State of the State...Beth Kohler of Beth Kohler Consulting and former Deputy Director of AHCCCS will address integrated care, new geographic service areas, work requirements and other

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STAT

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E 20

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June 2015Dear Friends and Colleagues,

Welcome to the 32nd Arizona State-of-the-State.

Thank you for choosing The Hertel Report (THR) as your trusted resource for news and information

impacting the Arizona healthcare industry. THR is proud to follow in the footsteps of Jim Hertel, founder

of the Arizona Managed Care Newsletter and former State-of-the-State host and sponsor.

As the publisher of The Hertel Report, I’m responsible for ensuring the information you receive on THR’s

website, monthly newsletter, data editions and this State-of-the-State is timely, accurate and impartial.

With three decades in the healthcare industry and a passion for healthcare policy, I’m equally commit-

ted to encouraging professional collaboration and dialogue on the important topics facing the health-

care industry today.

During this morning’s presentation we’re excited to provide you a Medicare & AHCCCS industry update,

an opportunity to explore how Accountable Care Organizations (ACOs) are growing in Arizona and how

the new Regional Behavioral Health Authority is progressing in the state.

ACOs are accelerating the pace of change across the country, and Arizona is leading the effort. The

Affordable Care Act encourages the healthcare industry to create organizations designed to improve

quality and reduce costs for the traditional Medicare population. Arizona has one of the 19 remaining

Pioneer ACO’s and 11 Medicare Shared Savings ACO’s. The Medicare ACO’s are the focus of today’s

panel discussion. We have Medicare ACO leaders from across the state joining us to share information

and data with us.

Integrating behavioral and physical health is the impetus behind the new Regional Behavioral Health

Authority (RBHA) structure in Arizona. The new RBHA in Maricopa County, Mercy Maricopa Integrated

Care (MMIC), has been delivering coordinated care for five months now, and we will hear a progress

report from Jennifer Sommers, Director, Network Development & Contracting at Mercy Care Plan and

MMIC.

My thanks to Jennifer and the representatives of our state’s leading Accountable Care Organizations, as

well as my friend and colleague Steve Rees for joining me in today’s discussion. We encourage you to

be a part of the discussion, too.

Thank you for joining us today.

Jim HammondCEO/PublisherThe Hertel Report, LLC

Continue the conversation as a member of The Hertel Report at www.thehertelreport.com or contact us at [email protected]

STAT

E OF

THE

STA

TE 2

019

Good Morning,

Welcome to the 37th edition of the Winter State of the State breakfast meeting.

For nearly two decades, our membership organization has brought together leaders from throughout the Arizona healthcare industry to learn the latest market trends while gaining additional insight and intelligence from our collection of unbiased, locally sourced data, and our curated collection of federal and state reports.

This year, the State of the State is hosting seven industry experts to share their perspectives on a specific industry segment. We will learn about the roll-out of new legislation and explore potential legislative changes coming in 2019. We’ll hear about the impacts of changes to our Medicaid program, and updates on the health insurance marketplace including enrollment and new players. The program also includes exciting changes and trends impacting Medicare Advantage from new benefits and health plans to new enrollment periods. Attendees will also hear the latest on ACOs and value-based medicine and get a bird’s eye view of the latest commercial rules, short term plans and trends in narrow networks and self-funded plans. Today’s experts are listed on our agenda page, please review their information to learn more.

As the Publisher of The Hertel Report it’s my mission to ensure our Arizona healthcare community receives trusted, impartial and timely news and data. As the host and moderator of the State of the State, it brings me great pleasure to share the stage with other industry professionals who share our commitment to providing solution-focused insights for our growing healthcare community across Arizona.

Please let us know how we are doing in that effort and share what you think we can do to improve future sessions.

Thank you very much,

JimJim HammondCEO/Publisher - The Hertel Report, [email protected]

January 2019

7AM NETWORKING BEGINS

7:30AM BREAKFAST

8AM PROGRAM BEGINS

WELCOME & INTRODUCTIONS PAULA BLANKENSHIP & JIM HAMMOND

HEADLINE NEWS JIM HAMMOND & JIM WHITFILL, MD

MARKET UPDATE JIM HAMMOND & JIM WHITFILL, MD • AHCCCS • MA • HIM • ACOS

A BRIEF HISTORY OF U.S. PUBLIC HEALTH POLICY LEONARD KIRSCHNER, MD

ACA REPEAL & REPLACE JIM HAMMOND, JIM WHITFILL, MD & LEONARD KIRSCHNER, MD

THANK YOU & CLOSING REMARKS

10:30AM PROGRAM ENDS

2019 Winter State of the State Agenda8amIntroductions

Breakfast Sponsor Managing Editor Paula BlankenshipPublisher Jim Hammond Founding Sponsors

8:30amProgram Begins

Discussion Facilitated by Publisher Jim Hammond

Jeff Buehrle, CFO at Banner and current AZ HFMA President, will welcome attendees and speak about collegiality, community cooperation and the path toward value.

Pele Fisher of Peacock Legal will address pending legislation, opioids, surprise billing, credentialing, prior authorization fixes, CHIP, Medicaid expansion and other Arizona news.

Beth Kohler of Beth Kohler Consulting and former Deputy Director of AHCCCS will address integrated care, new geographic service areas, work requirements and other trends in Medicaid. Marcus Johnson, Director of State Health Policy and Advocacy at Vitalyst Health Foundation will give an update on the health Insurance marketplace and the uninsured rate in Arizona.

Paul Rose, Co-CEO of Western Asset Protection (WAP) will give an update on Medicare Advantage, Medicare Supplemental, agent climate and more.

Blue Beckham of Blue Sky Consulting will present the latest trends in value-based networks and ACOs as well as discussions on risk transfer, provider readiness, Stark Law changes, network culling, MLR and more.

Chris Scherzer of The Clear Group will share his take on the commercial market, including narrow networks and the impact of non-ACA plans.

10:15amDiscussion/Audience Questions

10:30amProgram Ends

AGENDA

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A Better State of Care

For Patients ACN offers a broad network ofhigh-quality providers who collaborate for your best care and N Compass Care Coordination to resolve challenges that impact your health. Together with your provider, ACN can improve outcomes and deliver a better healthcare experience.

For Providers ACN is a governed by physicians so decisions are made by those who know healthcare best. Our tools, resources and personal support help you save on administrative costs and succeed in the new healthcare environment.

For Employers Insurance plans built on ACN give you access to a large, diverse network. Our innovative approach to healthcare delivery has improved outcomes and reduced total medical costs by $40.5 million compared to products that don’t actively manage care like we do. Contact us to learn more.

Named to Becker’s Hospital Review ACOs to Know 2017 & 2018.Learn more about ACN at www.azcarenetwork.org or call 602.406.7226

About Arizona Foundation

Arizona Foundation is an independent, not-for-profit Preferred Provider Organization. Originally established by physicians in 1969 as an alternative to health maintenance organizations, we have grown into Arizona’s largest statewide, independent network by providing highly-accessible, quality care.

We work directly with brokers, consultants, general agents, third party administrators, and insurance companies to provide the freedom of choice by offering and/or endorsing a variety of healthcare solutions.

Our Workers’ Compensation Plan, Foundation Comp, was designed for self-funded employers and workers’ compensation carriers. Foundation Comp offers its clients aggressive discounts and the largest, most accessible network of hospitals, occupational health medical centers, urgent care centers, physical therapy centers, and outpatient surgery centers, as well as a comprehensive network of physicians.

To help control the rising costs of healthcare, Arizona Foundation - through our strategic partnerships - has compiled a comprehensive package of nationwide Medical Management services and Wellness Programs that include:

About VyStream

VyStream - was established in Phoenix, Arizona in 1988 as a "one-stop-shop" medical billing repricing clearinghouse. VyStream utilizes its own proprietary repricing system that is maintained internally. Since its inception over 25 years ago, VyStream has expanded its services to include Medicare-Like Rates Repricing, Chiropractic Cost Containment, and Digital Imaging. VyStream has the experience and our service is impeccable.

Our repricing process is one of the most efficient and accurate in the industry. We have a 99% accuracy rate thanks to our multiple levels of system and quality control measures that are built into our process. With an average turn-around-time of1 hour, we are able to Auto-Adjudicate over 90% of our claims.

