Www.shstrategists.com The KanCare Program: Medicaid Managed Care and Local Health Departments Kansas...

www.shstrategists.com

The KanCare Program:Medicaid Managed Care and Local Health Departments

Kansas Association of Local Health DepartmentsJanuary 20, 2012

Martie Rossmross@shstrategists.com

913.327.5152

The KanCare Solution

• On November 8, Governor Brownback announced his plan to reform Kansas Medicaid program

• Move nearly all Medicaid beneficiaries to managed care

• State to contract with three Managed Care Organizations (MCO) to operate the program

MCO Selection

• Response to State RFP• Applicants must submit technical proposal

by January 31; cost proposal due February 22

• State to select three MCOs sometimes this spring

• Selected MCOs must have provider network in place by October

• KanCare takes effect January 1, 2013

Requirements for MCOs

• Statewide coverage; all populations• Maintain current reimbursement levels• Maintain current level of services and

beneficiary protections

Person-Centered Care Coordination• Population-specific and statewide

outcomes measures will be integral to the contracts and will be paired with meaningful financial incentives

• RFP requires MCO to demonstrate care coordination capabilities

• RFP requires MCO to create of health homes, with an initial focus on individuals with a mental illness, diabetes, or both

Home and Community-Based Services• Kansas currently has the sixth highest

percentage of seniors living in nursing homes in the country

• KanCare forces transition away from institutional care and toward services that can be provided in individuals’ homes and communities

• Outcome measures will include lessening reliance on institutional care

Consumer Voice• Administration will form advisory group of

persons with disabilities, seniors, advocates, providers, and other interested Kansans to provide ongoing counsel on implementation of KanCare.

• Additionally, managed care organizations will be required to:• Create member advisory committee to receive

regular feedback• Include stakeholders on the required Quality

Assessment and Performance Improvement Committee

• Have member advocates to assist other members who have complaints or grievances

Pay for Performance: P4P

• Program identifies operational measures in the first contract year, and 15 quality of care measures in years 2 and 3, tied to incentives

• State withholds 3 to 5 percent of total capitation payments until certain quality thresholds are met

• Quality thresholds increase each year to encourage continuous quality improvement.

• Measures chosen for P4P program will allow the State to place new emphasis on key areas

Savings

State expects to achieve $853 million (state and federal) over five years through outcomes-focused, person-centered care coordination model

5-year Total

Savings FY13 FY14 FY15 FY 16 FY 17

All Funds 29,060,260 113,513,129 198,041,997 235,439,877 277,004,864 853,060,127

SGF 12,522,066 48,912,807 85,336,296 101,451,043 119,361,396 367,583,609

Now What?

• Letters of Intent• Individual contracts with MCOs• Joint contracting

• Advantages• Risks

Antitrust Law Regulates Market Power

• Single entity or group has ability to control prices or exclude competition• In a defined area• For a specific product or service

Forms of Market Power

In a single entity• Monopoly (seller) or• Monopsony (buyer)In collaboration with competitors• Joint ventures• Collaborations• Associations• Agreements – Written and Unwritten

Two Basic Antitrust Questions

If you have market power, what can you do to your competition?

If you don’t have market power, what can you do with your competition?

Yes NO

Do you have market power?

What can you do to your competitors?

What can you do withyour competitors?

Rule #1Rule #2Rule #3Rule #4

Rule #1

The exercise of market power to exclude competitors – actual or potential – is illegal.

• U.S. and Texas v. United Regional Health Care System (February 2011)

• U.S. and Michigan v. Blue Cross Blue shield of Michigan (October 2010)

Rule #2

Agreements with competitors to exercise market power are illegal.

Let’s agree to demand an increase in reimbursement rates.

Let’s agree to share cost information so we can avoid undercutting each other.

Let’s agree not to compete in these areas.

Let’s agree not to deal with any business that works with that new clinic.

Rule #3

Sharing survey information with competitors is permitted if not likely to produce market power.

Safety zone requirements:

1. Independent 3rd party collects information.

2. Current fee information is provided only to purchasers.

3. Fee information shared with providers is more than 3 months old.

4. At least 5 data sources for each category.

5. Information is aggregated.

Multiprovider Networks

Ventures among providers that jointly market services to health plans and other purchasers

Such ventures may contract to provide services at jointly determined prices if:

1. Providers are financially or clinically integrated2. Venture structured to produce significant

efficiencies that benefit consumers3. Joint pricing reasonably necessary to realize

efficiencies

Financial Integration

• Participants share “substantial” financial risk in providing all services that are jointly priced through network

• Reliable indicator that participants are motivated to achieve significant efficiencies

Clinical Integration

• Practice protocols and performance benchmarks

• Effective operating procedures• Membership requirements

Practice Protocols and Performance Benchmarks• Evidence-based practice guidelines• Case and disease management

procedures• Standards for use and maintenance of a

computerized clinical information system• Quality and cost benchmarks for

evaluating participant performance• Standards for measuring member

performance on benchmarks

Effective Operating Procedures• Introduction, explanation, and periodic

review of practice guidelines• Training in use of technology • Peer review of provider performance and

adherence to practice requirements• Review of provider aggregate performance

under quality and cost benchmarks• Enforcement of individual and overall

compliance with program requirements

Membership Requirements

• Refer patients to other network participants when appropriate

• Share information on all services rendered to network patients

• Follow care management procedures and protocols

• Adhere to established educational and disciplinary requirements

• Serve on committees, such as quality assurance and medical management

• Invest capital to establish and maintain infrastructure and capability to achieve quality and cost improvements

Rule #4

Collaborations are viewed with suspicion.

Key questions: 1. Will the arrangement produce market power

for the participants?2. Is the arrangement structured and likely to

produce increased efficiencies?3. Do the efficiencies outweigh any decrease in

competition?

www.shstrategists.com

Martie Rossmross@shstrategists.com (913) 327-5152

Join the conversation at www.shstrategists.com/blog/