HCA Partner & Stakeholder Interviews

Prepared by
Cathy Gordon, MPH
Naomi Newman, MBA, MPH

September 2017
“One of the greatest accomplishments of Healthier Washington is that it has
 gotten people who have never talked to each other before talking to each
 other in all kinds of advisory groups and now the ACHs and subject matter
 groups. That in itself has changed the way we all think about health care.”


The Washington State Health Care                 implementation.
Authority (HCA), as part of its Healthier
Washington initiative, launched the              Payment and service delivery
Medicaid Transformation Project                  transformation projects like the Healthier
Demonstration (Demonstration) in January         Washington initiative are complex and
2017. The Demonstration is a five-year           require significant resources and strong
agreement with the Centers for Medicare          partnerships to succeed. HCA contracted
& Medicaid Services (CMS) authorizing up         Manatt Health and its subcontractor
to $1.5 billion in federal investments to help   the Center for Evidence-based Policy
improve the overall health of Apple Health       (collectively the Manatt Team) to support
(Medicaid) beneficiaries. Initiative 1 of the    Demonstration activities, including
Demonstration seeks to transform care            providing technical assistance to HCA
delivery by creating incentives for providers    project staff and all nine ACHs. The
to provide whole-person care through             Manatt Team worked with HCA to refine
partnerships with regional Accountable           the certification processes for ACHs and
Communities of Health (ACHs). The                develop technical assistance resources
ACHs are partnering with a wide range            for ACHs. The team is assisting ACHs
of community stakeholders to implement           to meet certification requirements and
a portfolio of transformation projects           develop comprehensive project plans. The
designed to catalyze regional population         Manatt Team also provides consultation
health improvement while using resources         and support for HCA’s stakeholder and
more efficiently.                                partner engagement activities. As part
                                                 of this work, the Manatt Team and HCA
ACHs engage a diverse group of                   designed a process to identify partner
stakeholders in Demonstration activities,        and stakeholder perspectives, determine
and HCA leadership and Demonstration             satisfaction with engagement opportunities
staff are committed to meaningful                to date, identify knowledge gaps regarding
stakeholder engagement in the                    key elements of the Demonstration, and
Demonstration. Accordingly, they have            inform the development of educational
engaged a broad range of partners and            materials for stakeholders for the
stakeholders to establish the vision, values,    remainder of Demonstration Year 1 (DY1).
and roadmap for transforming care across         In consultation with HCA, the Manatt Team
Washington. As part of their ongoing             identified key partner and stakeholder
commitment to meaningful engagement              organizations to participate in a series of
of key partners, HCA continues to develop        qualitative interviews between June and
and support opportunities for stakeholders       August 2017. Methods, key findings, and
to provide input and feedback as the             recommendations are described in the
Demonstration progresses from planning to        following report.

In consultation with HCA, the Manatt             Table 1. Organizations participating in
Team identified 15 partner and                   key informant interviews
stakeholder organizations to participate
in key informant interviews focused on                                 STAKEHOLDER          # OF
Demonstration engagement opportunities            ORGANIZATION
                                                                           TYPE         PARTICIPANTS
to date, including provider and advocacy
organizations, Medicaid managed care             Amerigroup                MCO               2
organizations (MCOs), and leaders                Coordinated Care
                                                                           MCO               2
and staff members from state-level               of Washington
agencies who were active in the design           Community Health
                                                                           MCO               2
of the State Innovation Model (SIM) or           Plan of Washington
Demonstration activities. Organizations          Molina Healthcare
                                                                           MCO               2
were interviewed individually except for         of Washington, Inc.
representatives of the five contracted           National Alliance
MCOs, who were interviewed as a group.           on Mental Illness                           1
                                                 (WA Chapter)
The goal of the interviews was to identify
partner and stakeholder perspectives,            Northwest Health        Consumer
                                                 Law Advocates           Advocate
determine satisfaction with engagement
                                                 SEIU Healthcare
opportunities to date, identify knowledge                              Labor/Provider        2
                                                 1199 NW
gaps regarding key elements of
                                                 United HealthCare
the Demonstration, and inform the                                          MCO               2
                                                 Community Plan
development of educational materials
for stakeholders for the second half of
                                                 Academy of Family        Provider           5
DY1. Between June 15 and August 1, 2017,         Physicians
the Manatt Team interviewed 37 key
                                                 Washington Council
informants representing 15 organizations         of Behavioral            Provider           3
(Table 1).                                       Health
                                                 Washington Low
                                                 Income Housing                              1
                                                 Washington State
                                                 Department of         State Agency          5
                                                 State Hospital           Provider           4
                                                 Washington State
                                                                          Provider           1
                                                 Medical Association
                                                 Washington State
                                                                          Provider           4
                                                 Nurses Association
                                                 TOTAL                                       37