The following value-added services integrate with your existing system to reduce your operating costs:

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Connecting People to Healthcare

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• EDI Connectivity• Utilization Management • 24-hr Nurse Care Line

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Navigating the Healthcare Industry

Banner Health Network is a collaborative network across Maricopa County and beyond, including more than 5,000 physicians and a full spectrum of clinics, specialty facilities, urgent care and related services. Our members get convenient care in their neighborhood when they need it. You get an efficient, highly-coordinated partner who keeps costs down.

Care designed to fit your health.

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Blue Cross Blue Shield of Arizona is proud to be a founding sponsor of The Hertel Report and the work

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SUCCESS STORIES - EXPERIENCE & EXPERTISE

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Can WeHelp You?

Seeing you well

1/11/19

1

2019 Arizona Winter State of the State Market Update

Jim Hammond Publisher/CEO The Hertel Report Managing Consultant, Professional Healthcare SoluIons

January 2019

The Hertel Report

•  Trusted & Respected •  Impartial & Timely •  Solutions Focused •  Locally Owned

•  Weekly News •  Monthly Newsletter •  Quarterly Data •  Networking & Conferences

The Hertel Report Community

•  13 Founding Sponsors •  60+ Corporate Members •  10 Community Partners •  1000+ Individual Members •  11 NewsleSers •  4 Data EdiIons •  5 State of the State MeeIngs •  More…..

The Source that Connects the Arizona Healthcare Community

Thank You Breakfast Sponsor

•  Jim Hammond –  Publisher & CEO of The Hertel Report –  Managing Consultant, Professional Healthcare Solutions –  State-wide Healthplan & Provider Relations Expert –  Conference Speaker & Resource to:

AzHHA, AHE, MCMS, HFMA - AZ, CBIZ, ASPA, AMN, HCAA, CMSA, Sonora Quest, Humana, Dignity Health, U of A, CNBC, Money Radio, Wall Street Journal, NPR, Modern Healthcare, Phoenix Business Journal, Arizona Daily Star, Vitalyst Health Foundation, Web AZ, and more

–  Former AZ HFMA President

Introduction •  Welcome •  Introductions – Jeff Buehrle •  Headline News and Legislative Update – Pele Fisher •  Medicare Advantage – Paul Rose •  AHCCCS – Beth Kohler •  HIM ACA Coverage Update – Marcus Johnson •  ACO and Value-Based Networks – Blue Beckham •  Group and Self Funded – Chris Scherzer •  Healthcare Reform… Q&A

Agenda - Guest Speakers

1/11/19

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THANKS for our Programs

Find us on Facebook Follow us on TwiSer @thehertelreport Tweet using hashtag #AZSOS2018 Survey/Feedback, thanks! TM

The Source Connec,ng The Arizona Healthcare Community

Jeff Buehrle

CFO Arizona Rural Hospitals, Banner Health President AZ-‐HFMA Chapter

Community Partners Founding Sponsors

Founding Sponsors Corporate Members

1/11/19

3

Corporate Members Corporate Members

Corporate Members Corporate Members

The Hertel Report Community Partners ComarkeIng Today’s Event

2019 Arizona LegislaIve Session

Corporate Members

1/11/19

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Elec,ons Ma:er   Republicans held majority in Arizona Legislature …

  Senate 17(Rs) -‐ 13(Ds)   House of RepresentaIves 31(Rs) -‐ 29(Ds)

  Republican trifecta stands (House, Senate and Governor)   Democrats picked-‐up:

  U.S. Senate Seats: Krysten Sinema (D)   Congressional Seat District 2: Ann Kirkpatrick (D)   Secretary of State: KaIe Hobbs (D)   Superintendent of Public InstrucIon: Kathy Hoffman (D)

  Is Arizona turning purple? CompeIIve?   Appointed to fill McCain’s Senate Seat – Martha McSally (R)

2019 Legisla,ve Session •  Session begins on January 14th

•  State of the State & ExecuIve Budget

•  President of the Senate: Karen Fann (R) LD-‐1 •  House Speaker: Rusty Bowers (R) LD-‐25 •  Senate Health Chair: Sen. Kate Brophy-‐McGee (R) LD-‐28

•  Sen. Heather Carter (R) LD-‐15, Vice Chair •  House Health Chair: Rep. Nancy Barto (R) LD-‐15

•  Rep. Jay Lawrence (R) LD-‐23, Vice Chair

Priority Issues •  Budget •  Water •  Tax Conformity •  Red for Ed -‐ EducaIon Funding •  EducaIon Reforms •  Infrastructure / TransportaIon •  State Employee Raises •  School Safety •  Criminal JusIce Reforms

Health Issues

•  Fixing the Kids Care “Trigger” •  Dental Benefits for Pregnant Women •  HIE Reforms •  Telemedicine Coverage •  PBM Reforms •  Opioids

Public Health Issues

•  Public Health •  Tobacco 21 •  Vaping Reforms •  TexIng and Driving •  Prohibit indoor tanning

for kids under 18 •  Needle Exchange /

Syringe Access Programs •  IntervenIons to Improve

ImmunizaIon Rates

Implementa,on: Surprise Out-‐of-‐network Bill Dispute Resolu,on •  Dispute ResoluIon Process administered through DOI

–  For Healthcare services received on or aser January 1, 2019 in the amount of $1,000 or more aser deducIng the enrollee’s copay, coinsurance, and deducIble.

•  DOI plans to have an electric system up and running starIng on January 14, 2019

•  Process: –  Enrollee submits request for dispute resoluIon – DOI evaluates if the request qualifies –  Informal seSlement teleconference between the parIes –  If no agreement is reached, arbitraIon

1/11/19

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Opioid Update …

June 15, 2017 – December 27, 2018

Arizona Opioid Epidemic Act •  Expanding access to naloxone •  Prescriber EducaIon •  Prescribing Limits

–  5-‐day limit on iniIal opioid prescripIons with excepIons –  90 MME dosage limits

•  ProhibiIon on dispensing of opioids •  E-‐prescribing of controlled substances •  RegulaIon and licensing of pain management clinics •  Electronic prescribing required for Schedule II opioids •  ExpediIng Prior AuthorizaIon

In 2018, Arizona has seen . . . •  36% decrease in the number of opioid prescripIons, compared to 2016; •  60% decrease in the number of paIents potenIally doctor shopping, compared to

July 2017; •  58% increase in the percent of overdoses referred to behavioral health providers,

compared to July 2017; •  296% increase in the number of naloxone doses dispensed by pharmacies,

compared to September of 2017; •  37% increase in the percent of providers who are checking the Controlled

Substances PrescripIon Monitoring Program, compared to July 2017; •  78% decrease in the number of opioid naive paIents given prescripIons for over

90MME since 2016; •  And 56% decrease in the number of opioid naive paIents given prescripIons longer

than 5 days compared to 2016.

