AmeriHealth Caritas Family of Companies

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1 AmeriHealth Caritas Family of Companies Care Coordination Demonstration for the Aged, Blind, and Disabled Oklahoma Health Care Authority August 26, 2015

2 Introductions Tom Lyman Senior Vice-President, Market Development AmeriHealth Caritas Family of Companies Sharon Alexander Vice-President, Medicare Special Needs Products AmeriHealth Caritas Family of Companies Karen Michael Vice-President, Corporate Medical Management AmeriHealth Caritas Family of Companies Mary Pat Sherry Director, Market Development AmeriHealth Caritas Family of Companies 2

3 Agenda Company Overview & Perspective AmeriHealth Caritas Aged, Blind, and Disabled (ABD) Experience Recommended Path Forward Managing At-risk Populations AmeriHealth Caritas Integrated Care Model Provider Network Development Value-based Purchasing Program Summary 3

4 Company Overview & Perspective 4

5 Company Overview and Perspective AmeriHealth Caritas is a mission-driven company AmeriHealth Caritas is a leading national Medicaid managed care organization (MCO) with a differentiated model of care that operates in 16 states and the District of Columbia, serving 6.9 million members through a variety of services. Established as a Medicaid Managed Care Organization in 1983 by a community hospital system, AmeriHealth Caritas has a long history of care for populations who are most in need and at risk. We are committed to providing access to high-quality health care services to all members, regardless of their ability to pay. We have a strong sense of social mission striving to help people get care, stay well, and build healthy communities. AmeriHealth Caritas serves medically frail and complex populations in at-risk programs Extensive experience serving the Aged, Blind, and Disabled (ABD) population since 1997 in capitated programs. Recently launched in two Medicare-Medicaid Pilot Demonstration Programs in Michigan and South Carolina. PerformCare, the behavioral health subsidiary of AmeriHealth Caritas, administers the New Jersey Children s System of Care for children with behavioral health challenges, substance abuse treatment needs, and intellectual and/or developmental disabilities. We provide a family-centered, community-focused single point of entry for New Jersey s eligible children. 5

6 AmeriHealth Caritas Has an Expanding National Footprint 6

7 Track Record of Achievement NCQA Health Plan Accreditation AmeriHealth Caritas of Pennsylvania (since 2001) Keystone First (since 2001) Select Health of South Carolina (since 2010 previous URAC certification) AmeriHealth Caritas Louisiana (since 2013) Arbor Health Plan (interim 2013) AmeriHealth District of Columbia (interim 2014) Multicultural Health Care Distinction (NCQA) AmeriHealth Caritas Pennsylvania (since 2010) Keystone First (since 2010) Select Health of South Carolina (since 2010) Blue Cross Complete (since 2015) AmeriHealth Caritas health plans were 3 of the first 7 plans to receive NCQA s Multicultural Health Care distinction. NCQA Managed Behavioral Healthcare Organization Accreditation PerformCare URAC Accreditation PerformRx 7

8 Aged, Blind, and Disabled Experience 8

9 Experience Managing Special Populations Dual Eligible / MMP D-SNP AmeriHealth Caritas serves dual-eligible members in the federally-sponsored Financial Alignment Demonstrations in South Carolina and Michigan. In these programs, the health plans are referred to as Medicare-Medicaid Plans (MMPs). In both of these demonstrations, all LTSS benefits are the responsibility of the MMP operated by AmeriHealth Caritas. Programs include the frail elderly, adults with disabilities, and the developmentally/ intellectually disabled. AmeriHealth Caritas operates dual-special needs plans (D-SNPs) in our southeast and central Pennsylvania markets serving approximately 3,200 dual-eligible members. Experience with our D-SNPs gives us a deep understanding of the complex, multidimensional care needs of dual eligibles. 9

10 Experience Managing Behavioral Health and Pharmacy Benefits Behavioral Behavioral Health Health Pharmacy Pharmacy Full Service Behavioral Health Managed Care Organization (MCO). Part of the AmeriHealth Caritas Family of Companies since First Pennsylvania-based Behavioral Health MCO with Medicaid NCQA Accreditation. PerformRx manages pharmacy benefits. PerformSpecialty is a specialty pharmacy business that provides case management and fulfillment of specialty medications. Serving over 3.2 million lives in 13 states and the District of Columbia with extensive experience managing pharmacy benefits for Medicaid beneficiaries. Both PerformRx and PerformSpecialty complement other services provided by the AmeriHealth Caritas Family of Companies. Achieving integrated and coordinated care for Medicaid beneficiaries through the AmeriHealth Caritas Family of Companies. 10

