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5. Evaluation: Outcomes; ROI. 6. Communications: Website - different “visitors”. 7. Funding: $ for Business Developm
IGNITE ACTION. FUEL CHANGE. NASTAD Annual Meeting May 2015

Kathye Gorosh, MBA SVP Strategy & Business Development [email protected] 200 WEST JACKSON BLVD. | SUITE 2100 | CHICAGO IL 60606 | TEL 312 -922-2322 | FAX 312-922-2916 | AIDSCHICAGO.ORG

I. The Environment

• Transformation • Sea change • Collaborative • Sustainable ACA Managed Care

TRANSFORMATION = Delivery & Payment Reform Service Delivery

Finances

Integration, FQHC/CHC, ACO, Care Coordination, Screening Tools, Health & Wellness Health Insurance Marketplace/Exchange, Third Party Billing, Medicaid, Dual Eligibles

Infrastructure

Workforce Development, Performance Outcomes, Business Capabilities

Rules/Regs

Health Information Technology/EHR, Compliance, Contracts, MOUs, Confidentiality

We are Going From Long History of Grants To FFS  to  Capitation TODAY (YESTERDAY)

FUTURE (NOW)

1. Volume over Value

1. Value over Volume

2. Focus on Quality Can Hurt Bottom Line 3. Payment & Accountability are Fragmented

2. Focus on Quality Rewarded

4. Care Coordination often NOT FUNDAMENTAL reimbursed

3. Payment & Accountability are Aligned 4. Cost-effective Care FUNDING SHIFT: management seen as an investment

FUNDAMENTAL FUNDING SHIFT: ENTIRE HEALTH/MEDICAL SYSTEM

To Bill or Not to Bill ?? • NCSD: Shifting to Third-Party Billing Practices for Public Health STD Services: Policy Context and Case Studies • NACCHO: Billing for Clinical Services: Health Department Strategies for Overcoming Barriers (1/14) • NASTAD ISSUE BRIEF: Billing and reimbursement health departments and capacity for third-party billing and reimbursement: a status report and resources for capacity building (4/13)

VERY FIRST STEP

MUST BUILD INTERNAL CAPACITY MUST BE READY !!

WHAT DOES THIS REALLY MEAN? HOW WILL WE/YOU BE IMPACTED? 1. 2. 3. 4. 5. 6. 7. 8. 9.

Staffing Capacity: Prevention, Care, Housing Data: Collection, Analyze, Transmit IT: hardware, software for data; fiscal; MCO reports Finance/Billing/Contracts: How? Who? Evaluation: Outcomes; ROI Communications: Website - different “visitors” Funding: $ for Business Development Operations Policy

Sustainability & Innovation I.

Why did AFC respond/see this as a need?

II.

How do we demonstrate “value-add”?

III.

What was our approach?

IV. Where are we at today?

I. WHY IS AFC GOING THIS ROUTE?? • Continuity: to serve some/many (?) of the clients we have been serving • Expand: To apply our experience and expertise to be able to serve thousands more • Diversify: funding sources • Adaptability & Sustainability

AIDS Foundation of Chicago The mission of the AIDS Foundation of Chicago is to lead the fight against HIV/AIDS and improve the lives of people affected by the epidemic. Founded in 1985 by community activists and physicians, the AIDS Foundation of Chicago (AFC): Advocates with and for people affected by HIV/AIDS Funds and coordinates prevention, care, housing and advocacy campaigns

Cultivates the capacity and expertise of individuals and organizations dedicated to ending HIV/AIDS locally, nationally and internationally

Service Model Systems Integration • Link Health and Human Services Sectors • Bundling and braiding funding streams for greater impact • Training and continuing education • Contract and grants management

Partnerships • Convening diverse partners for collaborative efforts • Building multi-agency systems and partnerships Quality and Data Management • Program evaluation • Training and certification • Data and performance management for funded services

Program & Service Networks for Vulnerable Populations  Case Management Network CY 2014  5400 Clients/year  118 Staff (RW and DRS)  30+ Agencies (RW and DRS)

 Housing Stabilization Network

 Supportive housing and housing navigation assistance programs  Benefit 1,000+ people/year affected by HIV/AIDS and other chronic illnesses.  AFC has access to cost-effective housing rental units and manages funding for programs throughout Chicago metropolitan area

 Prevention//HIV Testing + Linkage to Care  5000+ FY 2014  1000 provided linkage services  950 screened HCV 2013

READINESS: HOW IS AFC RESPONDING? Approach: Planning and Analysis • 3 Action Areas: 1. 2.

