Governing Board Meeting (Materials 1), Jan. 11, 2018 · 2018-04-19 · 2.2x 1.5x 1.5x 1.4x 1.2x Elevated risk for… 2.7x 1.7x 1.9x 1.8x 1.3x 4.5x 1.8x 4.3x 5.4x 1.4x 5.6x 2.1x 4.2x

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Agenda Packet Page 1 of 24





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Performance Measurement & Data Committee | ACH data strategy

Key findings from the King County ACHRegional Health Needs Inventory

January 8, 2018King County Accountable Community of Health nuary 8 2018Agenda Packet Page 7 of 24


Who are Medicaid members?

2

MedicaidNon-Medicaid

Notes:

1) Data source: US Census Bureau, American Community Survey, Public Use Microdata Sample, 2015

2) To make the comparison between Medicaid and non-Medicaid populations as similar as possible with respect to age, individuals with Medicare coverage alone are excluded from the non-Medicaid group.

3) Red highlight – Medicaid member estimate statistically significantly higher than non-Medicaid (p-value < 0.05)



Who are Medicaid members? (continued)

3

MedicaidNon-Medicaid

Notes:

1) Data source: US Census Bureau, American Community Survey, Public Use Microdata Sample, 2015

2) To make the comparison between Medicaid and non-Medicaid populations as similar as possible with respect to age, individuals with Medicare coverage alone are excluded from the non-Medicaid group.

3) Red highlight – Medicaid member estimate statistically significantly higher than non-Medicaid (p-value < 0.05)



Where do Medicaid members live?

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9,067 19,361Number of enrollees ranges from:

ZIP Area98001 Auburn98002 Auburn98003 Federal Way98023 Federal Way98030 Kent98031 Kent98032 Kent98042 Covington98058 East of Renton98092 East of Auburn98108 Georgetown/ Beacon Hill98118 Rainier Valley98133 Shoreline98168 SeaTac/Tukwila98178 Renton98188 SeaTac/Tukwila98198 Des Moines



Which Medicaid members have greatest opportunity for improvement?

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Any mental health need

Serious Mental Illness

SUD treatment

need

Co-occurring MI/SUD

2.2x 1.5x 1.5x 1.4x 1.2x

Elevated risk for…

2.7x 1.7x 1.9x 1.8x 1.3x

4.5x 1.8x 4.3x 5.4x 1.4x

5.6x 2.1x 4.2x 4.9x 1.5x

Behavioral health concerns tied to healthcare and social outcomes

Black Medicaid members

AIAN Medicaid members

1.6x

1.5x

1.7x

1.6x

3+ ED visitsper year

Homelessness

Arrest

No follow-up after ED visit for alcohol or drug dependence within 7 or 30 days

2.3x

2.6x

2.6x

1.6x 1.8x

Homelessness

Arrest3+ ED visits

per year

1.6x

No follow-up after ED visit for alcohol or drug dependence within 7 or 30 days

No breast cancer

screening

No blood sugar testing for diabetes

Persistent racial/ethnicdisparities also exist

Notes:1) Data source: Measure Decomposition Data, 7/7/2017, DSHS, Research & Data Analysis Division

2) Data represent adults (18-64, except breast cancer screening – 50-64) with full-benefit Medicaid coverage, excluding members with third party coverage but including members with Medicaid dual eligibility.

?Agenda Packet Page 11 of 24


Which geographic areas have greatest room for improvement?

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Measure Worst-performingZIP code

Best-performingZIP code

asthma diagnosis 6% 1%asthma med management 19% 46%

ambulatory visit (1-19) 75% 100%ambulatory visit (20+) 63% 84%

ambulatory visit (20-44) 61% 83%ambulatory visit (45-64) 67% 90%ambulatory visit (65+) 76% 100%

well-child visit (3-6) 44% 74%diabetes diagnosis 7% 2%diabetes eye exam 17% 49%diabetes HbA1c test 63% 100%diabetes kidney test 71% 100%depression diagnosis 24% 6%

