WASHINGTON HCA Partner & Stakeholder Interviews - MEDICAID TRANSFORMATION DEMONSTRATION PROJECT - Washington State ...
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WASHINGTON MEDICAID TRANSFORMATION DEMONSTRATION PROJECT 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.”
OVERVIEW AND
INTRODUCTION
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.
RESEARCH
METHODS
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
Consumer
MCOs, who were interviewed as a group. on Mental Illness 1
Advocate
(WA Chapter)
The goal of the interviews was to identify
partner and stakeholder perspectives, Northwest Health Consumer
1
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
Washington
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
Consumer
Income Housing 1
Advocate
Alliance
Washington State
Department of State Agency 5
Health
Washington
State Hospital Provider 4
Association
Washington State
Provider 1
Medical Association
Washington State
Provider 4
Nurses Association
TOTAL 37
3
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.
4
KEY
FINDINGS
“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
management.
5
CONFUSION REGARDING KEY DEMONSTRATION
ELEMENTS
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
6
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.
7
OPPORTUNITIES TO IMPROVE STAKEHOLDER &
PARTNER COMMUNICATION
“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
developments.
Even those respondents who remain
deeply integrated in Demonstration work
8
NEED FOR ADEQUATE INFRASTRUCTURE TO SUSTAIN
TRANSFORMATION
“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
9
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
10FOCUSING ON SUSTAINABLE SOLUTIONS
“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.
11SUMMARY
CONCLUSION
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.
12APPENDIX A
INTERVIEW GUIDE
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?
13APPENDIX B
DEMONSTRATION OVERVIEW
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