Key informant interviews were scheduled              Emergent themes were coded and ranked
through the Manatt Team via email and                for relevance to the Demonstration project.
telephone. Respondents were invited                  The Manatt Team conducted a high-level
to include additional staff members or               analysis, and key themes are reported in
colleagues in interviews, at their discretion.       the Findings & Recommendations section.
The Manatt Team provided interview
questions (Appendix A) and an overview
of the Demonstration (Appendix B) to
respondents at least three days in advance
of interviews. Interviews were conducted
by telephone, were approximately 60
minutes long, and were digitally recorded
with verbal consent.

The MCO group interview was conducted
in person and aligned with the June ACH
Convening at Lake Chelan. A five-question,
standardized interview guide was used
to focus the conversation on partner
and stakeholder experiences with the
Demonstration, including Domains I, II, and
III from the Project Toolkit.

Key informant and group interviews used
standard qualitative interview techniques,
including open-ended questions with
scripted and spontaneous probes. In
addition to providing individual background
information, respondents provided
feedback on:
   §§ Experience with the Demonstration
      to date
   §§ Organizational or membership
      interest in Toolkit projects
   §§ Infrastructure critical to
      Demonstration success
       §§ Workforce capacity
       §§ Value-based payment (VBP)
       §§ Population health management

Each interview was conducted by two
researchers. Team members periodically
reviewed emerging high-level themes
during the data collection phase. Interview
notes were analyzed using constant
comparison and a framework approach
based on the interview instrument.


 “I have never in my 40 years of working in this field ever seen a state agency do
 as honest and good a job of organizing people around the topic. It’s hard to find
anyone remotely related to healthcare who they [HCA] hadn’t engaged. They did
an extraordinary job of aligning whole sets of people around values at the 35,000
        feet. I have never seen that done in all of my work in government.”

All of the respondents had significant                    acknowledged the significant burden on
familiarity with the Demonstration, and                   HCA Demonstration staff to implement
their perspectives varied widely, reflecting              a complex transformation project and
the diversity of partners and stakeholders                expressed willingness to assist HCA
statewide who have contributed to                         however possible. Respondents identified
shaping the Healthier Washington                          several key areas common across
initiative and Demonstration project.                     stakeholder groups, including confusion of
Despite this variance, common themes                      key Demonstration elements, opportunities
emerged from the interviews, and all                      to improve stakeholder communications,
respondents expressed gratitude to the                    the need for adequate infrastructure to
HCA staff for their willingness to engage                 sustain transformation, and the importance
diverse partners and stakeholders in the                  of focusing on sustainable solutions.
work. Additionally, most respondents

Summary of Key Findings

   CLARIFY                    ENHANCE                           ENSURE                   FOCUS ON
DEMONSTRATION               STAKEHOLDER                        ADEQUATE                SUSTAINABILITY
  ELEMENTS                 COMMUNICATION                    INFRASTRUCTURE
  Respondents noted          Respondents noted                Respondents noted        Respondents urged a
    a need for more        opportunities to improve            a need to ensure        focus on developing
   information about       stakeholder and partner          adequate infrastructure    sustainable solutions,
    funds flow, roles          communications.                      to sustain          including leveraging
  and responsibilities,                                          transformation         or coordinating with
 engaging with ACHs,                                         efforts, including VBP,       existing efforts.
and avoiding duplication                                      workforce capacity,
        of efforts.                                          and population health