ED broad (0-17) 52 per 1000 mm 10 per 1000 mmED broad (18+) 194 per 1000 mm 21 per 1000 mm

avoidable ED (1-17) 29% 10%avoidable ED (18+) 17% 8%

plan all cause readmission 41% 10%

Data source: HW Dashboard, Medicaid claims data 10/2015 – 9/2016



Relative disparity does not take volume into account

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Measure Worst-performing Best-performingNo ambulatory visit, child 98121 98039

No well-child visit 98101 98007ED visits, child 98101 98040

Avoidable ED visits, child 98051 98116




Gap analysis takes both volume and room for improvement into account

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ZIP AreaNo

ambulatorycare, child

No well-child visit

ED visit, child

Avoidable ED visit,

child98001 Auburn X X X98002 Auburn X X X X98003 Federal Way X X X X98023 Federal Way X X X X98030 Kent X X X X98031 Kent X X X X98032 Kent X X X X98034 North Kirkland X98058 East of Renton X98092 East of Auburn X X98101 Downtown X X X98104 Pioneer Square/ID X X X X98108 Georgetown/Beacon Hill X X X98118 Rainier Valley X X X X98121 Belltown X98122 Central District X X X X98125 Lake City X X98133 Shoreline X X X X98144 Mt. Baker X X X98168 SeaTac/Tukwila X X X X98178 Renton X X98188 SeaTac/Tukwila X X X X98198 Des Moines X X X X

23 ZIP codes hold half of members/eventsfor 4 child metrics



Gap analysis estimates number needed to treat to hit 100% of performance targets

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King County Performance Gap Analysis



Performance targets for ED visit measures

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King County Performance Gap Analysis



Cultural representativeness of providers – How likely is it for a Medicaid member in King County to see themselves represented in their care providers?

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Population Percent non-white Percent LatinoMedicaid members1 49% 16%

Primary care physicians2 21% 3%

Primary care nurse practitioners2 10% 2%

Primary care physician assistants2 22% 3%

Data source: 1) HW Dashboard, 2016 data; 2) WA State Primary Care Provider Survey, 2011-2012, Center for Health Workforce Studies

For example, compared to King County Medicaid members of color, white Medicaid members are almost 4 times and 9 times as likely to be served by a primary care physician or nurse practitioner with a similar racial/ethnic identity, respectively

member inAgenda Packet Page 17 of 24


National, state and local policies that may affect health and social well-being

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Affordable Care Act repeal &

replacement

Federal immigration

reform

↓ federal food

assistance funding

(Farm Bill)

↓↓ Planned Parenthood

funding (Title X)

n↓ housing &

homelessness funding

(HUD budget)

Local real estate trends

Regressive tax system

Medicaid transformation

Seattle income tax

Seattle Preschool Program

Best Starts for Kids

Communities of

Opportunity

Affordable Care Act

Threats

Opportunities

National State Local



Approaches to identifying target populations for the Medicaid demonstration

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Path of least resistance for performance-based initiatives not necessarily transformative change

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Find the common denominator across all projects – Medicaid members with chronic disease & behavioral health concerns who may benefit from opioid dependence prevention/treatment and transitional care services

Maximal overlap approach

Find providers who have established health or social service relationships with the largest number of Medicaid members not meeting performance measures

Volume approach

Identify Medicaid member subgroups with largest burden of relative health and social disparities –AI/AN, Black, mental illness & SUD treatment needs

Equity & social justice approach

Identify the small subset of Medicaid members with the most complex health and social needs and thus the highest utilization and cost of health care services (e.g. 5% responsible for 50% of total cost of care)

Familiar Faces approach

Optimize efficiency, but may only be able to move interconnected P4P measures (e.g. may miss child P4P measures)

Grounded in justice, accountability to underserved populations, but may not be able to move region-level needle

May be well designed for shifting region-level needle, but not necessarily linked to transformative change

May blend elements of both performance and ESJ, given focus on members with maximal suffering and high, costly utilization of health services