CoaliIon Members Create 5-‐point plan to Reduce AdministraIve Burden of Prior AuthorizaIon

–  American Hospital AssociaIon (AHA) –  America’s Health Insurance Plans

(AHIP) –  American Medical AssociaIon (AMA) –  American Pharmacists AssociaIon

(APhA) –  Blue Cross Blue Shield AssociaIon

(BCBSA) –  Medical Group Management

AssociaIon (MGMA)

1.  SelecIve ApplicaIon Based on Quality, Performance or Evidence-‐based Medicine

2.  Program Review & Volume Adjustment

3.  Transparency & CommunicaIon 4.  ConInuity of PaIent Care 5.  AutomaIon to Improve

Transparency & Efficiency

Independent Agency Perspec,ve on Provider Topics

Paul Rose, Co-‐CEO Agency in business since 1982 Large MAPD/Med Supp Insurance Distributor 500+ cerIfied agents in Arizona

Topics •  Provider/Agent RelaIonship •  Mobile Urgent Care – Benefits of •  Mobile PCP – Benefits of •  Telemedicine •  ACO/Network Membership Growth Concerns

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Provider /Agent RelaIonships

•  Providers can’t steer specific plans •  CredenIaled advisors can •  Opportunity to develop relaIonships •  Partnership benefits

–  RetenIon, paIent growth, value –  Partnership benefits

•  Ways to grow/retain –  Calls, mailings, educaIon/sales events

MOBILE URGENT & PCP CARE

New added value benefit in some MA plans Cost effecIve way to deliver care Key is to educate brokers how to leverage Could see a significant shis next 2-‐3 years

TELE-‐MEDICINE

Network adequacy challenges Boomers more prepared for mobile medicine IntroducIon on moderate tele co-‐pays Expect a lot more virtual visits 2020 and on

ACO/NETWORK MEMBERSHIP GROWTH CONCERNS

Future of MAPD High performance network challenges:

Size of major metro areas Agent confidence & educaIon Less provider choice Takes Ime to build

1/11/19

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Medicare is not just one thing

Dual Medicare/Medicaid Zero premium & Low premium Premiums vary based on benefits Premiums vary Very High Income

Dual Medicare and Medicaid Integrated AHCCCS Medicare

Advantage Plan

Medicare Advantage

Medicare Advantage plus Part D

Plan

TradiIonal Medicare Plus Part D

Plan

TradiIonal Medicare

TradiIonal Medicare Plus a Supplement

High Income Part B Premiums

AHCCCS Complete Care = Integrated MCO Responsible for Physical and Behavioral Health October 2018 CC Contract Awards

Central GSA* Maricopa, Gila & Pinal Coun1es

• UnitedHealthcare Community Plan • Banner-‐University Family Care Plan • Care1st Health Plan Arizona • Health Choice Arizona (Steward) • Arizona Complete Health (Health Net) • Magellan Complete Care of Arizona • Mercy Care +

South GSA Cochise Graham, Greenlee, La Paz Pima, Santa Cruz & Yuma Coun1es • Arizona Compete Health (Health Net) + • Banner-‐University Family Care Plan • UnitedHealthcare Community Plan (Pima County only). North GSA Apache, Coconino, Mohave, Navajo & Yavapai Coun1es • Care1st Health Plan Arizona • Health Choice Arizona (Steward) + *Central GSA zip codes 85542, 85192 & 85550

are in the South GSA + RBHA Affiliated En,ty

RBHA Changes 10.1.18 No Longer Serving Most Adults & Children – Services Provided by ACC Plans

EXCEPTIONS

•  Foster Children Enrolled in CMDP (~13,000)

•  Members Enrolled with DES/DD (~33,000)

•  Individuals with a Serious Mental Illness (~40,000)

•  Crisis Services, Grant-‐Funded and State Only Funded Services 21

Care Delivery System as of Oct. 1, 2018

As Of October 1, 2018

1/11/19

8

Medicaid Enrollment – Dec 18

Families & Kids

938,134

Individuals w/SSI

182,377

Childless Adults 313,241

Expansion Adults 77,044

Sobra Pregnant 19,028

KidsCare 32,367

ALTCS EPD: 30,717 DD: 32,976

OTHER: 244,546

AHCCCS Enrollment Trends Acute MCO Enrollment

ACC 2018 Enrollment Report Doesn’t include ACC SMI Plans

AHCCCS Acute Plan Enrollment Shift January 2017 to December 2018

HEALTH PLAN

JANUARY 17 MEMBERSHIP

JANUARY 18 MEMBERSHIP CHANGE

DECEMBER 18 MEMBERSHIP CHANGE

United Healthcare 441,820 507,409 14.8% 366,259.00 (27.8)%

Mercy Care Plan 365,348 368,137 0.8% 351,856.00 (4.4)%

Health Choice AZ 250,463 248,971 (0.6)% 222,734.00 (10.5)%

Care 1st AZ 111,923 146,386 30.8% 181,457.00 24.0% University Family Care 137,905 131,948 (4.3)% 177,012.00 34.2% Health Net Access 57,756 58,567 1.4% 194,898.00 232.8%

November 2017

December 2017

April 2018

5-‐year Life,me Benefit Tabled

April 2017 – SIll WaiIng on CMS IMD Exclusion Waiver

1/11/19

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MEDICAID WORK REQUIREMENTS – LATEST NEWS 10 States have pending waivers to implement Work Requirements •  Alabama •  Arizona •  Kansas •  Maine •  Michigan •  Mississippi •  Ohio •  South Dakota •  Utah •  Virginia

5 States Approved for Work Requirements •  Arkansas •  Indiana •  Kentucky – Judge’s Ruling by EOM; Re-‐Approved •  New Hampshire •  Wisconsin

Source: KFF as of Dec. 7, 2018

States will be required by CMS to describe strategies to assist beneficiaries in mee,ng work requirements but may not use federal Medicaid funds for suppor,ve services to help people overcome barriers to work.

AHCCCS Care Premium & HSA Program on Hold

Arkansas Early Data Shows

ImplementaIon Challenges

Goals of Work Requirement Waivers

Medicaid Categorical

Medicaid Expansion

Marketplace -‐ Subsidized

Marketplace Unsubsidized/Commercial

The State of Coverage in Arizona 2019

Marcus Johnson Director, State Health Policy and Advocacy

Vitalyst Health FoundaIon

Health Coverage Reform

Coverage

Cost Quality

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Uninsured Trends (AZ v US)

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 United States 17% 17% 18% 17% 17% 17% 14% 11% 10% 10% Arizona 21% 20% 20% 20% 20% 20% 16% 13% 12% 12%

0%

5%

10%

15%

20%

25%

Uninsured Rates for the Nonelderly

ACA U.S. AZ

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

TEXAS

OKLAHOMA

ALASKA

GEORGIA

FLORID

A

WYOM

ING

MISSISSIPPI

NEVADA

SOUTH CAROLINA

NORTH CAROLINA

IDAHO

ARIZONA

TENNESSEE

ALABAM

A

UTAH

MISSOURI

NEW MEXICO

SOUTH D

AKOTA

VIRGIN

IA

UNITED STATES

KANSAS

MONTANA

LOUISIAN

A

NEBRASKA

INDIAN

A

MAINE

ARKANSAS

NEW JERSEY

NORTH D

AKOTA

COLORADO

CALIFORNIA

OREGON

ILLINO

IS

MARYLAND

WASHING

TON

WEST VIRGINIA OHIO

NEW HAMPSHIRE

NEW YORK

PENNSYLVANIA

CONNECTICUT

DELAWA

RE

WISCONSIN

KENTUCKY

MICHIGA

N

IOWA

RHODE ISLA

ND

VERMONT

MINNESOTA

HAWA

II

DISTRICT OF CO

LUMBIA

MASSACHUSETTS

AZ 10.1% U.S.

8.7%

AZ = 12th Highest Rate of Uninsured (2017, All Ages)

Medicare Employer Individual Market

Marketplace 138-‐400FPL

Medicaid <138%FPL Uninsured

Coverage Con,nuum

•  Integrated Coverage

•  Broad Networks •  No premiums,

cost sharing

•  Comprehensive benefits

•  Affordable w/Subsidies

•  Lower premiums

•  More OpIons?


