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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
Performance Measurement & Data Committee | ACH data strategy
Who are Medicaid members?
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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)
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Performance Measurement & Data Committee | ACH data strategy
Who are Medicaid members? (continued)
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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)
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Performance Measurement & Data Committee | ACH data strategy
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
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Performance Measurement & Data Committee | ACH data strategy
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.
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Performance Measurement & Data Committee | ACH data strategy
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
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Performance Measurement & Data Committee | ACH data strategy
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
Data source: HW Dashboard, Medicaid claims data 10/2015 – 9/2016
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Performance Measurement & Data Committee | ACH data strategy
Gap analysis takes both volume and room for improvement into account
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Data source: HW Dashboard, Medicaid claims data 10/2015 – 9/2016
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
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Performance Measurement & Data Committee | ACH data strategy
Gap analysis estimates number needed to treat to hit 100% of performance targets
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King County Performance Gap Analysis
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Performance Measurement & Data Committee | ACH data strategy
Performance targets for ED visit measures
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King County Performance Gap Analysis
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Performance Measurement & Data Committee | ACH data strategy
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
Performance Measurement & Data Committee | ACH data strategy
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
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Performance Measurement & Data Committee | ACH data strategy
Approaches to identifying target populations for the Medicaid demonstration
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Performance Measurement & Data Committee | ACH data strategy
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
Performance Measurement & Data Committee | ACH data strategy
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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COMPARISON OF U.S. AND TRIBAL GOVERNMENTS
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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.
TRIBAL EXPERTISE IN HEALTH CARE
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
TRIBAL EXPERTISE IN HEALTH CARE
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!