Exploring Strategic Change with your Boards of Directors

Presented by: • Kandy Ferree, President & CEO – 360˚ Strategy Group • Anne Donnelly, Director of Health Care Policy – Project

Inform

• State of the science, cutting edge information presented by expert practitioners

• Broad range of topics including – Access to Care – Health Care Reform – Harm Reduction Advocacy series – Retention in Care – Sector Transformation series including Changing Healthcare Environment, CBO

Sustainability, and Board Engagement

• Today’s webinar is part of our Sector Transformation series – Navigating the New Reality (last month) – Remaining Relevant (last month) – Board Engagement

• Limited resources available to help CBOs decide whether to merge, grow, or go responsibly (Contact Stephanie Cruse, scruse@aidsunited.org)

• Stay tuned for our new website debut in June!

AU Commitment to Informing the Field

• All attendees are in listen-only mode

• Everyone can ask questions at any time using the question/chat feature

• This webinar has too many attendees for questions to be submitted over the phone

• During Q & A segment, the moderators will read questions that have been submitted

Webinar Instructions

.

Use the Question Feature to Ask Questions or Email Questions

• Funded by: AIDS United and Johnson & Johnson • Contributors:

– Anne Donnelly – Kandy Ferree

• Acknowledgements:

– Project Inform – 360˚ Strategy Group – Countless direct service providers and people

living with HIV/AIDS from whom we have learned so much and contributed to this presentation.

Webinar Acknowledgements

Presentation Overview

• Overview of the HIV/AIDS and Healthcare Landscape • Overview of the Affordable Care Act (ACA) at the

national level • Discussion of important implications and choices

facing AIDS Service Organizations

• The role of Boards

EXPLORING STRATEGIC CHANGE

HIV/AIDS AND HEALTHCARE LANDSCAPE

Part 1

Ask Yourself: Do I have the courage to Lead?

We did not come to fear the future. We came here to shape it.

PRESIDENT BARACK OBAMA Speech to Joint Session of Congress September 9, 2009

• External • Environment

State Budget Deficits

G#1: Reduce HIV Infections

G#2: Increase Access to

Care

INCREASE POSITIVE HEALTH

OUTCOMES

G#3: Reduce Health

Disparities

Medicaid Expansion or NOT?

High-Impact Prevention

Where States Stand on Medicaid Expansion

Source: Kaiser Family Foundation

Medicaid Expansion & HIV

HIV/AIDS Treatment Cascade

Major Gaps: •Linkage •Retention

Major Gap: Testing & Identification

“Change” is Constant … “Transformation” is Not

(at least historically) QUANTITY

NHAS RWCA

HCR/ACA State Budgets

Funder Priorities

Speed

Frequency

Constant Transformation

2 KEY ELEMENTS CRITICAL FOR ASO TRANFORMATION

IDENTITY (Founders & Brand)

BUSINESS MODEL (Financing)

Healthcare Organization that Ensures PLWH/A have access to and get the most benefit from

Medical Care & the Services that Facilitate Optimum Health

Outcomes

AIDS Service Org Harm Reduction Org

Syringe Exchange Program

THE CHOICES & STAGES IN THE HEALTHCARE REFORM AND AIDS SERVICES PARADIGM SHIFT……

AFFORDABLE CARE ACT &

HEALTH CARE REFORM

IT’S A PROCESS NOT AN EVENT & ONLY PART OF THE PICTURE…

Part 2

What Does HCR Do? Component U.S. (Federal)

Requires Most Individuals to Have Insurance Coverage

• U.S citizens and legal residents must maintain health coverage or face a tax penalty (some exemptions )

Expands Coverage: Focus on the Uninsured • State option to expand Medicaid • Federal or state-run Insurance Marketplace in all states

Creates Essential Health Benefits Examples: (see list in resource slides) • Ambulatory Care, Emergency Care, Hospitalization • Prescription Drugs

Increases Access to Preventive Care Examples: (see list in resource slides) •HIV screening ( everyone age 15-65) •Hepatitis C screening (for high risk adults)

Helps with Costs • Subsidies for lower income people – in marketplace • Out of pocket caps on coverage – for all

Reforms Private Insurance: Creates New Protections

• Eliminates denials and increased premiums for pre-existing conditions; no annual or lifetime limits on coverage

Health Care Reform Encourages

Component Selected Examples Coordinated Care • Accountable Care Organizations (ACOs)

• PCMH/Medicaid Health Homes • ASOs can use RWCA funds now to build a case that your

services (i.e. Linkage, Medical C/, retention) are cost effective or should be reimbursable

Increased Quality & Focus on Health Outcomes

• Health Care Innovation Awards • Pay for Performance Programs • Bundled Payments for Care Improvements

Strengthening the Health care Workforce

• Increased Medicaid reimbursement rates for primary care providers

OTHER….