•  Robust Networks

•  Large Risk Pool


•  Low cost •  More OpIons

(MA)

•  Disease •  Unemployment •  Uncomp. Care •  Cost Shising

•  Gov’t Budget Impacts

•  Lower Reimbursement

•  Expensive w/o subsidies

•  High DeducIble •  Narrow

Networks

•  Fewer consumer protecIons

•  More OpIons? •  Narrow

Networks

•  Not portable •  Narrow

Networks •  Family Glitch

•  Gov’t Budget Impact

Medicare Employer Individual Market

Marketplace 138-‐400FPL

Medicaid <138%FPL Uninsured

Coverage Con,nuum

Family Size 100% 133% 138% 250% 350% 400%

1 $11,880 $15,800 $16,400 $29,700 $41,580 $47,550

2 $16,020 $21,300 $22,100 $40,050 $56,070 $64,100

3 $20,160 $26,800 $33,600 $50,400 $70,560 $84,650

4 $28,440 $37,850 $39,250 $60,750 $85,050 $97,200

5 $28,410 $37,785 $39,205 $71,100 $89,210 $113,800

Source: US Census

Employer 50.1 Direct-‐Purchase 13.3 AHCCCS 22.5 Medicare 18.7 VA 2.9 Uninsured 10.1

Source of Health Insurance Coverage, All Arizonans, 2017

Source Percent Number Employer 50.1% 3,460,000 Medicaid 22.5% 1,554,000 Medicare 18.7% 1,292,000

Direct-‐Purchase 13.3% 917,000 Uninsured 10.1% 695,000

VA 2.9% 198,000 *Total is greater than 100% due to individuals with more than one source of coverage

2019 Marketplace Headwinds •  Tax Bill Zeroes-‐Out Individual Mandate Penalty •  75% Funding Cut to Navigators •  90% Funding Cut to Adver,sing •  Short term plans and associa,on plans •  Rates highly variable in AZ •  Inverse relaIonship to economy •  Cost Sharing ReducIons unfunded, but sIll part of silver benefits package for under 250% FPL

1/11/19

11

AZ Marketplace Plans 2019 Maricopa

County Only All Rural Counties

plus Pima Maricopa and

Pima

Arizona Marketplace Enrollment

2014 2015 2016 2017 2018 2019

120071

205666 202295 196291 165758 161241

Marketplace Plan SelecIons

Source: CMS Snapshots -‐ hSps://www.cms.gov/newsroom/fact-‐sheets/weekly-‐enrollment-‐snapshot-‐week-‐6

Coconino Maricopa Pima

$42 $70 $73

2019 Marketplace Premiums Aoer Tax Credits – Silver Plan 40-‐year-‐old, $20k (165%FPL)

Source: Kaiser Family FoundaIon



$168 $196 $199




$290 $318 $321


2019 Marketplace Premiums Unsubsidized – Silver Plan 40-‐year-‐old, Above 400%FPL


$648 $415 $332


1/11/19

12

2019 Marketplace Premiums Aoer Tax Credits – Bronze Plan 40-‐year-‐old, $20k (165%FPL)


$0 $0 $6

HOWEVER DeducIble ~$6,300

Uninsured Eligible for a Zero Premium Bronze Plan

AZ U.S. 54,673

(18% of the Uninsured) 4.2 Million

(27% of the Uninsured)

Bo:om Line: ACA Coverage in AZ

Who’s Benefi,ng •  Medicaid Expansion •  Marketplace consumers

earning up to 400% FPL, receiving subsidies

Who’s Hur,ng •  Arizonans earning above

400% FPL, who don’t have… –  Employer Insurance –  Medicare –  VA –  Or live in rural county

What’s Next?

Foreseeable Future -‐ Health Insurance Policy TEXAS v AZAR •  12/14/18 -‐ Judge rules enIre ACA

is unconsItuIonal. •  Trump AdministraIon did not

defend. •  No immediate changes. •  Next: Appeals and Supreme Court

1332 WAIVERS •  State flexibiliIes for: Reinsurance,

underwriIng, changes to minimum essenIal benefits, annual/lifeIme maximums, subsidies for AHPs and STP’s, etc.

•  States to pursue state-‐based individual mandate and expand Marketplace subsidies PUBLIC CHARGE RULE

•  PotenIal chilling effect on enrollment

MEDICAID WORK REQUIREMENTS •  PotenIal reducIon in enrollment •  Could lead to Expansion in non-‐

Expansion states

DISRUPTIVE CHANGE •  Medicare-‐For-‐All / Single-‐Payer •  Public OpIon offered through

Marketplace •  Medicare Buy-‐In OpIon <65yrs old •  Medicaid Buy-‐In

Foreseeable Future – Health Policy Payment Reform

Delivery System Reform

Accountable Health

CommuniIes

Health InformaIon Exchanges

Social Determinants of Health

Hospital-‐Public Health CollaboraIon

Telehealth Technologies

1/11/19

13

VBNs, ACOs, Market Reform

Blue Beckham Principal

•  Risk Transfer at the Payor Level –  CapitaIon –  AHCCCS – Medicare Advantage –  Etc.

•  Risk Transfer at the Provider Level –  CPT Codes –  Case Rates –  Per Diem –  DRGs –  Bundled Payments

•  Shared Savings and Pay for Performance (P4P) – Process Payments (TransacIonal Revenue) – Earned Shared Savings – Outcomes Payments

•  Enhanced FFS •  Prospec,ve Payments

LEVELS OF FINANCIAL RISK VERSUS INCENTIVES

Provider Incentives:

High

Degree

of Risk

Low

Fee-for- Service (FFS)

Discounted Fee-for- Service (DFFS)

Per

Diems Per

Case (DRG)

Capitation & Percent

of Premium

• • •

• More ancillaries

• More days • More cases

• • • • More ancillaries • More days • More cases

•

• •

• Less ancillaries

• More days • More cases

•

• •


• Less days • More cases

•

• •


• Less days • Less cases

•

•

•

•

•

•

• •

•

Fee-‐for-‐service (FFS)

P4P VBM

Transac,onal Services

Per Diem Per Case

DRG Payment

Shared Risk Upside only Gainsharing MSSP Track 1 Transac,onal incen,ves

Shared Risk upside and downside

ACO Tracks 1+, 2, 3 Next Gen Bundled

Payments

Percent of Premium Capita,on

Medicare Advantage

More $ Prove quality IdenIfy high

cost efficiency Upfront costs,

reward Provider is decision-‐maker

Financial Risk Full-‐Risk

Incidence and prevalence

More Cases More Cases More Cases Avoid waste prevenIon

Quality Measures

Reserves Partnerships Risk tolerance

Reduce uIlizaIon

True Pop Health

PROVIDER

INCENTIV

ES EVOLVE

Provider Accountability Risk/rew

ard

Value=Quality/Cost Time

• Health Plan Cost = Provider Revenue • Health Plan reduces price •  Providers incenIvized to

Cost = Rate x UIlizaIon

Increase U,liza,on wait for it……..

Fee-‐For-‐Service

1/11/19

14

Objec,ve: Reduce Overall Healthcare Costs

79

So, reduce costs and make pie smaller, right?

A smaller pie means less $ for hospitals providers as well as for brokers and plans.

All incented to make the pie bigger.

79

Providers Payors

Providers Hospital Ancillary Others

Brokers Admin. Profit

Medical Loss Ra,o

80

CLAIMS

ADMINISTRATION

Claims Admin

CARE

ADMINISTRATION

Profit Brokers CEO Salary Other Salaries UM/QA Claims/Administra,on Creden,aling

Care Admin

CARE

ADMINISTRATION

Acute Hospital Ambulatory Surgery Center Specialists Primary Care Physicians Skilled Nursing FaciliIes Home Health/Hospice Pharmacy Telemedicine Transplants ESRD SDOH And more…

New Clinical Models

InnovaIon

CollaboraIon

Efficient predictable

safe

PaIent Centered Wellness PrevenIon

New Funding Models

Risk to Provider

Reward Quality

Embrace Technology

Process improvement

Shared InformaIon

Safety

Decrease DuplicaIon

“Value Based Networks”

Aggregated Providers

AffiliaIon

Evidence of Quality, Efficiency

Willing to Take Risk

•  Value = Quality/Price • Quality requires definiIon •  Evidence criIcal – IT and UM/QA • MeeIng criIcal measures • Prove to yourself, then the market • Bundled payments • Pay for performance, earn shared savings • Moving to Risk

Word of the Day Let’s talk about Nomenclature •  Accountable Care OrganizaIons – ACO’s are funded by the ACA and specifically address tradiIonal Medicare

•  Clinically Integrated Networks •  Physician Hospital OrganizaIons •  Independent Physicians AssociaIons

– Primary Care – MulIspecialty

•  Single TIN Groups

All can be Value-‐Based Networks

1/11/19

15

Medicare ACO Start Date

Ownership/Structure Service Area

2018 Track PCP's Summer

#Beneficiaries Winter

#Beneficiaries

Banner Health Network 1/1/2012 Banner Health & Networks Maricopa and Pinal Coun,es

MSSP Track 3 1032 50,737 Pending

Arizona Connected Care 4/1/2012 Community Providers, TMC Southern Arizona

MSSP Track 1 637 8,318 9,734

Arizona Care Network 1/1/2013 Dignity Health & Abrazo Health Arizona Next Gen 1220 33,000 35,000