3.

Planning – Assessment of current programs & services Internal Development: Product Line; Messaging; Unit Costs; Return on Investment (ROI) External Action & Implementation: Build relationships; meetings; be a resource

• Work across all AFC departments

• Assess & Understand current services/programs • Identify needs for business infrastructure

• Established and facilitate bi-monthly health reform team meetings • Created Health Care Reform Strategic Planning outline • Work with Team members to implement work plan • Staff included in MCE meetings as Subject Matter Experts

AFC’s Strategy & Business Development Activities GOALS: • Identify business lines of service that are marketable to health plans and other emerging networks.

• Promote and sell our services to expand our network • 2 Pronged Approach: 1. Landscape Overview 2. AFC Approach

…..so we can continue to make a difference in the

lives of people living with HIV/AIDS and other related chronic conditions.

II. OUR VALUE Core Competencies: Systems Integration & Advocacy Proven track-record:  Coordinate service networks: HIV prevention & care; housing, transportation, social services  Coordinate and braid multiple funding streams to maximize services → Manage quality and data systems → Administer grants and contracts → Educate providers, community stakeholders → Demonstrated commitment to high-quality, culturally competent care coordination and care delivery → Shape and lead advocacy and public relations campaigns

STRATEGY AND MARKETING: WHAT IS OUR VALUE-PROPOSITION? • Why a customer should buy a product or use a service. Specifically targeted towards potential customers such as third party payers. • Designed to convince customers that one particular product/service will add more value or better solve a problem than others in its competitive set. Why should XXX (insert: MCO, other health plans) purchase services from AFC vs other agencies” – Or, what do we bring to the table that the others do not?

Unique Selling Proposition (USP) • Consequences of Nonadherence to ART • Barriers to Adherence • “The Cascade” • Case Management impact on VL Suppression (80% Part B, 74% Part A)

Link & Retain members in Care Grants & Contract Administration

Systems Integration

Engage the Hard to Reach & Complex to Manage

Extensive Provider Network

III. OUR APPROACH DOING BUSINESS WITH US

STRATEGIC READINESS Checklist for Negotiating Managed Care Contracts

Know our costs Know our capacity Define our competitive advantages Know our market & define it for each MCE Understand the requirements & standards of each MCE

Strategic Process Prior to approaching Health Plans: • Assessment of Managed Care landscape • Reviewed IL HIV specific claims data • Provided Series of workshops for network partners – Managing Change; SSP; Securing New Business • Developed Lines of Business • Prepared material for Managed Care proposals

Meetings with MCEs Active Solicitation started December 2013

• Prepared a priority list • Asked for meetings w/ Exec & Program staff to introduce ourselves • Presented “Who We Are & What We Do” • Made the “ask” (w/ HIV metrics) • Identified next steps • Follow up; Follow up; Follow up and MORE

HURRY UP and WAIT • Many Health Plans new to IL and/or pop’n • Revolving Door of Executive MCE staff • Contracts with the “community” – new concept; round peg/square hole • Contract/procurement staff not always aligned with their clinical/program staff • Delegation vs “co-manage” • Many Contract negotiation “hoops”

AND…..Our Partners? Readiness is Challenging:

1. 2. 3. 4. 5.

Secured Data Transfer New Contracts/BAA Payment structure: units of service vs grants Staffing Capacity Increased Accountability – documentation; reports; tracking 6. Willingness to join AFC on this journey??

CHALLENGES: • Different Language • Need to meet MCOs where THEY are at • Making “braided services” REALLY work (RW services; ADAP, Housing; Testing; L2C) • Compatible database systems; exchange data • Staffing Capacity • Risk Management

High Accountability Moderate Accountability Low Accountability

Accountability

Pricing VERY tricky – what financial risk can you take ?

