11/16/2015. Presented By: David Swann, MA, LCAS, CCS, LPC, NCC Senior Healthcare Integration Consultant 2
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1 David R. Swann, MA, LCAS, CCS, LPC, NCC MTM Services The National Council for Behavioral Healthcare Understanding the new roles and processes of effective LME-MCO Boards-on becoming more corporate Examining the lines between Whole Board, Committees and Staff Reaffirming Essential Governing Responsibilities 2 There is nothing that goes on in the organization that the board has not either caused or allowed. What decisions and judgments do board members need to make, and what information do we need to have? The challenge is for the board to understand and carry out its distinctive role as a body Polices to the rescue. If you have not said how it ought to be, then don t ask how it is. 3 1
2 A general direction on Medicaid Reform has been set by the NC General Assembly LME/MCO primary role is to manage Medicaid and State funds for behavioral health services. It is clear that Commercial MCOs and health systems will have a big role under reform The reality is that the rapidly evolving world of delivery and payment reform will require collaboration and new approaches. David R. Swann, Senior Healthcare Integration Consultant MTM Services 4 No longer a mental health program but a Contracted Manager of Medicaid Public Funds Subject to a 1915 B/C Medicaid Waiver approved by the Centers for Medicaid and Medicare Services Medicaid Budget reductions Limits to Managed Care Tools needed for success Session Law (HB 372) An Act to Transform and Reorganize North Carolina s Medicaid and North Carolina Health Choice Programs NCDHHS desire to reduce the number of LME/MCOs 5 What will the Medicaid System look like in 2020? Moving Medicaid to a hybrid insurance model where Medicaid recipients will receive their care from Managed Care Organizations (MCOs) or Provider Led Entities (PLEs) MCOs and PLEs would assume financial risk for enrollee care. Providers will receive their service payments from MCOs/PLEs 3 state-wide plans (commercial or provider-led) Up to 10 PLEs in 6 regions Certain services, i.e., mental health, dental, dual eligible, are carved out or will be added later Reform plan needs CMS approval (will take ~ 2 years) Implementation: ~ 18 months after CMS approval David R. Swann, Senior Healthcare Integration Consultant MTM Services 6 2
3 3 statewide contracts with PHPs selected from request for proposals and competitive bidding Up to 10 regional contracts with PLEs selected from request for proposals and competitive bidding. PHPs and PLEs compete for Medicaid Member market share. David R. Swann, MA, LCAS, CCS, LPC, NCC Senior Healthcare Integration Consultant 7 Prepaid Health Plan (PHP): A commercial plan or a provider led entity responsible for the delivery of healthcare to its enrollees, Medicaid recipients, on a prepaid basis (capitation). Commercial Plan (CP): A PHP that is for profit or not for profit operating to provide or arrange for the delivery of health care services to enrollees and licensed by the Dept. of Insurance. Provider Led Entity (PLE): A PHP whose primary purpose is the ownership or operation of providers who will deliver health care services to enrollees and has a majority of providers on its governing body and licensed by Dept. of Insurance David R. Swann, MA, LCAS, CCS, LPC, NCC Senior Healthcare Integration Consultant 8 Two Levels of MCO Competition Capability Required: 1. Must compete with other commercial MCOs for the contract to manage the Medicaid population in an integrated healthcare environment 2. Must compete with other operating MCOs for consumers to join the plan under mandatory enrollment requirement (i.e., Federal requirement for consumers/families to have a choice of plans in order to get the best access to treatment and treatment outcomes). This means each MCO will have to be competitive regards: Number and quality of providers in the panel for consumers to choose Timely Access to Treatment Identified outcomes that consumers are benefiting from the treatment provided 9 3
4 David R. Swann, MA, LCAS, CCS, LPC, NCC Senior Healthcare Integration Consultant 10 Decisions will be made to improve effectiveness Decisions to be efficient Must overcome negative image and provide value-added management services Board must govern set the ENDS Expert staff must design solutions implement the MEANS David R. Swann, MA, LCAS, CCS, LPC, NCC Senior Healthcare Integration Consultant
5 Defining the organization s purpose: An organization s purpose lies not in its activities but in its results. The board will need to focus its efforts on the goals, results, and ends which describe the purpose. Example: Policy Governance Boards describe their committee s in terms of the extra value they are expected to produce such as an analysis of policy options on a specific issue and their implications. 13 Policy Governance boards: set the results to produce the intended benefits for the intended beneficiaries. determine what difference the organization will make and what policies will drive the work of the staff. Example: The board through policy sets the results and decides on a consistent and intelligent method of assessing the output. 14 Ends the board decides the ends at the highest and broadest level for the organization in sufficient detail that allows comfort with any reasonable interpretation being made by the CEO (staff). Ends policies describe organizational purpose and focus on the expected outputs for the recipients. Ends are results, not routes. Example: Benefits for employees board defines the ends (what are the results that you want to achieve) and staff define the means to achieve those results within the executive limitations. 15 5
6 Means The CEO (staff) decide the means to accomplish the ends within the boundarysetting executive limitations policies of the board. The board s best control over staff means is to limit, not prescribe. 16 One Voice is about the board s use of authority to give instruction or to take an official position on an issue. The board s authority resides in the board as a body, not in its individual members. This principle allows those over whom board authority is wielded to be able to tell the difference between an instruction and a statement that is not an instruction. It allows people to tell the difference between the board s position and a board member s opinion. It does not assume the board will arrive at unanimity in its decisions. The board exists to represent the interests of a diverse ownership and should expect and welcome diversity among its members. 17 Policy governance places the board clearly in control of the organization, but at a very broad level. Through clear and proactive delegation of expectations and authority to the CEO, it simultaneously fulfills the board s fiduciary role and empowers the CEO to flexibly and creatively perform what the board has defined. 18 6
7 Principle: The boards authority resides in the board as a body, not in its individual members. This principle allows those over whom board authority is wielded to be able to tell the difference between an instruction and a statement that is not an instruction. This principle also allows all others to tell the difference between the board s position and a board member s opinion. 19 The one voice principle does not assume that the board will arrive at unanimity in its decisions. The principle simply asserts that when the board has made a decision, only the board can change it; individual board members may not. 20 Disciplined people, thought and action result in an inclusive process that allows all to have their say and a culture of respect in which all are heard. The board must expect that all members support the legitimacy of the board s decision. Any other action undercuts the board s authority and the decision. Example of policy statement: Board members will support the legitimacy and authority of the final determination of the board on any manner, irrespective of the member s position on the issue. 21 7
8 A Governance board understands that if it cannot govern itself, it can hardly govern an organization. Good governance should produce results rather than a list of activities. Three primary outcomes/results are: Connection with owners Written governing policies Organizational performance 22 Accountable governance results in clear and written communication to the CEO on results expected. Example: governance policies and minutes capturing board decisions. When the board does not speak with one voice, it jeopardizes accountability. Ex: CEO is only held accountable for meeting board expectations and not board member expectations. Nothing prevents the CEO from asking for input from members, but members pushing themselves into management clouds the issue of just who the CEO reports to and impedes accountability. 23 Must govern like a Trustee/owner Governance through Medicaid Reform Legislation Commercial Plan MCOs and Provider Led Entities will be governed differently from LME/MCOs. For profit, notfor-profit, PLEs will provide and manage care. Operations must be nimble boards must support. Disciplined boards will strive for the highest governance ENDS to give the greatest flexibility to the organization. David R. Swann, Senior Healthcare Integration Consultant MTM Services 24 8
9 Questions? Feedback? Next Steps? David Swann, MA, LCAS, CCS, LPC, NCC Senior Healthcare Integration Consultant 25 9
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