Commonwealth PCACO 1/1/2013 Independent PCP's Arizona, New Mexico

MSSP Track 1 90 16,000 15,000

Sco:sdale Health Partners 1/1/2014 Honor Health Maricopa County

MSSP Track 2 300 23.500 45,000

ASPA-‐Connected Community 1/1/2015 Independent Physicians (ASPA)

Arizona, New Mexico MSSP Track 1 50 6,200 6,800

North Central AZ Accountable Care 1/1/2015

Yavapai RMC, with NEAR-‐Summit

Apache, Coconino, Yavapai

MSSP Track 1+ 150 14,500 15,000

Abacus ACO 1/1/2016 Arizona Community Physicians Southern Arizona

MSSP Track 1 131 28,000 Pending

Pathfinder ACO 1/1/2018 Northern Arizona Healthcare Coconino and Yavapai Coun,es

MSSP Track 1+ 78 9,843 Pending

Physicians Performance Network of Arizona 1/1/2018 Tenet Healthcare –Carondelet

Pima County MSSP

Track 1+ NR NR NR

Arizona’s Medicare ACO’s 2018

Optum ACO Exits Next Gen Tenet ACO Launches 2019 JC Lincoln ACO Merges with ScoSsdale Health Partners ACN is All In With Next Gen

ACO Movement/News •  Pathfinder Health leaves NCAAC and starts MSSP Track 1+ •  Summit (NEAR network) Joins NCAAC •  NCAAC moves to Track 1+ •  Banner Health Network moves from Pioneer to Track 3 •  ACN Sunsets MSSP – Runs Only Next GeneraIon •  ScoSsdale Health Partners Combines with JC Lincoln ACO •  Optum Care ACO leaves Next GeneraIon Program •  Tenet adds MSSP •  ACC signs management agreement with P3 Health Partners

CMS Finalizes New Risk Tracks for MSSP

•  Current •  Track 1 – Upside Only, 50% share •  Track 1+ limited Up and Down Risk

•  Track 2 – Up and Down Risk •  Track 3 – Highest level up and Down Risk in MSSP

•  Next GeneraIon Model

•  New •  T1 = Basic A&B (Upside Only) •  T1+ = Basic C and D (Up and Down) •  T2 = Basic D and E (Up and Down) •  T3= Enhanced (AAPM) •  Next GeneraIon Model (AAPM)

BASIC A&B BASIC C BASIC D BASIC E

One-‐sided Risk-‐Reward Risk-‐Reward Risk-‐Reward

Limited to 2 years Years 3-‐5 Years 3-‐5 Immediately AAPM

25% share max up to 10% of benchmark




RISK TO ACO

Degree of Risk

Enhanced Next Genera,on

Current Track 3 AAPM

Current high Risk AAPM

75% up to 20% of benchmark

1/11/19

16

ACO Name 2017 Track 2018 Track

Banner Health Network MSSP Track 3 MSSP Track 3

Arizona Connected Care MSSP Track 1 MSSP Track 1 Arizona Care Network MSSP Track 1 and

Next Generation Next Generation

Commonwealth PCACO MSSP Track 1 MSSP Track 1 John C. Lincoln ACO MSSP Track 1 MSSP Track 1 Scottsdale Health Partners MSSP Track 1 MSSP Track 2 ASPA Connected Community MSSP Track 1 MSSP Track 1 North Central Arizona AC MSSP Track 1 MSSP Track 1+ Abacus ACO MSSP Track 1 MSSP Track 1 PathfinderHealth N/A Track 1+

2018 Arizona ACO Tracks VBN’s All a%ributed lives in the Medicare column are through the MSSP or

Next Genera;on programs.

PCPs is total MD/DO and mid-‐level prac;;oners

This table illustrates a%ributed lives for many Value-‐based Networks in

Arizona. While this list is comprehensive, we know there are other VBN's in Arizona not accounted

for in this report. The data was aggregated by The

Hertel Report, sourced from responses directly from the VBN’s.

Summer 2018

Es,mated Value-‐Based Contracted Lives in Arizona Organiza,on Name Medicare* Medicare

Advantage Commercial Medicaid Es,mated Total Lives

Es,mated Number of

PCP's Abacus ACO * 28,000 23,200 30,000 7,100 88,300 131 Arizona Care Network 35,000 9,000+ 147,000 116,000 307,000+ 1,220 Arizona Connected Care 9,734 7,505 16,414 0 33,653 637 Arizona Priority Care* N/A 11,005 0 0 11,005 322 ASPA Connected Community 6,800 0 0 0 6,800 65 Banner Health Network* 50,737 90,381 288,644 13200 442,962 1,032 Cigna Medical Group WND WND WND WND WND WND Commonwealth ACO 15,000 24,000 4,000 43,000 90 District Medical Group/MIHS N/A 0 0 94,000 94,000 60 Equality Health Network N/A 2,383 0 160,505 162,888 900 Health Choice Preferred N/A 6,000 1,000 31,000 38,000 125 Innova,on Care Partners* 45,000 23,000 37,000 0 105,000 300 Iora Health WND WND WND WND WND WND North Central Arizona Accountable Care 15,353 0 0 0 15,353 150 PathFinder ACO* 9,843 0 6,056 0 15,899 78 Phoenix Children's Care Network* N/A 0 2,300 126,000 128,300 359 Summit Healthcare NEAR Network* N/A 0 4,500 0 4,500

Data Updated December 2018 *May 2018 Data

N/A: Not Applicable WND: Would Not Disclose

AssociaIon Health Plans On June 21, 2018, the DOL published a final rule that expands the ability of employers to join together to form AHPs. New guidance issued by the IRS and DOL provides that: •  Employer parIcipaIon does not trigger Employer Shared responsibility rules.

•  2 Parts -‐ An AHP is a group health plan and a mulIple employer welfare arrangement (MEWA) subject to ERISA’s requirements.

AssociaIon Health Plans AHPs offer coverage to some or all employers geographically or by trade, industry or line of business ISSUE: AHPs are not subject to Essen,al Health Benefits. Some examples include: •  PrevenIve services at no cost •  Emergency Services •  Mental Health •  Maternity

AssociaIon Health Plans Compliance and for AHPs •  Summary plan descrip,on (SPD) •  Summary of material modifica,ons (SMM) •  Summary of Benefits and Coverage (SBC) Filing Requirements Fully insured or self-‐insured, must file Form 5500 and a Form M-‐1 with the DOL.

Short Term Medical Plans Short Term Health Plans to extend coverage up to 364 days with opIons •  Some policies may renew for up to a 3-‐year period.

STM Plan Quote in AZ: •  Premium = $218.89 / mo. •  $2,500 DeducIble •  $1m Max •  12-‐month period 59 Limita;ons and Exclusions

1/11/19

17

Short Term Medical Plans Short Term Medical Plan on Covered Benefits •  Plans are underwri:en •  Limits on hospitalizaIon •  Pharmacy limits – ex, drugs only covered during hospital stay •  Typically don’t cover maternity benefits •  Pre-‐ex applies •  Addi,onal Limits may apply

–  Ex: Appendectomy $2.5k, Kidney stones $1.5k, Gallbladder Removal $2.5k

Actuarial Values

Metal Tier Cost Share Plan vs. Consumer Features

Pla,num 90% No/low Deduc,ble Co-‐pays 90/10

Gold 80% Small Deduc,bles

Silver 70% Big Deduc,bles (CSR’s)

Bronze 60% Max Deduc,bles

Copper 50% Catastrophic

Nickel 40% Skinny Plans

Short Term Medical Plans On December 10th California Department of Insurance Banned

Short Term Health insurance

AssociaIon Health Plans / Short Term Medical Which carriers are offering STM and AHPs in Arizona?

STM AHP AHP Comments

Aetna No No Looking into it -‐ interested BCBS of AZ Yes No No AHPs, 4 AcIve Trusts Cigna No No Not likely to add United Healthcare No Yes 1 local AHP, 30 naIonally SLOW TO ADOPT!

