How do Medicaid Waivers Expand the Possibilities of Whole-Person Care?

Today's Healthcare Landscape

POOR HEALTH OUTCOMES

INCREASED PROVIDER COSTS

The healthcare landscape is fragmented, with services split among multiple programs and providers

The silo-ed approach subjects individuals to overlapping and non-coordinated care plans, leading to:

Medicaid Reform• Medicaid reform is a hot

topic in political and medical circles due to the recent change in administration

• State Medicaid programs must find innovative ways to improve patient outcomes and reduce costs due to the likelihood of decreased federal funding

Why Medicaid Waivers?

The waiver system allows the Department of Health and Human Services (HHS) to approve experimental,

pilot, or demonstration projects for states that promote the objectives of the Medicaid system

Section 1115 Medicaid Waivers

• Section 1115 Medicaid Waivers empower states to try experimental programs that:

-Provide additional services

-Reach targeted populations

-Introduce innovations in service delivery

• States maintain control at the local level over programs that fit their unique needs – a key theme in healthcare reform discussions

Medicaid Waivers

TYPES OF INNOVATIVE MEDICAID PROGRAMS INCLUDE:

• Expanding eligibility to individuals who are not otherwise eligible

• Providing services not typically covered by Medicaid

• Using innovative service delivery systems that improve care, increase efficiency, and reduce costs

Health of a Population

Experience of Care Per Capita Cost

IHI TRIPLE AIM

Medicaid Waivers Drive Innovation

Medicaid Waivers are the functional vehicle that allows states to experiment with programs that reduce overall costs, improve care, and maintain program

control at the state or regional level

Reduced Program Costs for States

Increased Program Control for States Improved

Patient Care

1115 Whole-Person Care Waivers

• Whole-person care is the rare program that delivers desired objectives to all stakeholders in the healthcare ecosystem

• Whole person care treats the full scope of patient needs jointly, whether those needs are medical, behavioral, socioeconomic, or other needs

• Medical, behavioral health, and community-based service providers collaborate on patient care

What is a Whole-Person Care Waiver?

Whole Person CareCoordination

Primary Care

Behavioral HealthCommunity-BasedOrganizations

Whole Person Care

WHOLE-PERSON CARE HOLDS THE POTENTIAL OF DELIVERING MULTIPLE,

DESIRABLE BENEFITS

Improve health outcomes by addressing multiple conditions

simultaneously

Improve the patient experience by eliminating healthcare silos which lead to redundancy and waste

Drive delivery system and

payment reform

Avoid costlier, more intensive care settings, such as emergency or

institutional care

Lower overall system cost

State ExamplesCALIFORNIA

CaliforniaMEDI-CAL 2020 PROGRAMS

• Medi-Cal 2020 is a five year 1115 waiver program that seeks to integrate the principles of whole-person care with the state Medicaid system

• The whole-person care pilot is not a single standardized program, rather, multiple programs will run concurrently within the state, each with its own objectives and metrics

CaliforniaMEDI-CAL 2020 PROGRAMS

SOME OF THE DIFFERENT PROGRAMS FOCUS ON:

Reducing resources consumed by healthcare super-utilizers

Providing housing services for people experiencing homelessness as a way to improve health outcomes

Improving provider communication across disparate systems

“The Whole Person Care Pilot challenges county agencies, health plans, and service providers to think differently about how they work with one another and most importantly, to

put patients at the center of that redesign . . .these new ways of thinking

and collaborating have the power to improve care in the safety net for all

patients.”