11 Experience Providing Integrated Managed Long Term Services and Supports (MLTSS) AmeriHealth Caritas has built distinctive and operational programs to serve dual-eligible members, in the federally-sponsored Financial Alignment Demonstrations in South Carolina and Michigan. In both of these demonstrations, all MLTSS benefits are the responsibility of the MMP operated by AmeriHealth Caritas. Programs include the frail elderly, adults with disabilities, and the intellectually disabled. Serve dual eligibles in both urban and rural areas; for example, our MMP in South Carolina operates in 38 out of 46 counties of the state, most of which have a rural designation. We also have significant experience serving high-acuity members nationwide through our broad Medicaid managed care experience, including serving disabled individuals. 11

12 Recommended Path Forward 12

13 Recommended Path Forward Oklahoma Health Care Authority (OHCA) should consider a fully capitated Managed Care model in order to coordinate delivery of the appropriate care to the ABD population. MCOs should integrate Behavioral Health (BH), long term services and supports (LTSS), and pharmacy services for this high-need population. MCOs should have the infrastructure and expertise to provide all the benefits and additional services in a highly effective, integrated manner for the Oklahoma ABD population. MCOs should partner and collaborate with Oklahoma stakeholders to ensure the benefits and programs meet the state s goals of improving access and quality. A fully integrated Managed Care approach provides coordinated care, resulting in improved outcomes. 13

14 Key Points for States to Consider when Selecting Managed Care Organizations States are best served by partnering with MCOs that have experience managing the ABD population through either: A fully-aligned financial model; or A capitated managed care approach for Medicaid populations receiving Long-term Services and Supports (LTSS) and/or Home and Community based Services (HCBS). The right MCO partner will have: Demonstrated ABD expertise; Experience building provider networks, including those specific to ABD; Expertise in providing integrated care management; Commitment to community partnerships; Collaborative relationships with community advocates; Experience in integrating Medicare and Medicaid benefits; and Innovative value-based payment models. 14

15 Benefits of Managed Care Managing special populations, including behavioral health, intellectually and developmentally disabled, and those with long-term care needs, through a capitated fullrisk Medicaid managed care model is an important step to improve access, quality, and coordination of care, while controlling costs in Oklahoma. ACCESS Managed Care Organizations are responsible for building provider networks to achieve greater access for Medicaid beneficiaries. QUALITY COORDINATION Managed Care Organizations are contractually mandated to maintain quality standards, including national accreditation through NCQA. As the primary payer and coordinator, Managed Care Organizations have access to all information required to manage their members and serve as a primary advocate for their care. FINANCIAL Managed care allows states to achieve budget predictability and shift financial risk for the Medicaid program to the Managed Care Organizations. In successful programs, Managed Care Organizations serve as strong partners for its state customers and will serve as an active advocate for members to ensure they get access to appropriate health care at the right time and in the right settings. 15

16 MLTSS Program for the ABD Population -Design Features Key elements necessary for designing a successful MLTSS program: Mandatory enrollment of target populations Inclusion of all appropriate populations is necessary to increase program effectiveness and meet key state objectives of improved outcomes. Comprehensive, integrated service package of physical, behavioral, social, medical, and community resources Person-centered care planning with options for self-direction Care planning should align the member s highest priority issues and preferences identified through the assessment process, with goals and interventions that are member-driven. 16

17 MLTSS Program for the ABD Population -Design Features cont d A high touch model of care Should be holistic and provide care management services that include assessing social conditions which may affect health or present barriers to independence. Enhanced focus on home and community based services There should be an emphasis on developing innovative care management models across the community care continuum. Strong member protections Continuity of care coverage periods during the member transition. Member Advisory Councils to give consumers a pathway for providing direct feedback to the state and health plans. Independent choice counseling supports and an Ombudsman. 17

18 MLTSS Program for the ABD Population -Design Features cont d Collaboration with locally-based organizations and partnerships with provider and advocacy organizations with expertise in serving Medicaid LTSS Network of high performing providers Provider collaboration through innovative payment arrangements Providers must be aligned financially and share in the goal of achieving the best patient outcomes. Standardized, integrated health information platform Use a unified, comprehensive platform that can be accessed by providers, members and caregivers through a secure portal so that members and providers can readily exchange care data to encourage cooperative care management. 18

