insurance industry requiring a larger pool of insured individuals to
cover the cost of eliminating insurance underwriting (i.e., pre-existing
conditions) while standardizing insurance benefits and pricing.
2. Creates Health Benefits Exchanges for Individuals and Small Businesses to
compare and purchase health insurance;
– Offers subsidies to low-income individuals with income between 100 and 400
percent of poverty to purchase insurance
3. Encourages Innovation
The Patient Protection and Affordable Care Act
3 Major Components

4. 4
The Supreme Court’s decision leaves it to state policymakers to
decide whether or not to expand Medicaid’s income
eligibility levels to cover all individuals up to 138% of the
poverty level
What does Medicaid Expansion Include?

5. MandatoryProvisions
($142m)
OptionalExpansion
$280m
Estimated Costs of the Affordable Care Act for Virginia: 2014-2022
These costs
and savings
are already
reflected in
the
Governor’s
Introduced
Budget
These costs
and savings are
identified in
the Fiscal
Impact
Statement for
the ACA
Expansion
Annual Impact of Mandatory Provisions
Annual Impact of Optional Expansion (only)
5
SFY 14:
($36,673,715)
SFY 14:
($52,050,282)

6. 6
Federal Match for Expansion Population
The 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 to
enhanced federal funds)
– Inmate Inpatient Hospital Savings (shift from local and state funds to
enhanced federal funds)
– Indigent Care Savings (shift from state funds to enhanced federal funds)
Estimated Cost of Expansion in Virginia

7. 7

8. —No consideration of expansion until significant
reforms are underway within the Medicaid
program.
—2013 Legislative Session
—concluded with budget language authorizing
three phases of Medicaid Reform
—created the Medicaid Innovation and Reform
Commission
8
Virginia’s Legislative Approach to Medicaid Expansion

9. 9
Improve
Service Delivery:
Improve Quality, Predict
Costs, and Innovate when
Needed
Improve
Administration:
Streamline Administration
and Minimize Waste,
Fraud, and Abuse.
Increase
Beneficiary
Engagement:
Showcase Wellness and
Cost Sharing
Objectives of Medicaid Reform

10. All Medicaid Populations
Including LTC in
Coordinated System
Continued Stakeholder
Engagement
(Phase III)
Value Based Purchasing in
Managed Care for Medical
Services, Administrative
Simplification and
Flexibility and Innovation
(Phase II)
Ongoing Reforms
(Phase I)
Three Phases of Medicaid Reform
10

11. 11
Phase II: Improvements in Current Managed
Care 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 Pilots
Three Phases of Medicaid Reform

12. Phase II (Process)
New Medallion II (Managed Care) Contracts
– Total reformat based on review of 13 state contracts – focus on
life 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
– Wellness
Three Phases of Medicaid Reform
12

13. Phase II (Process)
Three Phases of Medicaid Reform
Medicaid 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 Models
13

14. 14
Phase III: Coordinated Long Term Care
– Move remaining populations and waiver
recipients into cost effective and coordinated
delivery models
– Report due to 2014 General Assembly on
design and implementation plans
Three Phases of Medicaid Reform

15. Savings accrued during the first five years of
the expansion should be protected and
reinvested to improve the health delivery
system.
—Reinvestment and Savings Strategies Include:
– The flexibility to invest in high quality, cost saving health
care innovation models
– Improved analytical and oversight capability at DMAS
• Requirement of timely and accurate encounter data from
contracted Medicaid managed care plans
• Creation of Data and Analytics Unit at DMAS
– Need to identify structure to protect savings and ensure
reinvestment
Reinvestment of Medicaid Funding
15

16. Cost and Value Problems in the Healthcare Arena can’t be
Solved without Significant Innovation
―Innovation opportunities within PPACA are lost in the
uncertainties 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 Commerce
System Wide Innovation
16