Looking More Closely at Coverage Expansion

• 26 states have adopted • 0-138% of FPL (Approx. $15,800 individual; $32,500 family of 4)

• Covers low-income adults without children, even if they are not disabled

• No asset test

Medicaid Expansion

• All states • Website to compare and select private insurance plans • Any income level:

• 100-250% FPL get some help with premiums & out of pocket costs

• $11,500 individual; $23,500 family of 4 • $28,700 individual; $46,000 family of 4

• 250% - 400%FPL get help with premiums

Private Insurance Marketplaces

• Enrollment deadlines differ Marketplace - March 31, 2014 Medicaid - enrollment at any time

19

Medicaid Expansion & PLWH

Alternative Medicaid Expansion Plans: Medicaid Premium Assistance Programs

State decides to expand Medicaid to people with income up to 138% FPL (Yay!)

Traditional Medicaid

Alternative Benefits Plan that could be different from traditional Medicaid

Premium assistance program to purchase Qualified Health Plans (QHPs) for Medicaid beneficiaries

How to structure the expansion??

Weighing the Pros and Cons of Premium Assistance Plans

The Good Politically feasible way to get state

to expand Medicaid Reduces churn between Medicaid

and QHPs May allow access to bigger provider

networks

The Concerns May weaken Medicaid oversight and

protections May weaken the benefits provided by

Medicaid programs States are using 1115 waivers to ask for even

more flexibility from Medicaid rules Could threaten the “entitlement” nature of

Medicaid

The ACA – Ryan White Conundrum

• Transformation of the HIV care and delivery system • Most uninsured and underinsured PLWH depend on

RW – RW became its own system of care

• As more coverage options open up through HCR, more people with HIV will have to change coverage – RW is a payer of last resort: Can’t pay for services

that can be provided under other coverage – Transitions to new plans, providers, pharmacies

Continued Need for RW Services

– 70% of people currently on RW have some type of insurance and still need RW to fill gaps

– Critical services not covered in most insurance plans:

• Outreach, HIV testing, referral & linkage to care • Dental, vision, specific types of case management,

navigation assistance with new coverage, adherence, linkage to housing, food, transportation

– Help with Affordability: Insurance Premiums & Out-

of-pocket costs for care and medications

Ryan White “PAYER of LAST RESORT”: HRSA Requirements for Health Care Reform

For every RW funded client your organization MUST: 1. Make every effort to enroll RW clients in other insurance coverage or

payer options 2. Document your efforts to do so…

Language from HRSA Guidance: • RW funds cannot be used for items or

services “for which payment has been made or can reasonably be expected to be made” by another source. (PHS Act)

• Grantees must “vigorously pursue” enrollment, “make every effort” to enroll clients, document their efforts to enroll clients, etc.

• HRSA enforces the requirement through audits; organization could be liable to repay HRSA for care provided under RW that could have been paid for by a different program

25

RW - Continuity of Care

• Interpretation of “Payer of Last Resort” guidance varies across jurisdictions – Follow developments in your state/locale – Be prepared to challenge interpretations that may

negatively impact clients • Ryan White programs will and must continue to serve

clients who are not enrolled in other coverage

• The priority must be to ensure clients don’t drop out of care and have access to appropriate high-quality care

26

Ryan White Program & Funding WILL Change!

• RW will continue for uninsured • RW will offer less primary care and more “care

completion services” • More likely to have to justify RW funding and services by

outcome & support of health and well being • Ryan White funding is likely to decrease in the long run

CBOs need to: innovate, ensure services remain relevant, credential and professionalize staff, demonstrate & document health outcomes & diversify funding sources

Ryan White Program Client Transitions

≤100% FPL 45%

101-138% FPL 14%

139-200% FPL 19%

201-300% FPL 15%

301-400% FPL 6%

>400% FPL 2%

Unknown <1%

NASTAD Annual ADAP Monitoring Report, January 2013

2014 ACA Coverage Option Income Eligibility Threshold

Medicaid Expansion Income up to 138% FPL

Advance Premium Tax Credit for purchase of private insurance through exchanges/marketplaces

Income between 100 and 400% FPL (ineligible for Medicaid or affordable employer-based coverage)

Cost-sharing subsidies to offset out-of-pocket costs of private insurance through exchanges/marketplaces