May be worthwhile to consider a blended approach that includes both needle-moving, condition-specific clinical and social strategies (e.g. diabetes management) AND ESJ-grounded, system-level transformative change (e.g. centralized referral hub for clinical and social services to support improved care coordination)

essarilyAgenda Packet Page 20 of 24


Eli Kern MPH RN | EpidemiologistAssessment, Policy Development & EvaluationPublic Health - Seattle and King CountyPhone: 206.263.8727 | Email: [email protected]

Explore the PMD: www.kingcounty.gov/pmdExplore Regional Health Needs Inventory: https://goo.gl/j5eJav

For more information…

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AGENDAIntroductionsI. Background on American Indian Health Commission for

Washington StateII. An Introduction to Indian Health Care in Washington State

A. Tribal sovereignty and federal trust responsibilityB. Tribal governmentsC. Complex Indian health care delivery systemD. American Indian/Alaska Native (AI/AN) health disparitiesE. Complex federal requirements

III.Tribal Expertise, Challenges, and ConcernsIV.Working with Tribes - DiscussionV. Questions

I. BACKGROUND

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Created in 1994, became a non-profit agency in 2003.

Mission: Improve the health of American Indians and Alaska Natives (AI/AN) through tribal-state collaboration on health policies and programs that will help decrease disparities

Constituents: The Commission works with and on behalf of the 29 federally-recognized tribes and 2 urban Indian health programs in Washington State.

Commission Membership: Tribal Councils appoint delegates by Council resolution to represent their tribes on the Commission.

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The Commission provides many health policy-related services under contracts with:

Washington State Department of Health

Washington State Health Care Authority

Washington Health Benefit Exchange

Office of the Insurance Commissionernsurance C

II. AN INTRODUCTION TO THE INDIAN HEALTH CARE DELIVERY SYSTEM

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A. TRIBAL SOVEREIGNTY, TREATIES, FEDERAL TRUSTRESPONSIBILITY

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U.S. RECOGNITION OF TRIBAL SOVEREIGNTY

Indian nations within the United States possess the inherentpower to govern.

“The Indian nations had always been considered as distinct,independent, political communities, retaining their originalnatural rights, as the undisputed possessors of the soil, fromtime immemorial…”– Worcester v. Georgia, 31 U.S. 515, 559 (1832)

As sovereign nations, Indian tribes operate fullgovernments and often coordinate their servicesacross multiple governmental departments.

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1854-56: Treaties with Tribes in Washington Territory

1854-56: Treaties with Tribes in Washington Territory

Federal Trust Responsibility to Tribes

The federal government has a trust relationship withthe tribes that is derived from treaties, statutes, andopinions from the Supreme Court.

The federal government has a legal obligation toprotect tribal sovereignty and property.

See Worchester v. Georgia, 31 U.S. 515 (1832) and

Cherokee Nation v. Georgia, 30 U.S. 1(1831).

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Federal Trust Responsibility for Health Care to All American Indians/Alaska Natives

Indian Health Care Improvement ActSection 3, P.L. 94-437:

“…it is the policy of the Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians…to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.”

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SIMILAR RELATIONS: FEDERAL-STATE & FEDERAL-TRIBAL

Federalism – Governmental Relations between States and U.S.“The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.”

– U.S. Constitution, Tenth Amendment

Federal-Tribal Governmental Relations“…the treaty was not a grant of rights to the Indians, but a grant of rights from them—a reservation of those not granted.”

– U.S. v. Winans, 198 U.S. 371 (1905)

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Tribes in and near Washington Today

B. TRIBAL GOVERNMENTS

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GOVERNMENT-TO-GOVERNMENT RELATIONS:FEDERAL-TRIBAL

– Executive Order 13175– Various agency regulations

Brian Cladoosby, Chair Swinomish Tribe with President Obama

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GOVERNMENT-TO-GOVERNMENT RELATIONS:STATE-TRIBAL

Centennial Accord of 1989: Agreement between the State of Washington and the Tribes where each party “respects the sovereign status of the parties, enhances and improves communications between them, and facilitates the resolution of issues.”