Self-‐funding

Chart provided by Kaiser Family FoundaIon

Self-‐Funding Advantages •  Tax savings •  Claims transparency •  Flexibility in plan design •  Lower fixed cost •  Eliminate carrier profit margins – carriers expect between 3-‐7% margin.

•  Custom / Narrow Networks

1/11/19

18

Narrow / High-‐Performing Networks

There is a pronounced shis from broad PPO networks to narrow / high-‐performing networks in Arizona. •  High performing physicians and faciliIes •  CombinaIon of lower unit costs, lower total medical costs through eliminaIon of waste and improved care paSerns and value (vs volume) based reimbursement methods

•  Not there yet – slowly moving away from fee-‐for-‐service contracts.

Narrow / High-‐Performing Network Partners

Future of Commercial Healthcare Underwri:en Plans •  STM •  AHP •  Pooled Programs •  Level-‐Funded •  Self-‐funded plans

Growing trend is risk stra,fica,on, high-‐performance networks and cost management programs like disease management and wellness.

Indiv. / Community / Limited Underwri:en •  Individual Insurance Plans •  Fully insured community-‐rated products •  Limited underwriIng for groups

ACO Value Based Network

Healthplan Network

OON/OOA OON/OOA No Benefits

Healthplan Network Reduced Benefits

ACO ”Value Network” Best Benefits

Can be System Independent Owned Affiliated Networked Share •  Values •  Informa,on •  Measurement •  Risk

Be part of our membership community and sign up today for ,mely, impar,al market news, data and exclusive reports!

The Hertel Report is the Source that Connects…. •  Local News

– Marketplace plans, counIes and premiums; AHCCCS Waiver acceptance and implementaIon, ACO/VBN, Systems data, more value-‐based deals and risk contracts, innovaIon.

•  NaIonal News: – ACA Repeal: Impact of sales across state lines, associaIon plans, short-‐term plans etc.

– Congressional AcIon: Pharmacy costs, repeal & replace efforts, Medicare for all, reinsurance, state-‐by-‐state market reform, etc.

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www.thehertelreport.com

The Source that Connects the Arizona Healthcare Community

Volume XXI, No. 11/November 28, 2018The Hertel Report - All Rights Reserved ©2018

DUPLICATION WITHOUT WRITTEN AUTHORIZATION VIOLATES FEDERAL LAW

The Arizona Health Care Cost Containment System (AHCCCS) manages the healthcare of one in six adults in our state with a budget nearing $12 billion. At the agency’s helm for nearly a decade has been Tom Betlach, who will retire in January 2019 as the longest serving Medicaid director in the state’s history. As a seasoned leader and expert on Medicaid managed care and nation-al and state healthcare policy, Betlach also served as president of the National Associa-tion of Medicaid Directors and was named by the Congressional Budget Office to its Panel of Health Advisers.

AHCCCS, an agency billed as a system of competition and choice because of its man-aged care approach to providing acute and behavioral health services to Medicaid bene-ficiaries, is responsible for providing medical services to 1.9 million individuals and families in Arizona. Among his many achievements, Betlach led the agency after the Great Recession in 2009 slashed $2 billion from the AHCCCS budget, froze enrollment and even elimi-nated transplant coverage for people with certain conditions.

Since then, Betlach has overseen Medicaid expansion and has since focused on confront-ing and meeting the challenges of integrated care and ensuring the state’s low-income and disabled seniors receive coordinated services.

He’s also created partnerships to help people released from jail more easily access physical and mental health services while envision-ing an entire AHCCCS managed care mod-el committed to a value-based healthcare delivery system.

Last month on October 1, AHCCCS Complete Care kicked off across the state, creating a model that serves both the physical and be-havioral health needs of most adults enrolled in Medicaid across the state – about 1.5 million.

AHCCCS DIRECTOR SCHEDULES RETIREMENT FOR JANUARY 2019

The Arizona Board of Regents, governing body to the state’s three public universities, has vowed to continue its lobbying efforts to exit the state’s health insurance program.

Arizona State University and the University of Arizona want to set up their own insurance program for 47,000 enrollees rather than continue to pay into the state health insur-ance fund, which currently covers 147,000 state employees.

The argument from ABOR goes straight to the bottom line – the organization argues the universities will save $30 million annual-ly if left to manage their own healthcare. But pulling members and their associated dollars out of the trust will likely raise premiums for other state workers and could jeopardize its viability, a concern Arizona legislators won’t likely ignore.

As the state ends its five-year contract cur-rently served by Aetna, Blue Cross Blue Shield of Arizona, Cigna and UnitedHealthcare and begins to prepare its next RFP to attract insur-ers in 2019, ABOR’s desire to secede from the state insurance program is worth watching.

ABOR WANTS NEW HEALTH INSURANCE OPTION

I want to express my deep appreciation for the opportunity to serve Arizona and to work with the talented team at AHCCCS who’ve inspired and educated me every day. Tom Betlach AHCCCS Director

It was the largest transition of Medicaid mem-bers from one model to another in the nation.

During his tenure at AHCCCS, Betlach also championed dual alignment – requiring acute plans to offer a dual, special needs Medi-care Advantage plan for the 140,000 state residents eligible for both Medicaid and Medicare. The state now leads the nation in dual alignment.

In order to improve coordination with the Ar-izona Department of Corrections to improve healthcare access for people released from the criminal justice system, the agency also began a data exchange process with Arizona Department of Corrections (ADOC) and most Arizona counties. The new approach allows AHCCCS to suspend rather than terminate el-igibility upon incarceration and receive release dates to assist those transitioning out of jail in need of physical or behavioral healthcare.

The Hertel Report appreciates the culture of openness and transparency displayed by Di-rector Betlach.

Betlach retires from a 27-year career of ser-vice under five different governors. Prior to joining AHCCCS, he served Arizona as the state budget director for five years. Betlach will remain in his position as AHCCCS Direc-tor through January 4, 2019.

On November 7, 2018 Arizona state legisla-tors voted on their respective party leadership. Representative Rusty Bowers of Mesa was elected Speaker of the House and Senator Karen Fann of Prescott was elected the next Senate President – only the second woman ever to preside over the Arizona Senate.

Other GOP House leadership elected include Representative-elect Warren Petersen of Gil-bert as House Majority Leader and Represen-tative Becky Nutt of Clifton as House Majority Whip. Senator Rick Gray of Legislative District 21 will serve as Senate Majority Leader and Senator Sonny Borrelli of Legislative District 5 was chosen as Senate Majority Whip.

The first regular session of Arizona’s 54th Legislature begins January 14, 2018.

NEW ARIZONA LEGISLATIVELEADERSHIP

www.thehertelreport.comDUPLICATION WITHOUT WRITTEN AUTHORIZATION VIOLATES FEDERAL LAW

Dignity Health and Phoenix Children’s partner to bring families in the East Valley a medical facility designed to serve women and children by 2020.

2020 WOMEN’S & CHILDREN’SPAVILION IN GILBERT

The new women’s and children’s facility will be a home to many of PhoenixChildren’s pediatric specialists and those looking to join the PCH family--many of whom live here in the East Valley.

Bob Meyer President & CEO Phoenix Children’s

Plans for the Women’s and Children’s Pavilion on the Dignity Health Mercy Gilbert Medical Center campus includes 24 new la-bor and delivery rooms (six dedicated to high-risk patients) plus 48 postpartum beds. The pavilion will also include an emergency de-partment dedicated to obstetrics. Phoenix Children’s will operate 48 pediatric beds, a 12-bed pediatric emergency department, pediatric operating rooms and a new 60-bed Level 3 neonatal intensive care unit (NICU).

“Since we first brought our strengths togeth-er, Phoenix Children’s and Dignity Health have become a tremendous force in the care of children and women in this country,” says Linda Hunt, president and CEO of the Dignity Health Arizona Service Area. “This pavilion is an extension of those initial ef-forts and will mean better care for families in this rapidly growing part of the greater Phoenix area.”

The partnership between the health system and one of the nation’s premier pediatric hos-pitals also includes Arizona Care Network, one of the state’s largest accountable care organizations with more than 5,000 clini-cians. It’s also produced a convenient ac-cess point of care for members of the state’s only clinically integrated pediatric network, Phoenix Children’s Care Network.