Income between 100 and 250% FPL (ineligible for Medicaid or affordable employer-based coverage)

Unsubsidized private insurance coverage through exchanges/marketplaces

Income below 100% FPL (ineligible for Medicaid)

≤100% FPL 45%

101-138% FPL 14%

139-200% FPL 19%

201-300% FPL 15%

301-400% FPL 6%

>400% FPL 2%

Unknown <1%

≤100% FPL 45%

101-138% FPL 14%

139-200% FPL 19%

201-300% FPL 15%

301-400% FPL 6%

>400% FPL 2%

Unknown <1%

ADAP Clients Served, by Income Level (June 2012)

Essential to also focus efforts on those outside of the Ryan White Program/ADAP systems of care to address unmet need and health disparities

Assessing and Filling Gaps in Coverage SERVICE QHP MEDICAID RW/ ADAP/CDC

HIV Testing Continue to cover in certain settings

RX Cost-sharing assistance and gap coverage

MEDICAL CASE MANAGEMENT

ORAL HEALTH

LABS Cost-sharing assistance

MENTAL HEALTH SERVICES

Cost-sharing assistance and in some settings care continuation

SUBSTANCE ABUSE TREATMENT

Cost-sharing assistance and in some settings care continuation

HIV PRIMARY CARE Cost-sharing assistance

MEDICAL TRANSPORTATION

Limited Coverage

INPATIENT HOSPITAL SERVICES

Adapted from West Virginia Ryan White Part B Program

Example: Case Management Coverage

Private Insurance Benchmark Plan

Ryan White Program

Case management Periodic phone calls to discuss appointments and assist in finding services.

Medical case management Coordination and follow-up of medical treatments, ongoing assessment of the client’s and other key family members’ needs and personal support systems, development of a service plan, coordination of services, provision of treatment adherence counseling to ensure readiness for, and adherence to HIV/AIDS treatments.

Non-medical case management Includes provision of advice and assistance in obtaining medical, social, community, legal, financial, and other needed services (does not include coordination and follow-up of medical treatments).

Some Ongoing Issues That NEED our Attention

• Health care delivery advocacy is increasingly important and needed in more areas. The best policy decisions are made with provider input: – Continuation of the Ryan White program

• RW to ensure safe transitions from one payer source to another • Remains relevant to unique needs of PWLHA • Serves those most in need

– Medicaid expansion in all states – Ensure that Medicaid, Medicare and private insurance systems deliver

quality HIV services – Adequate reimbursement rates for providers of a continuum of services in

patient centered medical home models – Health care for undocumented and residually uninsured individuals – More affordability for low income individuals with chronic conditions – Ensuring providers and clients understanding the rights to access to

benefits and services in insurance plans

Possible opportunity for more community based organizations to build policy/advocacy skills and funding

THERE ARE AT LEAST THREE

MAJOR REALITIES ASO’S NEED TO PREPARE FOR

Part 3

REALITY: Growth in Coordinated Care Patient Centered Medical Home (PCMH) or Medicaid Health Home (MHM) • NCQA sets standards around organizing primary care around patients, working in teams and coordinating and tracking care over time. (Note: HIV Could be one Area of Accreditation) Triple AIM a core strategy: • Improve the health of the defined population • Reduce, or at least control, the per capita cost of care • Enhance the patient care experience (including quality,

access and reliability) The Institute for Healthcare Improvement (IHI)

IMPACT: CBOs may be able to partner with clinical sites to expand services & improve linkage, retention and coordination. Use RW to build partnerships NOW!

REALITY: Growth in the Use of Electronic Health Record (EHR)

• The promise of EHR (electronic health records) is that if its use is

“meaningful” then benefits will result in the form of complete and accurate information to enable better care, better access to this information in order to diagnose health issues earlier, and patient empowerment with patients playing a bigger role in their health care.

• Medicare and Medicaid have provided incentive payments to CHCs when they adopt certified EHR technology in order to promote these benefits.

• “Meaningful use” is expected to evolve progressively over three stages.

IMPACT: Massive Capacity, Cost, and Infrastructure Issues for ASOs

REALITY: Clients Will Have More Choice • Under HCR patients will have an expanded choice of

medical providers. • Emphasis on human resources

– Accountability – Engagement – Integrity

• Process improvements – Time to appointment – Wait time – Appropriate counseling of clients

IMPACT: Patient Choice will require agencies to attend to quality and client satisfaction to survive. CBOs may be valuable partners.

SO WHAT…?

NOW WHAT…?

Darwinism: If you don’t evolve, you

become extinct.