Continuum of Risk-Based Contracting

(Gradual)

Financial Risk

progression that recognizes upfront investment needed to change delivery models

IV. MILESTONES….To Date 1. Developed our program model: lines of business/service lines 2. Developed pricing structures – based on unit costs of service; focused on encounters 3. Brand our model as CommunityLinks – logo; website; marketing materials 4. Held MANY meetings with the Managed Care Entities – MCEs, partners, SPC 5. Hired a Director for CommunityLinks

CommunityLinks Today? • Executed Contract for HIV-Connect w/ some initial Reach service • Executed Contract: Reach/HRQ/Testing and Linkage to Care; not HIV Specific; Housing services also available • 4 to 6 others “in the works” • Forms, Flows, & Fields

• Sub-contracting partners: new contracts, SOW; training; data reporting

What’s Next for AFC ? • Fully implement CommunityLinks • Overall data analysis – outcomes, ROI

• Address State Policy changes as needed (i.e. HFS/Medicaid; AIDS Waiver; Testing) • Develop other markets

Call to ACTION: LHDs • Understand your State Medicaid plan • Educate/engage Medicaid leadership, MCOs, new partners • Assess Needs, Identify appropriate partners • Look at Health Home opportunities • Make the business case • Determine data elements to track & evaluate • Measure success, assess ROI • Determine level of risk you can take

Your Call to ACTION HOW TO SUPPORT YOUR community providers? 1. Determine their level of readiness  How do services fill an unmet MCE need?  Can Value-add be demonstrated?  Infrastructure to support new service delivery & payment models?

2.

Identify $ or personnel for TA/Coaching  Can you offer 1:1 and/or group support?

3.

Determine if/how providers can collaborate w/ each other

4.

Collaborative Options for “Network formation”:    

Management Services Organization (MSO)/Provider Services Org’n (PSO) Independent Practice Association (IPA) Mergers/Strategic Alliances Data Exchange Coordination

CLOSING: - In the end…. It's about change and…. moving forward w/ a broad vision of "health“

Thank You!

Ideally…….

Realistically…….

No More “business as usual”

Shifting gears

BE PART OF THE SOLUTION. MAKE AN IMPACT.

Consequences of Nonadherence to Antiretroviral Therapy (ART) Although adherence is important in all chronic-disease management, it is crucial in HIV treatment because: • Nonadherent patients are more likely to experience virologic failure and resistance1,2 • Failure and resistance are often associated with disease progression, complications, and the need for alternate therapies3 • Adherence may result in decreased health care utilization and associated costs2,4

References: 1 Gardner EM, et al. AIDS. 2008;22(1):75-82. 2. Paterson DL, et al. Ann Intern Med. 2000;133(1):21-30. 3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. U.S. Department of Health and Human Services; March 27, 2012:1-239. 4. Gardner EM, et al. Appl Health Econ Health Policy. 2008;6(2-3):145-155.

Barriers to Adherence • Concomitant substance abuse • Low level of health literacy

• Age-related challenges (i.e, polypharmacy, vision loss) • Psychosocial issues (i.e, depression, homelessness)

• Difficulty taking medication (i.e, trouble swallowing, scheduling issues)

• Cognitive issues • Side effects • Not keeping clinical appointments

• Stigma

• Cost and insurance issues

• Regimens too complicated

• Treatment fatigue

Reference: Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. U.S. Department of Health and Human Services; March 27, 2012:1-239.

Current HIV Continuum of Care Chicago Metro Area 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 -

Case Management Northeastern Illinois HIV/AIDS Case Management Network • Founded in 1988, AFC operates the nation’s first and only coordinated case management system for people living with HIV/AIDS. • Braids public and private funds to create seamless case management system. • Trains all case managers to provide consistent, high quality services.

• Adhere to quality standards and compliance with federal regulations. • Provides centralized data base to ensure conformity in care and achievement of standardized health outcomes. Person-centered care -- evidence-based interventions

VL SUPPRESSION

TRIPLE AIM

Treatment Adherence & Chronic Disease Management =  Better HIV Health  Improved Health Outcomes  Cost Savings

What are the Risks for Providers/ Organizations with these new models? 1. Financial: • Significant costs associated with new models of care • Interoperable EHR, other infrastructure costs • Development of Care Coordination/Management program • Time, organizational culture- change is hard 2. Reimbursement: New and Different • Phase out of FFS • Care Management fee (depending on payment model) • Shared savings, global or bundled payment • Medicaid “shared” savings: May be difficult to find much savings in Illinois program ???

IV. WHAT DOES “TODAY” LOOK LIKE? • • • •

CONTRACTS IMPLEMENTATION DATA MANAGEMENT IT/SECURITY