Chapter 43.376 RCW: Law requires state agencies to “make reasonable efforts to collaborate with Indian tribes in the development of policies, agreements, and program implementation that directly affect Indian tribes…”

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GOVERNMENT-TO-GOVERNMENT RELATIONS:TRIBAL CONSULTATION REQUIREMENTS

American Recovery & Reinvestment Act of 2009: Requires State Medicaid agencies to seek advice on a regular, ongoing basis from designees of Indian health programs (IHS, tribes, and urban Indian health programs) concerning Medicaid and CHIP matters that have a direct effect on AI/ANs or Indian health programs.

Chapter 43.376 RCW: Requires state agencies to “develop a consultation process that is used by the agency for issues involving specific tribes”.

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o

o

COMPARISON OF U.S. AND TRIBAL GOVERNMENTS

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C. COMPLEX INDIAN HEALTH CAREDELIVERY SYSTEM

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History: Agency founded in 1955, but health care services provided through the War Department since the 1800sToday: Now in the Department of Health and Human Services, IHS is a sister agency to CMSFunction: Coordinates the Congressional appropriations for health care to be provided to AI/ANs through three broad types of programs, with facilities located on or near Indian reservations or in certain urban areasEligibility: Approximately 2.2 million eligible AI/ANs are eligible for care nationwide within the Indian health care delivery system, but eligibility varies depending on program and tribe

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Indian Health Care Provider

Health CareMental HealthSubstance Use Dental

Referral & Coordination

Non-Indian Health Care Provider

Specialty CareInpatient Care

dian Health Care Provid

Health Care

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x = Tribal facility located in county/IHS service delivery area

IHS CHSDAs by County and RSA

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NATIONAL HEALTH CARE SPENDING PER CAPITA

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

U.S. Medicare Medicaid IHS

Source: Jessie Dean – Analysis of Centers for Medicare and Medicaid Services (CMS) National Health Expenditure Accounts (NHEA) and the Department of Health and Human Services (DHHS) Budgets in Brief. 28

Federal government fails to fund IHS

adequately

Federal government requires AI/ANs to use other resources

first*

Tribes/UIHPs forced to fill in the gaps

Complex Payer Requirements for AI/ANs and Tribes

*42 CFR 136.61 – IHS is payer of last resort.29

EFFECTS OF UNDERFUNDING OFTHE INDIAN HEALTH SERVICE

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D. AMERICAN INDIAN/ALASKA NATIVE (AI/AN) HEALTH DISPARITIES

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“American Indian/Alaska Native populations are disproportionally affected by diseases, such as cancer, heart disease, and diabetes.

Furthermore, when looking at deaths in Washington state, American Indian/Alaska Native experience the highest age-adjusted death

rates when compared to other racial and ethnic groups. This makes the quality of care that they receive that much more important.”

(emphasis added)

WASHINGTON HEALTHALLIANCE: DISPARITIES IN CAREREPORT 2014:

SELECT HEALTH DISPARITIES DATA FORAI/ANS IN WA

In Washington, the mortality rate for AI/ANs was 1,233.6 per 100,000. A rate about 71% higher than the rate for non-Hispanic whites.

Top 10 Leading Causes of Death*Cardiovascular Disease 23.5%

Cancer 19.4%Unintentional Injury 11.4%

Diabetes 4.6%Chronic Liver Disease and Cirrhosis 6.1%Chronic Lower Respiratory Disease 5.9%

Suicide 3.5%Alzheimer’s Disease 2.1%

Influenza and Pneumonia 1.6%

2011-2015, Ages 1 year and over.Data Source: Northwest Portland Area Indian Health Board. American Indian & Alaska Native Community Health Profile – Washington. Portland, OR; Northwest Epidemiology Center, 2014 (WA State death certificates, 2006-2012, corrected for misclassified AI/AN race).

Premature Mortality Rates, Washington, 2013

Social Determinants of Health, Washington, 2013

E. COMPLEX FEDERAL MEDICAID REQUIREMENTSAPPLICABLE TO TRIBES AND AI/ANS

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Under federal law, Tribal governments are sovereign governments, like federal and state governments.