BRIANNA LIERMANChief Executive Officer,

Local Health Plans of California

EXAMPLE:

San FranciscoDespite numerous well-regarded programs to provide care for San Francisco’s homeless population, many among this group suffer poor physical and mental health

EXAMPLE:

San FranciscoUnder the Whole-Person Care Pilot, San Francisco will invest in technology infrastructure to enable data sharing across programs and providers. The program’s goals include:

Real-time data sharing across agencies

Universal assessment tool

Improved care coordination

A city-wide navigation system

State ExamplesMINNESOTA

• Fragmented healthcare delivery system

• Super-utilizers consume a large share of healthcare resources

• Unnecessary hospitalizations and emergency department visits drive higher costs

• Lack of care coordination results in poor health outcomes

Minnesota

Problem

Minnesota has established multiple initiatives to transition to whole-person care throughout the healthcare delivery system, including:

• Establishing fully accountable communities of care

• Identifying those whose health may be at risk because of nonmedical issues by supplementing medical information with data from other agencies, including:

-The corrections department

-Foster care system

-Housing providers

• Improving care coordination for individuals who are eligible for Medicaid and Medicare (dual-eligibles)

Minnesota

Hospital

Financial CareManagement

BehavioralHealth

Social Services

PharmacyTransportation

Housing

Food/Nutrition

Solution

Boosting Whole-Person Care Through Technology

Technology for Whole-Person CareThe high level of communication and coordination among providers that characterizes whole-person care demands a technology platform that enables and enhances this type of care coordination

MedicalProviders

Mental HealthProviders

Intellectual and DevelopmentalDisabilities Providers

Homeless ServiceProviders

Care Coordination& Reporting

Technology for Whole-Person CareRegardless of the specific delivery model, a whole-person care system inevitably involves:

Data sharing across systems, programs, and departments

Numerous tracking metrics to gauge the effectiveness of the demonstration program

Collaboration among multiple providers

Technology Challenges

Legal and privacy concerns over sharing patient data

Lack of a common data structure across disparate systems

Interoperability across multiple systems and disciplines, each with unique data requirements

Legal and Privacy Issues

• HIPAA standard security is required for all systems

• Behavioral health providers require stricter security for 42 CFR Part 2 regulations

• HIPAA allows sharing data for medical reasons, such as coordination of care

• All providers should adhere to “minimum necessary” standard for viewing patient data

Determining a Standard Data Structure�

• Using standard tools simplifies data sharing. Hennepin Health and the San Francisco whole-person care pilot used standardized assessment tools to standardize data collection across providers

• Determining a data standard is a necessary component of designing a large-scale system for data sharing. For example:

-Some programs use a unique patient identifier to identify an individual across multiple systems and programs

-Other programs choose to use identification algorithms to match patient records across systems

• Patients have complex health needs and it is next to impossible to deliver whole-person care when providers have inaccurate data

• Interoperability is needed in order to share data from one provider to another

• HL7 standards enable the transfer of clinical and administrative data between multiple providers

Achieving Interoperability

Characteristics of a Modern Care Coordination Platform

Characteristics of a Care Coordination Platform

Full medical history, including care provided by social services to address the social determinants of health

Patient Care Plans

Identify and qualify patients automatically based on defined program criteria

Program Eligibility Evaluation

Add patients to a waitlist for services

Waitlist

Characteristics of a Care Coordination Platform

Interoperability

Able to share data across various medical health, behavioral health, social service, HIE, and other required systems

Data Integrity Checking

The system runs checks to validate data and ensure accurate data entry to prevent data error and redundancy

Online portal

Web-based portals simplify the process of data collection, reporting, and collaboration between patients and providers

Characteristics of a Care Coordination Platform

Flexible configuration

One size does not fit all. Care coordination platforms must adapt to the unique needs of individual programs and providers

Reporting and analytics

Pilot programs, such as 1115 waivers, depend on accurate data to analyze program results. Powerful reporting and analytics are essential to program goals

Whole Person CareCoordination

Primary Care

Behavioral HealthCommunity-BasedOrganizations

Conclusion

• Change in healthcare is almost certain as we move foward

• Many states are using Section 1115 Waiver programs to enact whole person care pilot programs

• Communication and collaboration across medical, behavioral health, and community-based providers will be key to achieving whole-person care

• Modern care coordination systems exist that simplify the process of delivering whole-person care across disparate providers and systems of care and enable innovation

Conclusion

Click to Download the White Paper