SONORA QUEST LABS DRAWS ON ANALYTICSKnown as one of the state’s leading provid-ers of diagnostic testing and information services, Sonora Quest is branching out by collaborating with an analytics company to offer a software platform designed to pro-duce savings for healthcare systems well beyond Arizona’s borders.

The product, Actionable Insights Manage-ment (AIM), leverages laboratory data in conjunction with insurance claims data, published clinical research and cutting-edge machine learning to prospectively identify population health risks, encourage clinical intervention and uncover risk adjustment (RAF) revenue opportunities, said the com-pany in a press release.

Sonora Quest collaborated with the health-care analytics company BaseHealth to offer the software that predicts risk within popu-lations for more than 40 chronic conditions. “By identifying and characterizing risk fac-tors that contribute to the progression of various health conditions, we can maximize revenue for health plans and providers,” said Hossein Fakhrai-Rad, PhD, founder and president of BaseHealth.

Commonwealth ACO recently partnered with Sonora Quest and used AIM analytics to support collaboration and improved health outcomes for members.

The local ACO, which includes more than 45 independent primary care offices and 150 total primary care providers, reported that within the first year of using AIM, SQL in-creased the volume and value of clinical data accessible to Commonwealth and assisted in the reduction of lag time associated with data access, thereby improving various met-rics and clinical initiatives for the ACO.

“The use of AIM greatly improved our coor-dinated care efforts and improved patient outcomes through Arizona,” said Common-wealth CIO Lance Donkerbrook. “Not only did AIM provide much more immediate ac-tionable data compared to past reporting through claims and disparate EMR reports, we also found additional information such as related diagnosis, and insight to supplemen-tary provider care that we hadn’t expected to uncover from this data.”

All eyes are fixated on Arkansas after the state became the nation’s first to roll out work re-quirements for its Medicaid program in June. Since then, disenrollments show no signs of slowing.

This month, the state reported another 3,815 of its Medicaid beneficiaries were kicked off the program for the rest of the year after failing to report compliance using a state website. Now with disenrollments totaling more than 12,000 and as many as 6,000 more at risk for losing coverage next month, criticism of the Arkansas program is growing louder and could impact Arizona’s pending work requirement waiver with the Centers for Medicare and Medicaid Services (CMS).

This month, the Medicaid and CHIP Pay-ment and Access Commission, (MACPAC) expressed concern about how the Arkansas program was operationalized. The state has a

low rate of Internet access and computer liter-acy, both cited as roadblocks for beneficiaries required to report. But as the majority of ben-eficiaries subject to the requirements continue to fail to report in Arkansas, MACPAC recom-mended CMS slow down approvals of all work requirement waivers until it has better evalua-tion designs in place.

“As HHS considers these proposals, it should require the development and approval of ro-bust evaluation and monitoring plans to mea-sure whether waivers achieve their intended purposes and provide meaningful information along the way, including during the early days of implementation,” wrote MACPAC in its letter to the agency.

Whether those concerns will cause other Medicaid directors pause as their state’s work requirement waivers are scrutinized is hard to predict.

12,000 LOSE COVERAGE: MEDICAID WORK REQUIREMENTS

Continued on Page 3

Using Actionable Insights Management to Improve Collaboration & Outcomes

in Healthcare

SQL & Commonwealth PCACO


Inside Health Policy reported that during the annual conference of the National Associa-tion of Medicaid Directors, the new director of the Center for Medicaid and CHIP Services (CMCS), Mary Mayhew promoted the use of waivers to advance new Medicaid policies, including work requirements. “As part of this initiative, we are seeing exciting results and partnerships at the state level spurred by these waivers,” said Mayhew during her first major public speech as CMCS director.

CMS has approved Medicaid work require-ments for Indiana, New Hampshire and Wis-consin. Kentucky was also approved but its work requirement program was blocked by a federal court.

Medicaid Work Requirements Cont’d From Page 2

MEDICAID IN ARIZONA

Source: Henry J Kaiser Family Foundation

Arizona Adults Ages 19-64

During its annual meeting of delegates, The Ameri-can Medical Association announced it wants gov-ernment officials to care-fully consider evidence that prior authorization (PA) harms patients and burdens healthcare pro-fessionals before they ex-pand prior authorization programs under Medicare and Medicaid.

According to a recent AMA physician survey, PA programs can delay necessary treatment, adversely affecting patient health outcomes. According to the survey, medical practices complete an average of about 29 PA requests per physician per week, which consumes nearly 15 hours of physician and staff time each week.

AMA RELEASES PRIOR AUTHORIZATION POLICY WISH LISTThe new AMA policy recommends the fol-lowing processes and parameters to PA pro-grams for Medicare Advantage plans and Medicaid as well as managed care organiza-tions contracted to deliver Medicaid health benefits.

• List services and prescriptions requiring PA on a website, ensure patient informa-tional materials include full disclosure of any PA requirements.

• Notify providers of any changes to PA requirements at least 45 days prior to change.

• Improve transparency by requiring plans to report on the scope of PA practices, including the list of services and pre-scriptions subject to PA and correspond-ing denial, delay, and approval rates.

• Standardize a PA request form.

• Minimize PA requirements and eliminate the application of PA to routinely ap-proved services and prescriptions.

• Pay for services and prescriptions for which PA has been approved unless fraudulently obtained or ineligible at time of service.

• Allow continuation of medications already being administered or prescribed when a patient changes health plans; no changes without discussion and approv-al of the ordering physician.

• Make an easily accessible and responsive direct communication tool available to resolve disagreements between health plan and ordering provider.

ENVISION HEALTHCARERetained by Cigna, Fighting Drop by UHCThe statewide, multi-year agreement impacts about 2,000 physicians in Arizona practicing at Banner Health, Dignity Health and Honor-Health hospitals. While Envision clinicians will be in-network for Cigna’s commercial, Medi-care and individual plan customers in Arizo-na, UnitedHealthcare has threatened to drop Envision after fighting over its emergency room billing practices. Envision Healthcare is a provider of hospital-based, post-acute care and ambulatory surgery services – it’s the na-tion’s largest provider of ER physicians. En-vision is lobbying to remain in-network with UHC while the insurer is seeking reasonable rates. The current contract ends December 31. At risk: one million UHC patients.

2019 WinterSTATE OF THE STATE

Tucson: 1.23.19 Phoenix: 1.25.19

Market Updates: AHCCCS, Medicare Advantage, ACOs, Value-Based Networks

Register Today!


COMINGS & GOINGSGautam Aggarwarl MD, is now medical director for Centene. He was previously CMO for NativeHealth.

Oscar Diaz is now VP of Business Develop-ment at CBIZ Benefits and Insurance. He was previously with Crest.

Shaun Johnson is now regional sales director for AZ and NM for Centene. He was previously the sales director for Steward Healthcare, Ari-zona and Utah.

Jim Whitfill MD, advisor to the Hertel Report and frequent speaker at The State of the State, is now Chief Transformational Officer for Hon-or Health. Whitfill will continue as CEO of Lu-metis Consulting and will leave his position as CMO for Innovation Care Partners.

Alliance Bank of Arizona/Western Alliance Bank’s healthcare group now includes the following team members: Senior VP Matt Gil-breath and VP Greg Kertman with its Health-care Banking division. Senior VP Brian Scott and VP Jon Brown are with its Healthcare Equipment Leasing division.

Sandy Marken is the new chief nursing offi-cer at Banner Thunderbird Medical Center, where she has worked as interim CNO since June. She was previously the director of the provisional state level one trauma center and observation unit at Banner Desert Medical Center and was also part of the construc-tion and design team for Cardon Children’s Medical Center in Mesa.

The Hertel Report29455 N. Cave Creek Road

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Prior to the Arizona Health Care Cost Con-tainment System’s (AHCCCS) Complete Care program launch on Oct. 1, most AHC-CCS beneficiaries had two health plans: one for physical health services and another for behavioral. AHCCCS Complete Care (ACC) moves those members to a single plan to better integrate care and facilitate provid-ers working together. In March 2018, seven managed care organizations (MCOs) won managed care contracts to coordinate phys-ical and behavioral health services under the ACC program.