17. Virginia Health
Innovation Plan
Improving
Transparency and
Availability of Data
Improving Early
Childhood
Outcomes
Payment and Delivery
Reform: Improving
Care Integration
for Physical and
Mental Health
Educating and
Engaging
Consumers to
Purchase Value
Improving the
Effectiveness,
Efficiency, and
Appropriate Mix of
the Health Care
Workforce
Payment and Delivery
Reform: Improving
Chronic Disease
Care
Each priority has a
dedicated workgroup
assigned to explore
pilot programs and to
reach consensus on
a recommended
three-year
implementation plan.
Workgroups include
members of the
VHRI Advisory
Council, the VCHI
Board of Directors,
as well as key
thought leaders in
each particular
priority area.
Virginia Center for Health Innovation Priorities
17

18. MIRC
Purpose: To review, recommend and approve innovation and
reform proposals affecting the Virginia Medicaid and Family
Access to Medical Insurance Security (FAMIS) programs, including
eligibility and financing for proposals set out in Item 307 (Virginia
Budget) 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 as
benefit design, service delivery, payment reform, and quality
and cost containment outcomes; and
(iii) implementation of reform measures.
The Medicaid Innovation and Reform Commission
18

19. Chair of Senate Finance, or his
designee & 4 members of
Senate Finance
Chair of House Committee on
Appropriations, or his
designee, & 4 members of
House 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. O'Bannon, II
—Beverly J. Sherwood
—Johnny S. Joannou
MIRC Membership
Ex Officio Members:
Secretary of Health and Human Resources
Secretary of Finance 19

20. • 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 Abuse
eHHR Effort

21. —CommonHelp Portal
—Case Management System
—Enterprise Data Management (EDM)
—Business Rules Engine
—Document Management System
—Enterprise Service Bus (ESB)
21
eHHR Core Elements

22. 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 Security
Administration, IRS, Homeland Security
• Income must be computed using IRS Modified Adjustable Gross Income
methodology
• 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 coverage
Preparing to comply with ACA

23. 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 Facilitated
Exchange (FFE)

24. Department of Social Services
• Leader on Eligibility System
modernization
• Interface with Local DSS network
Department of Medical Assistance
• MAGI Call Center Operations
• Interface with Center for Medicare
and Medicaid Services
• Affordable Care Act policy experts
• Federal Exchange experts
eHHR Team
VITA
• IT Hosting
• Enterprise Data Management
• Enterprise Service Bus
mentorship
Department of Motor Vehicles
• National leadership with on-line
citizen authentication
Virginia Department of Health
• Birth/death registry services

25. 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 language
needed to empower the modernized eligibility system
• IT system infrastructure to support Development and Testing secured
and deployed on-schedule by VITA; includes new Service Oriented
Architecture/Enterprise Service Bus (SOA/ESB) modularized
architecture
• DSS Enterprise Delivery System Program Contract solicited and
awarded, signed with Deloitte Consulting on 12/19/12 25

26. Making Government work smarter
VDSS winning the “Innovation in
Utilization Award” at RichTech this month
This award recognizes “the company or
organization whose creative use of
technology enhances processes,
methodologies, and /or services for theirs
or others’ benefit.”

27. • The capacity to collect and analyze client-specific
expenditure data for the significant fund sources and
to integrate that data with demographic and
assessment data will enable the Commonwealth to
answer critical questions such as:
– Are services available to the children who need them?
– Are services being provided in accordance with each
child’s needs?
– Are funds for services being spent wisely?
– To what extent is each program meeting the measurable
goals for that program based on the availability of services,
each child’s needs, and the funds for those services?
CSA Opportunities

28. Transparency
• OCS can identify the unique children
served by localities requesting those
funds.
• OCS can review individual charges that
constitute the aggregate reimbursement
requests.