We’re building it WHILE we fly it...

We’ve DONE This Before!

4-Stage Sector Transformation Process EDUCATE CHANGES:

• Policy • Financing • Service

Delivery Systems

• ISSUES: • Identity • Business

Model

• SKILLS: • Advocacy • Scenario

Planning • Succession

Planning

ENERGIZE • Assess

Organizational Readiness • Executive

Director • Board • Staff • Clients

• Develop an Agency Plan

• Engage National & Local Funders

• Build Trust

• Move to Action

EXPLORE • Actively

support organizations to: • explore

options • identify

possible partners

• test feasibility

• DECISION

• Merge • Grow • Go

EXECUTE • Actively support

organizations to engage in a structural transformation process • Collaborations • Business

Model Conversion (ASO to FQHC)

• Strategic Alliances

• Strategic Restructuring

• Responsible Closure

IMMEDIATE ACTION: DEVELOP A COMPRHENSIVE AGENCY PLAN

1. Landscape: Understand the specifics and the timelines for changes in your state.

2. Staff: Training, coordination, capacity & expertise assessment

3. Clients: 1. Know your client base & their evolving needs

2. Help clients with new coverage, enrollment, transitions, navigation, and troubleshooting access issues

4. Business/Funding Plan

39

Patient or AHP

Outreach

Linkage Vs. Referral

Enrollment

Education: Insurance, Disease,

progression, Tx Options, etc.

Supportive or Facilitative Services

Retention: Primary Care & Specialty Care

Adherence

An ASO’s Historical “Services” become…. Transferrable Skills or Sellable Commodities

BUT only with Measurable Outcomes & Clear Understanding of Service Costs

Client/Patient/Participant

Founding Identity Evolving Identity Curr

ent

Busin

ess M

odel

N

ew B

usin

ess M

odel

Responsible Closures

(To Ensure Continuity of Care!!!!)

ASO to FQHC Conversion

Strategic Restructuring:

•Management Services Org (MSO) •Parent - Subsidiary •Mergers •Acquisitions •Joint Ventures

Collaboration: •Info Sharing •Referrals •Joint Planning

Strategic Alliances To

Develop New Service Models: •Admin. Consolidation •Formal Co-education •Preferred Provider Referrals •Resource Sharing/Contracting

•Cash, Staff, EHR, etc. •Co-location •Integration w/ Primary Care

ASO Sector Transformation Model

CHOICES…..

Lessons from Pioneering ASOs

• Relevance + positioning = sustainability

• Never underestimate the value of relationship capital

• Readiness planning is critical – STAFF, BOARD and CLIENTS – Take time for strategic thinking . . . be proactive, forecast and don’t do it in

a bubble

• Know the data, the drivers and the deliverables required

• Be willing to take smart, calculated risks

• Must constantly evolve the way you do business – “evolve or become extinct”

• Power of advocacy and policy. ACTION CHANGES THINGS!

THE BOTTOM LINE… • Consolidate Administration/Infrastructure • Leverage Program Expertise • Create “new service model” or Continuum MERGE • Remain Stand Alone • Expand Mission to include other Populations,

Services or Geographies GROW • CLOSE RESPONSIBLY!

• Conscious Decision • Notify and Work with Funders to Transfer

Grants/Contracts • WORK PROACTIVELY to TRANSITION CLIENTS to

Other Providers! CONTINUITY OF CARE!!!!!

GO

Which will you Choose?

Acknowledgements

• AIDS United • Johnson & Johnson • Anne Donnelly – Project Inform • Kandy Ferree – 360 Strategy Group • Liz Brosnan – Christie’s Place • Countless direct service providers and people living with

HIV/AIDS from whom we have learned so much and contributed to this presentation.

THANK YOU!

Questions

• Ask your questions using the webinar question feature.

• If we don’t get to your

question it will be logged and we’ll do our best to follow up!

What’s Next

• Download & share the presentation and webinar recording (available in a few days)

• We need your feedback! When you sign off, take the quick survey about the webinar

• Watch for future webinar announcements

Thank You Kandy Ferree, President & CEO – 360˚ Strategy Group kferree@360strategygroup.com Anne Donnelly, Director of Health Care Policy – Project Inform adonnelly@projectinform.org For more information about sector transformation, please email: Stephanie Cruse, Program Manager– AIDS United scruse@aidsunited.org

Exploring Strategic Change with your Boards of Directors

Presented by: • Kandy Ferree, President & CEO – 360˚ Strategy Group • Anne Donnelly, Director of Health Care Policy – Project

Inform