HealthBI president Scott McFarland says a continuum of care is, “absolutely critical” in his opinion, and is also ultimately what the ACC program is focusing on.

Recently HealthBI, a private subsidiary of Equality Health, has become integral to the ACC program with their CareEmpower plat-form, selected as the central technology for AHCCCS’ new whole-person approach.

The platform will facilitate care coordina-tion for five of the seven Medicaid-man-aged care plans including Banner-Uni-versity Family Care Plan, Care1st Health Plan Arizona, Arizona Complete Health, Mercy Care, and UnitedHealthcare Community Plan.

McFarland calls the platform a “care coordi-nation solution for health plans,” explaining that the technology specializes in interoper-ability and data sharing in order to identify gaps and act as a middleman to address those discrepancies, whether they are phys-ical, behavioral or social health gaps in care.

“Medicaid is unique in that it runs state-by-state and depending on the incentives avail-able to manage the Medicaid population…the network can respond according to what the contract requires,” says McFarland.

One issue platforms like CareEmpower are trying to address is the many organizations that do not have a full roster of the patients assigned to them. They are aware of who they have seen but do not necessarily know they may actually have more members as-signed to them.

“A lot of time these gaps in care come from patient populations that organizations ha-ven’t seen before,” notes Jenn Sommers, Mercy Care Plan director of physician orga-nizations and relations.

McFarland believes a platform of CareEm-power’s nature offers an opportunity to de-liver better healthcare and outcomes for the patient, while giving the state, as a sponsor of Medicaid, better value.

Sommers adds, the goal of such platforms is to not only address populations with highest complexity and needs but to also address individuals that may not even recognize the services available and offered to them.

Data can act as a liaison for these gaps.

“You need to have data in order to stream-line your processes, if you’re doing outreach to people who have already had those visits done and there’s really not a care gap then it’s really just wasted time with your staff and personnel,” explains Sommers. The CareEmpower platform ultimately aims to take a more holistic approach to healthcare and get away from the “sick-care model” as McFarland puts it. There is no shortage of market competition in Ar-izona, which according to McFarland is good because of the state’s requirements to get to risk and value-based care for Medicaid populations.

“I’ve seen even more rapid progress toward getting to dynamic interoperability as op-posed to the linear silos in old legacy data re-pository solutions that we had when I began my career,” McFarland says, optimistic that as long as an organization can “continue to foster good data security and management and facilitate interoperability in a responsible way” it can lead to unified care plans and care teams helping an individual access the system in the right way.

AHCCCS TURNS TO HEALTHBI TO TIGHTEN CARE COORDINATION

The platform essentially prioritizes important gaps by bringing forward relevant data to Medicaid plans and offers workflow solutions for practices interacting with members to close the gap. If the practice succeeds, it earns an incentive from AHCCCS.

NOTES

NOTES

THE HERTEL REPORT

•ARIZONA WINTER 2019

J STATE OF THE STATE I Connecting the Arizona Healthcare Community

As we celebrate nearly 30 years as the premier source for Arizona healthcare information in the state, The Hertel Report. formerly The Arizona Managed Care Newsletter, is updating its membership levels in 2019.

New Copper, Bronze, Silver, Gold and Platinum corporate options provide new opportunities to connect more employees with the timely, impartial relevant news, data and industry information you value from The Hertel Report. Bronze through Platinum levels continue to receive pre-paid admission(sl to the winter and summer State of the State breakfast meetings. Gold and Platinum levels also receive additional intranet permissions to provide all employee access to membership materials.

TH R MEMBER BENEFITS Thursday News Listings Monthly Newsletter Quarterly Data Issues Data Spotlight Reports Members-Only Website Resources

- Business Directory- Professional Directory- White Papers, Issue Briefs - Toolbox and more

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COPPER Level = 5 Total Members $1,000 Our former mini corporate membership has grown from three to five memberships. Three corporate profile members are listed on each organization's profile in our Business Directory and appear in our Professional Directory. The remaining two individual corporate members appear exclusively in our Professional Directory. No Pre-Paid SOS, PMPY: $200

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GOLD MEMBERSHIP = 30 Total Members $3,250 Permission to Print & Add Newsletter to Company Intranet Our former large corporate membership has grown from 20 to 30 memberships. Ten corporate profile members are listed on the organization's profile in our Business Directory and appear in our Professional Directory. The remaining 20 individual corporate members appear exclusively in our Professional Directory. Two pre-Paid SOS - All Locations, PMPY: $108

PLATINUM Level = 50 Total Memberships $3,900 Permission to Print & Add Newsletter to Company Intranet Our former jumbo corporate membership has grown from 30 to 50 memberships. Fifteen corporate profile members are listed on the organization's profile in our Business Directory and appear in our Professional Directory. The remaining 35 individual corporate members appear exclusively in our Professional Directory. Three pre-Paid SOS - All Locations, PMPY: $78

THE HERTEL REPORT

•ARIZONA WINTER 2019

J STATE OF THE STATE I Connecting the Arizona Healthcare Community

As we celebrate nearly 30 years as the premier source for Arizona healthcare information in the state, The Hertel Report. formerly The Arizona Managed Care Newsletter, is updating its membership levels in 2019.

New Copper, Bronze, Silver, Gold and Platinum corporate options provide new opportunities to connect more employees with the timely, impartial relevant news, data and industry information you value from The Hertel Report. Bronze through Platinum levels continue to receive pre-paid admission(sl to the winter and summer State of the State breakfast meetings. Gold and Platinum levels also receive additional intranet permissions to provide all employee access to membership materials.

TH R MEMBER BENEFITS Thursday News Listings Monthly Newsletter Quarterly Data Issues Data Spotlight Reports Members-Only Website Resources

- Business Directory- Professional Directory- White Papers, Issue Briefs - Toolbox and more

Individual Annual Membership: $375 Annual Paid Monthly: $35 a month

Subscriber Annual Membership: $200 Annual Paid Monthly: $20 a month

Subscriber Access Limited to: Thursday News Listings Calendar & Events

BECOME A MEMBER TODAY AT WWW.THEHERTELREPORT.COM/REGISTER

Contact Us Anytime: Publisher Jim Hammond, jim@thehertelreport

or Managing Editor Paula Blankenship, [email protected]

COPPER Level = 5 Total Members $1,000 Our former mini corporate membership has grown from three to five memberships. Three corporate profile members are listed on each organization's profile in our Business Directory and appear in our Professional Directory. The remaining two individual corporate members appear exclusively in our Professional Directory. No Pre-Paid SOS, PMPY: $200

BRONZE Level= 10 Total Members $1,300 Our former small corporate membership has grown from seven to 10 memberships. Four corporate profile members are listed on the organization's profile in our Business Directory and appear in our Professional Directory. The remaining six individual corporate members appear exclusively in our Professional Directory. One pre-Paid SOS - One Location, PMPY: $130

SILVER Level = 20 Total Members $2,600 Permission to Print Newsletter Our former medium corporate membership has grown from 12 to 20 memberships. Five corporate profile members are listed on the organization's profile in our Business Directory and appear in our Professional Directory. The remaining 15 individual corporate members appear exclusively in our Professional Directory. One pre-Paid SOS - All Locations, PMPY: $130

GOLD MEMBERSHIP = 30 Total Members $3,250 Permission to Print & Add Newsletter to Company Intranet Our former large corporate membership has grown from 20 to 30 memberships. Ten corporate profile members are listed on the organization's profile in our Business Directory and appear in our Professional Directory. The remaining 20 individual corporate members appear exclusively in our Professional Directory. Two pre-Paid SOS - All Locations, PMPY: $108

PLATINUM Level = 50 Total Memberships $3,900 Permission to Print & Add Newsletter to Company Intranet Our former jumbo corporate membership has grown from 30 to 50 memberships. Fifteen corporate profile members are listed on the organization's profile in our Business Directory and appear in our Professional Directory. The remaining 35 individual corporate members appear exclusively in our Professional Directory. Three pre-Paid SOS - All Locations, PMPY: $78

Documents

State of the State...Beth Kohler of Beth Kohler Consulting and former Deputy Director of AHCCCS will address integrated care, new geographic service areas, work requirements and other