Tribes and States are both sovereigns.

Tribes are not subject to State law; States are not subject to Tribal law.

Tribal governments have sovereign immunity.

Tribes are presumptively immune from state law.

Tribes cannot be sued unless they consent to the lawsuit or they waive their sovereign immunity.

Tribal Sovereignty & Sovereign Immunity

IHS is the Payer of Last Resort

See 42 C.F.R. 136.61.

HIPAA (45 C.F.R. 164.512) provides that covered entities may disclose public health information (PHI), without written authorization of the individual, to a Tribe as either:

A public health authority that is authorized by law to collect and receive such information for the purposes of preventing or controlling disease, etc., or

A health oversight agency that is authorized by law to oversee the health care system (whether public or private) or government programs in which health information is necessary to determine eligibility or compliance.

HIPAA: PHI Disclosures to Tribal Governments

IHS Direct facilities and Tribal 638 facilities that choose to be IHS facilities (as defined in the 1996 Memorandum of Agreement between CMS (formerly HRSA) and IHS (MOA)) will receive the IHS Encounter Rate (currently $391) for Medicaid-covered services provided to Medicaid enrollees. See MOA and Medicaid State Plan definition of encounter.

For Medicaid-covered services provided by IHS Direct facilities or Tribal 638 facilities to AI/AN Medicaid enrollees in fee-for-service, the Federal Medical Assistance Percentage (FMAP) is 100% (42 U.S.C. 1396d(b)).

For comparison:

Medicaid Expansion FMAP: 100% until 2017, then declines to 90%

Presumptive SSI FMAP: 80% currently

Classic Medicaid/Other MAGI-Based Medicaid FMAP: 50% currently

IHS Encounter Rate & Federal Participation

Health care professionals employed by a Tribal health program are exempt from the licensing requirements of the state in which the services are performed, provided the health care professional is licensed in any state. (25 U.S. Code 1621t)

Similar to Veteran’s Administration licensing requirements under 38 U.S. Code 7402

Provider Enrollment: Licensing Exemption

Tribal health providers are covered by the Federal Tort Claims Act (FTCA)(25 C.F.R. Part 900)

The federal government becomes responsible for the negligent or wrongful acts of Tribal health providers unless the claim is for:

On-the-job injuries which are covered by worker's compensation;

Breach of contract rather than a tort claim; or

Acts performed by employee outside the scope of employment.

WACs 182-502-0006, -0010, -0012, -0016 reflect this.

Tribal health providers are not required to obtain professional liability insurance or other insurance coverage for tort claims to the extent covered by FTCA.

Provider Enrollment: Insurance & FTCA

Each MCO contract with the State must require the MCO to:

Demonstrate sufficient Indian Health Care Providers (IHCPs) in network for MCO-enrolled AI/ANs to have timely access to Medicaid-covered managed care services from IHCPs;

Pay IHCPs, whether contracted with the MCO or not, for Medicaid-covered managed care services provided to MCO-enrolled AI/ANs at a rate that is not less than the amount that would be payable to a contracted non-IHCP provider;

Make prompt payment to IHCPs, whether contracted with MCO or not; and

Pay IHCPs that are FQHCs, whether contracted with the MCO or not, for Medicaid-covered managed care services provided to MCO-enrolled AI/ANs at a rate that is not less than the amount that would be payable to a contracted non-IHCP FQHC (without affecting FQHC supplemental payments).

If the amount paid by the MCOs to a non-FQHC IHCP is less than the IHS encounter rate, the Medicaid State Plan must provide for payment of the difference between the MCO rate and the IHS encounter rate.

See 42 U.S.C. 1396u-2(h)(2).

MCO Contract Requirements

AI/ANs are exempt from:

Medicaid premiums and cost-sharing (42 C.F.R. 447.56(a)(1)(x))

CHIP premiums and cost-sharing (42 C.F.R. 457.125(b))

Qualified Health Plan premiums and cost-sharing if:

a) Under 45 C.F.R. 155.350:

Household income is equal to or less than 300% of the federal poverty level, and

Verified membership in a Tribe; or

b) Under Section 1402(d)(2) of the Affordable Care Act:

They receive care through an Indian Health Care Provider or through the Purchased and Referred Care program.