                                                 Roles & Responsibilities
“How will the ACHs dole
                                                 Respondents expressed confusion
out money? How will                              regarding who is accountable for various
that be objective and not                        aspects of the Demonstration. For
                                                 example, many respondents assumed
subjective?”                                     that ACHs will be involved in contracting
                                                 between MCOs and providers. This
A key finding of the interviews is general       appeared to be a misunderstanding based
confusion across stakeholders about              on the original requirement for ACHs to
many key Demonstration elements, even            include Domain I considerations (including
stakeholders with relatively broad and           VBP) in all Demonstration projects.
deep involvement. Key areas of confusion
included:                                        Engaging with ACHs
   §§ Funds flow                                 Respondents were unclear about
                                                 the timing and type of engagement
   §§ Roles and responsibilities
                                                 opportunities given the Demonstration’s
   §§ Engaging with ACHs                         tight timelines. For some respondents,
   §§ Complementarity of activities              this was compounded by perceived
                                                 inconsistent communication from HCA
                                                 and ACHs. Providers and provider
Funds Flow
                                                 organizations in particular noted concern
Respondents were keenly aware of
                                                 that Demonstration projects will be
the large amounts of money that will
                                                 planned without including frontline
be flowing to communities along new
                                                 clinicians and service providers.
pathways, including in VBP arrangements,
                                                 Respondents expressed concern
which are projected to account for 90%
                                                 that providers have limited capacity
of provider payments by the end of the
                                                 for engagement and participation in
Demonstration. Respondents expressed
                                                 ACH activities, particularly in regard
confusion and anxiety about:
                                                 to developing project proposals and
   §§ Who will disburse funds?                   meaningful partnerships.
   §§ How much funding will be
      distributed?                               The complexity of the Demonstration
                                                 itself is seen as a barrier to engagement
   §§ When will fund distributions occur?        for providers or organizations that
   §§ Who will receive fund distributions?       are not already engaged in other
   §§ What will fund distributions be tied       transformation efforts, such as team-
      to?                                        based care delivery models or early
                                                 adoption of integration efforts. Incomplete
Furthermore, some respondents were               information in areas such as funds flow,
concerned that small or rural providers          planning and implementation, baseline
may not have capacity or readiness to            measurements, and goals for project work
participate in new payment arrangements,         have contributed to a sense of confusion
which could negatively affect providers          and anxiety among respondents. Some
and the communities they serve.                  respondents expressed concern that
                                                 ACHs’ project proposal processes could

limit participation of smaller providers with       “Pathways is an evidence-
less capacity to engage.
                                                    based model that has
   “ACHs will need to answer                        worked well in other
   the question, ‘What are                          states or regions, but it is
   you asking me to do                              being layered on top of
   and what resources                               some infrastructure that
   will it require?’ This                           already exists. Medicaid
   clarity will allow health                        health homes exist in
   care organizations to                            every region and include
   determine if they are able                       care coordination. There
   to participate or not. The                       are lead entities that
   business case will need                          are overseeing the care
   to be made to providers if                       coordination.”
   they are expected to sign
   up for projects.”

Complementarity of Activities
Many respondents were unclear how
Demonstration activities such as the
Pathways Hub would align or be braided
into established work streams, given the
multiple other care coordination efforts
currently underway (e.g., Medicaid Health
Homes, chronic disease prevention and
management projects). Specifically, it
was unclear to respondents who will be
reimbursed if multiple entities provide care
coordination because this work can be
reimbursed only once by Medicaid.

In addition to reimbursement, respondents
raised the need for reconciliation to ensure
that all parties remain in compliance with
requirements because MCO contracts with
the state require higher licensure than the
Pathways model. Demonstration work will
need to be safeguarded against duplication
of effort and confusion for beneficiaries and
providers in regions where Pathways will
be implemented.


“In terms of aligning where                      expressed frustration at fragmented
                                                 communications and coordination of
we are going, we want                            efforts within HCA. Some respondents
to get communications                            noted that the communication irregularities
                                                 from HCA and ACHs coincided with
directly from HCA. As                            intensive work on the Demonstration. From
of now, we often get                             January to July, HCA was committed to
                                                 development and finalization of key project
information secondhand.                          materials such as the Project Toolkit,
First it flows to the ACHs,                      ACH certification applications, project
and our members who are                          planning templates, and workbooks.
                                                 Simultaneously, ACHs were focused on
on ACH boards report back                        achieving certification from the state, hiring
to us. We need to receive                        additional staff to carry out Demonstration
                                                 work, and devising inclusive engagement
information in real time as                      strategies for their communities. Based
the ACHs are receiving it so                     on stakeholder interviews, this intensive
                                                 ramping-up phase for HCA and the ACHs
that we can better partner                       affected stakeholder perceptions of
with them.”                                      transparency and inclusion.

ne of the most common themes across
interviews was frustration with perceived
fragmented communication from HCA and
ACHs. As noted previously, respondents
were impressed with HCA’s early efforts
to bring together diverse partners and
stakeholders in the rollout of Healthier
Washington, including the exemplary
communication led and facilitated by
HCA. Respondents noted, however,
that as the Demonstration has evolved,
communications from HCA have become
inconsistent and that dissemination of
messages has shifted to ACHs. Although
this change made sense to respondents
given the structure of the Demonstration,
they requested that centralized
communications from the state remain
inclusive and widely broadcast to keep all
participants abreast of the most current