29. Accountability
• Data are being integrated across programs to
identify the total funding per child over time.
• Database under development now includes
historical 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 procedure
codes

30. Integration of All Child-Centered Data

31. Even With CSA to Coordinate payments, Services for
Children Remain Fragmented

32. Local service provider data, e.g., specific costs for specific services, are not
currently reported to the Commonwealth. We have shown through a
brief, privately funded, proof of value project that these data can be
efficiently collected and can be matched to other data sources to enable
powerful analysis. We have documented things such as:
1. There is significant variability in the cost of services available to a child
receiving CSA services at the local level, even adjusting for child need.
2. A risk-adjusted payment model can be produced to allow for comparable
per diem per client estimates which will highlight outliers.
3. A linear model of payment per client per day allows us to account for the
effects 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

33. Lessons Learned
• Some localities cannot distinguish CSA from Title IV-E
funding
– Informally being stored in comment fields
• Some localities using non-standard accounting
practices
– methods for recording ongoing monthly payments
(ex., “Payment for June, July…” recorded only in
comment fields)
– Inconsistent process for recording re-payments or
cancelled payments.

34. • Recent payment of $48,446 was made to a
CSA vendor in error.
• Recent CSA payment for 25 shirts @
Burlington for the same child.
• New analytics process identified both of these
anomalies. Funds were recovered.
Results

35. Virginia’s Movement Towards Community-
Based Services
Prior to
1960
Late
1960s–
1970s
Early-
mid
1970s
19911972 Today
Large training
centers (TCs)
primary service
source
TC
Census is
5,240
Growth of community
services starts with
arrival of community
services boards
TC Census = 839;
Those on Waiver =
9943; Waiver Waiting
List = 7864
First group homes
appear, community
vocational
services begin
Medicaid Waiver for Home
and Community-Based
services and Medicaid State
Plan Option developed

36. Community Integration/DOJ
DOJ Settlement Agreement Timeframe
• February 2011 – Findings
• Jan. 26, 2012 - Negotiation completed and
settlement agreement signed
• Aug. 23. 2012 - Judge signs agreement as
consent decree
36

37. Community Integration/DOJ
Virginia will create 4,170 waiver slots by June 30, 2021:
37
State
Fiscal
Year
Individuals in Training
Centers to Transition
to the Community
ID Waiver Slots
for Individuals on
Urgent Wait List
DD Waiver Slots
for Individuals
on Wait List
20121 60 275 150
2013 160 225* 25**
2014 160 225* 25**
2015 90 250* 25**
2016 85 275 25
2017 90 300 25
2018 90 325 25
2019 35 325 25
2020 35 355 50
2021 0 360 75
Total 805 2915 450
These 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 large
ICFs.
**15 slots each year are prioritized for individuals less than 22 years who reside in homes or large ICFs.

38. 38
DOJ
Summary of Total Cost of the
Settlement Agreement
Total 10-Year Cost $2.4 Billion
Total GF cost of services $1.2 Billion
Total GF savings and offsets $ 826.9 Million
Total estimated new
GF required
$ 387.7 Million

39. Improve Waivers to
Resolve Current Challenges
Virginia must evaluate methods to move toward a more
flexible array of services that support system values and
resolves challenges with current waivers:
• Flexibility to address the most complex medical and
behavioral needs
• Expand the array of residential supports to include
smaller, more integrated environments
• Expand group and individual supported employment
options

40. Children’s Services
Virginia’s behavioral health services for children faces multiple challenges including an
incomplete, inconsistent array of services, inadequate early intervention services, a need for
workforce development and inadequate oversight and quality assurance.
0
5
10
15
20
25
30
35
40
Crisis Stabilization
Unit for Children
Emergency Respite
Care
In Home Crisis
Stabilization
Mobile Child Crisis
Response
Psychiatric Services Case Management Intensive Care
Coordination
Intensive In-Home
Services
Availability of Base Services by Number of CSBs
Adequate Capacity Inadequate Capacity Services Not Provided

41. 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 provided
funding to provide child psychiatry, crisis stabilization, and mobile
crisis services to children with behavioral health disorders.
Fiscal Year GF Dollars
FY 2013 $1.5M
FY 2014 $3.65M
TOTAL $5.15M ($3.65M ongoing)

42. Questions?