AI/AN Exemptions from Cost-Sharing

AI/ANs have the right to exempt themselves from an MCO or PCCM program, if they choose, unless the MCO or PCCM is an Indian Health Care Provider (42 C.F.R. 438.50(d)(2)).

AI/ANs enrolled in an MCO have the right to select an in-network Indian Health Care Provider for primary care (42 U.S.C. 1396u-2(h)(1)).

AI/AN Federal Rights and Medicaid Managed Care

III. TRIBAL EXPERTISE, CHALLENGES, & CONCERNS

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TRIBAL EXPERTISE IN HEALTH CARE

Providing care within a maze of federal and state regulation:IHS funding is subject to many federal regulations, which differ between programs and between tribes; an IHS facility has different rules for eligibility, referrals and billing than a Tribal program or an Urban Indian Health Program.

Indian health care provider billing staff can educate non-Indian providers on how and when the different regulations apply.

Creating and administering programs with limited funding:Indian health care provider revenues come from discretionary IHS appropriations and third-party billing, including Medicaid, Medicare, and private insurance.

With persistent Congressional threats to appropriations and Congress’s use of continuing resolutions instead of budgets, third party billing revenue has become a critical means for keeping Indian health care programs in existence.

Community Health Programs:Tribal health programs have utilized Community Health Nurses (CHNs) and Community Health Representatives (CHRs) for decades.

Home visiting, transportation to medical appointments, follow-up care from hospitalizations, prevention education, diabetes programs, walking and exercise programs help AI/ANs outside the clinical setting.

Social Determinants of Health:As governments, Tribes provide many governmental services to help address social determinants of health, including but not limited to housing, food banks, food vouchers, help with energy costs, employment services, education services, and case management.

Culturally Appropriate Services:Many Tribal clinics utilize traditional healers in their clinics but are unable to bill for their services. They provide them regardless of revenue as they know these services are important to the health of their people.


Best Practices: Creative solutions with limited fundingHolistic health care from which others can learnWrap-around services that include physical, social, spiritual, and behavioralIntegrated behavioral and physical health careFocus on population health through native public health practices

Other Common Tribal PrioritiesSustainabilityPrevention and wellnessCommunity connectednessCulture


Provider Recruitment and RetentionRecently, one Tribe had a provider position vacant for 15 monthsCommon, persistent vacancies: oral health, maternal-infant health, long-term care

Remote areas with few health care optionsLack of providers in rural communitiesTransportation and child care becomes a barrier

Cultural BarriersDiscrimination and distrustCommunication challengesLack of understanding of the Indian health care delivery system outside of Indian CountryAI/AN health literacy – AI/AN clients are used to IHS/Tribal clinics taking care of them and often don’t know how to advocate for their own health

CHALLENGES IN INDIAN HEALTH CARE

Healthier Washington/ Medicaid Transformation

Integration of Medical & Behavioral Health Services

Creation of Accountable Communities of Health

Transition from Fee-For-Service to Value-Based

Purchasing

State LawSB 6312

1915(b) Waiver

1115 Waiver

SOME TRIBAL CONCERNS

“There are always Tribal implications unless it turns out there are not.”

-- Stephen Kutz, Cowlitz Tribe

…and Tribes are the best source for whether a program, policy, or agreement will have Tribal implications.

FINAL THOUGHT: WHY WE NEED TO WORK TOGETHER

V. WORKING WITH INDIAN HEALTH CARE PROVIDERS

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Working with Indian Health Care Providers…

What are your thoughts?

Thank you!

Documents

Governing Board Meeting (Materials 1), Jan. 11, 2018 · 2018-04-19 · 2.2x 1.5x 1.5x 1.4x 1.2x Elevated risk for… 2.7x 1.7x 1.9x 1.8x 1.3x 4.5x 1.8x 4.3x 5.4x 1.4x 5.6x 2.1x 4.2x