Even those respondents who remain
deeply integrated in Demonstration work

“Our big concern is that                            Value-based Payment
                                                    Respondents cited anxiety over the move
as much as the principles                           from traditional to alternative methods
that are embodied                                   of provider payment. Some respondents
in the Accountable                                  noted that without basic infrastructure
                                                    support, many providers are unlikely
Communities of Health…                              to see successful outcomes from VBP
are indisputable, we fear                           agreements. Other respondents noted
                                                    that primary care providers are at capacity
that the infrastructure may                         given their current patient panels and work
not be in place to allow                            aligning with other transformation efforts
                                                    such as the CMS Quality Payment Program.
them to succeed. Issues                             Respondents also mentioned concerns
like workforce capacity and                         about provider burnout or the potential to
data-sharing capacity are                           stop accepting Medicaid patients if ACHs’
                                                    VBP efforts fail to align closely with other
especially concerning.”                             alternative payment methods already
                                                    employed within the state. Respondents
                                                    also pointed out that Medicaid rates are
Another key finding from the interviews             substantially lower than commercial or
was concern regarding the statewide                 Medicare rates, and many VBP models
infrastructure critical to short- and               are designed to increase efficiencies,
long-term success of the ACH model.                 cautioning that VBP models will need to be
Respondents with deep experience                    structured carefully to continue to provide
in health care systems and health                   basic support for delivery of care.
transformation efforts identified key
elements that will require strong, forward-         Workforce Capacity
thinking leadership at the state level to           A common theme identified in the
ensure sustainability of the Demonstration          interviews is that the Demonstration design
work. Of particular concern were the                creates the potential for nine different
Domain I strategies that each ACH is                workforce development strategies,
required to pursue: value-based payments,           resulting in piecemeal and potentially
workforce capacity, and population health           inefficient solutions across the state. There
management. Many respondents noted                  is concern that Demonstration funds will be
that these areas present high risk of failure       spent to develop unsustainable regional
to individual ACHs. Respondents also                infrastructure. For example, respondents
identified a lack of statewide standards for        noted the need for the state to consider
infrastructure development and concern              mandates of policy strategies for building
that too much design flexibility will lead          workforce capacity, especially in rural
to inefficient and unnecessary duplication          areas, to ensure success. Respondents
of efforts that will pose a risk to long-term       acknowledged that some pieces of this
sustainability.                                     can be achieved at the regional level, such
                                                    as retraining and redeploying efforts, while

others will need to be addressed at the              health information technology solutions
state level because of the concentrated              with unnecessary complexity and
location of major educational institutions in        insufficient interoperability among systems.
urban areas and the need for economies               Respondents urged strong leadership
of scale in curriculum development and               from HCA to coordinate statewide data
training.                                            infrastructure needs.

Population Health Management
Some respondents noted that population
health management and VBP models
both require robust data infrastructure to
produce significant progress toward goals.
Respondents expressed concern regarding
health information exchange systems in the
state and data-sharing capabilities across
providers and regions. Some noted that
other Demonstration projects, and similar
systemwide transformation efforts, are
focused on the development of robust and
sustainable data aggregation solutions
to support all participants and provide
a high return on investment. There was
also concern about provider readiness to
participate in data activities necessary for
effective population health management.

   “If the goal is to move
   toward value and be
   able to demonstrate
   that…the question is if
   they [providers] are even
   capable of measuring
   value. I don’t see supports
   available to help them do
   that in a timely fashion.”
Further, respondents noted that
Demonstration timelines to address
large-scale and sustainable data
solutions are tight and require immediate
action to support population health
management and value-based payments.
Many expressed concern that regional
approaches will lead to a patchwork of


“Sustainability is critical.
How do we work toward
sustainability while we are
in DSRIP? It’s not a Year 3
or Year 4 or Year 5 topic,
it’s a Year 1 topic. How do
you map across what is
expected in the [various
domains] so that you are
not duplicating efforts?”

A majority of respondents expressed a
lack of clarity regarding the sustainability
of Demonstration work beyond 2021.
Some respondents voiced concern about
a perceived assumption that MCOs would
continue to support the work at the end
of the Demonstration. Others questioned
the validity of the projects themselves
and whether or not the portfolios could
achieve the required outcomes of the
Demonstration. Respondents noted the
good work that has been, and continues
to be, done toward achieving Healthier
Washington goals, but some worried that
this ongoing work in the communities
will be overshadowed by Demonstration
projects that may or may not produce
desired outcomes. Respondents
suggested creating an inventory of all
current resources and transformation
projects as part of project selection to
leverage and complement, rather than
duplicate, existing efforts in the community,
particularly for ACHs implementing the
Pathways Hub.