19 Consideration for At-risk Populations 19

20 Population Risk Management 20

21 Lessons Learned 21

22 Considerations for at-risk Populations AmeriHealth Caritas utilizes a person-centered approach to address the needs of at-risk populations through: Engaging, educating and empowering members to actively participate in improving their health outcomes; Providing members with the information they need to improve and manage their health; Involving members, parents or guardians, care team members, providers, behavioral care providers, social services, and community group representatives in the care planning and management process; Utilizing community-based services to avoid or delay institutional-based care, supporting members who desire to remain in the home and community-based setting; and Incentivizing and rewarding healthy memberspecific behaviors. 22

23 Integrated Care Model 23

24 The AmeriHealth Caritas Integrated Care Model Our Integrated Care Model blends physical health, behavioral health, LTSS, and pharmacy services through a holistic model of care that uses a population-based health management program to provide comprehensive care management services. We have a unique set of tools and experiences that drive our exceptionally highquality and cost-effective approach to LTSS. AmeriHealth Caritas uses an interdisciplinary, member-centered approach that focuses on all aspects of a member s wellness, including social supports. Our Integrated Care Model ultimately drives better outcomes for our members and lowers costs for our state-partners. Physical health LTSS Behavioral health Pharmacy health (Rx) Better outcomes. Lower costs. Healthier communities. 24

25 Care Management Centered in the Community Care Management Staff Hired Locally. Patient-Centered Approach. Signature Programs. Community Outreach and Education Teams. Community Care Management Teams. Mobile Communication Platforms. 25

26 Integrated Care Management Holistic management model that incorporates an array of medical, health, and social needs Meets the behavioral health needs of people with physical health issues, as well as the physical health needs of people with behavioral health disorders. Include screening and treatment of mental health problems as part of medical case management services. Patient-centered needs assessment and service planning process Interdisciplinary Care Team (ICT) composed of MLTSS-specific professionals and providers, the beneficiary, and any individuals chosen by the beneficiary. Robust assessment system Identifies existing chronic conditions, unmet healthcare needs and social health. Stratifies member's risk level and prioritizes members based on needs. Provides the member with a single point of contact for the member based on his or her needs. 26

27 Behavioral Health Needs Integrate Care Management cont d High High Behavioral Health Needs Low Low Physical Physical Health Health Needs Needs Care Management with strong Behavioral Health Experience High Behavioral Health Needs High Physical Health Needs Care Management with strong Behavioral Health and Physical Health Experience Low Low Behavioral Health Needs Low Low Physical Physical Health Health Needs Needs On-Demand On-Demand Care Management Care Management Rapid Rapid Response Response Low Behavioral Health Needs High Physical Health Needs Care Management with strong Physical Health Experience Physical Health Needs 27

28 Integrated Care Management cont d 28

29 Provider Network Development 29

30 Building and Retaining Inclusive Provider Networks 30+ years building high-quality, high-performing provider networks, including: Primary and Specialist Care. Hospitals. Behavioral Health. Pharmacy. LTSS/HCBS. Recognized as a leader in ensuring quality through broad and inclusive networks that offer wide access to healthcare services Identified key elements for driving effective provider networks: Ease of doing business. Provider engagement with dedicated Provider Network Representatives. Timely claims payment. 30

31 Value-based Purchasing Programs 31

32 Value-based Programs AmeriHealth Caritas utilizes a portfolio of value-based incentive programs designed to encourage the right care in the right setting. Rewards physicians for timely, appropriate ambulatory care and positive patient outcomes; utilizing peer and trend based measurements, including HEDIS measures, to determine outcomes and link to rewards. Reimbursement incentives based on performance for closing gaps in care for agreed-upon HEDIS and other quality metrics, including: High-quality and cost-effective care. Member service and convenience. Accurate and complete health data. 32

33 Delivering Better Health Outcomes: Our Next Generation Model of Care LEADING-EDGE INFORMATICS TRUE INTEGRATED CARE MANAGEMENT VALUE-BASED PROVIDER PARTNERSHIPS NATIONAL INFLUENCE ON PERFORMANCE METRICS 33

34 Summary A successful managed care program will: Improve the health status of the people of Oklahoma by providing access to the highest quality of care; Provide access to the right level of care at the right time in the right setting to meet the needs of the member; Focus efforts to effectively coordinate health care for those most in need and at risk; and Ensure state Medicaid budget predictability. 34

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