from Mars MOW Annual Conference August 2015 Sharon R Williams CEO Williams Jaxon Consulting LLC When Worlds Collide Policy Catalysts Older Americans Act 1965 Social Security Act Titles III VII XVIII and XIX ID: 740511
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Community Based Organizations are from Venus; Health Care Organizations are from MarsMOW Annual Conference August 2015
Sharon R Williams, CEOWilliams Jaxon Consulting, LLCSlide2
When Worlds CollidePolicy CatalystsOlder Americans Act, 1965Social Security Act: Titles III, VII, XVIII and XIX Americans w/ Disabilities Act, 1973Rehabilitation Act, 1973Balanced Budget Act, 1997Medicare Prescription Drug Improvement and Modernization Act (MMA), 2003Affordable Care Act, 2010Medicaid MLTSS rules, 2015Olmstead DecisionSlide3
They’ve Been Living Among Us for a WhileMedicaid & Medicare managed care reforms have been revolutionizing health care delivery and changing the dynamics of other related industries/systems…Public Health InstitutionsHospitalsNursing HomesPhysicians Now it’s our turn!!!Slide4
Why We Must Join Forces With the KlingonsIntegrated Care MovementTriple AIM (ACA)Improving the experience of care for consumersImproving the health of populationsReducing per capita costs of health care Administrative/Programmatic SimplificationPerson Centered PlanningSlide5
WHO are Your Fellow Space Travelers?HospitalsAccountable Care Organizations (ACO)Insurers/Managed Care Organizations (MCO)Medicaid Managed CareDual Demonstration ContractorsMedicare AdvantageMarket PlaceCommercial Health PlansPhysician Groups/Federally Qualified Health Centers/Rural Health CentersMedicaid/Medicare fee-for-serviceOthers—unions/employersSlide6
There IS Common GroundQualityCare coordinationImproved consumer outcomes/satisfactionDe-emphasis on institutional careCost containmentUtilization of a network delivery system for covered Federal/State oversightSlide7
What Key Objectives are Important to the Aliens?Improving health outcomes/qualityImproved coordination of care Decrease gaps in care: behavioral, HCBS & medicalImprove Member Compliance: medication adherence, use of preventive services & PCP engagementReduce avoidable readmissions & emergency room visitsCost containment/financial metricsAchieving performance metricsMember satisfaction/retentionSlide8
Concepts that May be Alien to Traditional Health Care OrganizationsServices that aren't ‘clinical-ized’Person-centered care planning In home/community engagement with consumersImpact of Home and Community Based Services on quality/cost of careSlide9
Preparing for LaunchCBOs must develop an intimate understanding of the new CUSTOMERS’ needs, drivers and motivation and provide necessary support/servicesKnow how your products/services address health organizations' needs: Do they support contractual/regulatory standards?Do they address quality of care/health outcomes Health Employer Data information Set (HEDIS)Medicare Advantage Model of Care (MOC) or STAR Ratings Do they impact Pay for Performance (P4P) measures?Do they impact utilization goals?Do they impact consumer compliance/satisfaction/retention?What are the financial benefits?Slide10
Value PropositionHCBS agencies have keen sense of consumers’ community based needsDirect/personal contact with consumers/boots on the groundCompliance with the proposed Medicaid MLTSS rules Preventive engagement, routine monitoringTrusted and knowledgeable community resourceCost effective and essential services Network adequacy/competencySlide11
Knowledge IS Power!MOWA/state association resourcesCMS Medicaid/Medicare websitesState health care associations—HMO, hospital, providers, etc.State Medicaid Agency staff/websitesHealth care industry local/national trainingAlignment with other stakeholders, CILS, AAAs, Assisted Living, Nursing Homes, etc.Kaiser Foundation, SCAN websites, etc.Slide12
ReferencesHEDIS (http://www.ncqa.org/HEDISQualityMeasurement.aspx)CAHPS (https://cahps.ahrq.gov/) Medicare STAR Ratings (http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Downloads/2013-5-Star-Enrollment-Period-Job-Aid.pdf) The Commonwealth Fund, Assessing Care Integration for Dual-Eligible Beneficiaries: A Review of Quality Measures Chosen by States in the Financial Alignment Initiative (http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2014/Mar/1724_Zainulbhai_care_integration_dual_eligibles_ib.pdf) Medicare Shared Savings Program (ACO) Quality Measures and Performance Standards (
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality_Measures_Standards.html) Disability Rights Education & Defense Fund with National Senior Citizens Law Center, “A Guide for Advocates: Identifying and Selecting LTSS Outcome Measures” (January 2013)
Health Outcomes Survey (HOS) (www.cms.gov/Medicare)Slide13
May The Force Be With You!!!Thank You