The Demonstration launched in                        Alignment among all transformation
Washington State in January 2017 under               efforts will be essential to achieve
the auspices of the HCA. The five-year               outcomes of importance to the Healthier
agreement between HCA and CMS                        Washington initiative. Without central
authorizes up to $1.5 billion in federal             coordination within HCA and across all
investments to help improve the overall              partners and stakeholders, ACHs will be
health of Apple Health beneficiaries. An             unlikely to improve population health
innovative approach that will promote                in the most critical areas defined by the
whole-person care through collaboration              Demonstration.
of a wide range of community stakeholder
partnerships has been established through            HCA recognizes the magnitude of change
the selection and certification of nine              that is being planned and welcomes
regional entities called ACHs. The ACHs              partner and stakeholder collaboration.
are required to implement a portfolio                It has used the Healthier Washington
of transformation projects designed to               initiative to lay a strong foundation for the
bring about regional population health               planning and implementation of the State
improvement while using resources more               of Washington Medicaid Transformation
efficiently.                                         Demonstration Project and has effectively
                                                     engaged a broad and diverse group
Each of the nine regional ACHs has                   of partners and stakeholders who are
succeeded in gaining the first of two                committed to the vision and values of the
levels of certification by the state, and            Demonstration.
they have each submitted comprehensive
applications for the second phase of                 This report identifies areas of strength and
certification. As is perhaps inevitable in           potential opportunities for HCA to improve
any ambitious reform initiative, particularly        current program processes and build on
one requiring federal authorization,                 the strong foundation of work to date. In
myriad pressures and tight timelines                 reviewing next steps, HCA should consider
have negatively affected communication               the potential effects on the Demonstration
quality and strained coordination efforts.           project, partners, and other stakeholders;
Communications with partners who                     compliance with federal requirements for
previously had been deeply engaged have              the Demonstration; available resources
been affected during the ACH certification           at HCA; and alignment with state and
processes of Demonstration Year 1. This              regional goals and vision.
has led to some partners feeling “in the
dark” regarding the evolution of the
Demonstration. In addition, Demonstration
goals related to changes in finance have
created expected anxiety throughout
the state as HCA partners, stakeholders,
and providers attempt to understand and
influence the transformation work that will
be undertaken in their communities.

 1.   Please provide a brief overview of             implemented as part of the
      your role and experience within                Demonstration. Which projects
      your organization.                             are of particular interest to your
                                                     organization and why?
 2. The state of Washington                           §§ 2A: Bi-Directional Integration
    is undergoing a five year,                            of Care and Primary Care
    comprehensive Medicaid                                Transformation (Required)
    transformation effort designed to:
                                                      §§ 2B: Community-Based Care
      §§ Integrate physical and                           Coordination
         behavioral health
                                                      §§ 2C: Transitional Care
      §§ Convert 90% of Medicaid
         provider payments to value                   §§ 2D: Diversions Interventions
         based models                                 §§ 3A: Addressing the Opioid Use
      §§ Implement population health                      Public Health Crisis (Required)
         strategies to improve health                 §§ 3B: Maternal and Child Health
         equity                                       §§ 3C: Access to Oral Health
      §§ Provide targeted services that                   Services
         address key determinants of                  §§ 3D: Chronic Disease Prevention
         health                                           and Control

      Nine Accountable Communities                4. To support the work of the individual
      of Health have been established                projects, HCA has required ACHs to
      based on Medicaid service areas                address overarching infrastructure
      and these community based                      issues across all projects. These
      organizations are responsible for              include:
      project selection, planning and
                                                      §§ Workforce capacity
      implementation. There are two
      required projects, Behavioral Health            §§ Value based payment
      integration and Opioid Use, which               §§ Population health management
      all ACHs will be implementing. The
      remaining six projects are optional             Which of these areas are of
      and they include community based                most interest or concern to your
      care coordination, transitional care            organization?
      models, diversion interventions,
      maternal and child health, access           5. Changing the way providers are
      to oral health and chronic disease             paid is a key objective of the
      prevention.                                    Demonstration. By the end of Year
                                                     5, HCA has set a goal of 90% of
      Can you describe your                          provider payments in some form
      organization’s experience with the             of value based arrangement.
      Demonstration project to date?                 What have your experiences with
                                                     transitions to VBP been to date?
 3. HCA is interested in hearing
    stakeholder feedback on the                   6. Do you have any additional
    specific projects that will be                   comments for HCA?


You can also read