CMDP_Narrative_Response_Draft_5.pdf

1 Health Choice Arizona | Narrative Submission

Introduction

Health Choice Arizona (Health Choice), together with our new owner, Blue Cross Blue Shield of Arizona, and our continuing affiliation with the NARBHA Institute, is happy to propose an innovative approach to address the needs of the Department of Child Safety’s Comprehensive Medical & Dental Program (CMDP). Our proposal is designed for the singular purpose of ensuring that Arizona’s foster children receive the care they need on a timely and effective basis. Health Choice’s integrated organizational structure reflects our behavioral health-led approach to the merged operations of Health Choice Arizona’s legacy physical health programs with NARBHA and Health Choice Integrated Care’s legacy behavioral health and programs.

Health Choice’s vision for the future of care for Arizona’s foster children, their families, and support systems, is that of a provider led care management and coordination approach committed to the highest quality care for them that improves health outcomes while containing cost. Our primary strategy is to work collaboratively with specialty health home based provider network, utilizing an innovative, integrated, care management model.

Health Choice has had the pleasure to serve our home state of Arizona’s Medicaid program since 1990, beginning as a small AHCCCS Acute Plan associated with St. Luke’s Hospital. Health Choice has grown to manage physical and behavioral health services for over 200,000 members in eight counties throughout central and northern Arizona. Over the last 17 years, our geographic coverage has included both the heavily populated and competitive urban health care market of the Phoenix and Tucson metropolitan areas, as well as the 93,000 square mile rural expanses of Northern Arizona. As a result, Health Choice has developed extensive capabilities to address the needs of both urban and rural members as well as the provider network that serves them.

Health Choice also brings with us the 50-year history of the NARBHA Institute. NARBHA began in 1967 as an administrative service organization serving the needs of community based non-profit behavioral health providers throughout the rural and frontier region of Northern Arizona. NARBHA then transitioned to a Regional Behavioral Health Authority (RBHA) when Arizona implemented the RBHA system. In 2015, Health Choice began the evolution of its unique behavioral health care network and care management approach to serve both the physical and behavioral health needs of our members on a fully integrated basis, leveraging this experience.

Health Choice’s expertise and history, coupled with the expertise and 80 year history of our new owner, Blue Cross Blue Shield of Arizona, is the foundation of our proposed strategy to address CMDP’s needs: A behavioral health led, fully integrated, person-centered, Specialty Health Home based provide network, supported and supplemented by our extensive broader provider network and health plan-based integrated care management team, to ensure that foster children and families safely and smoothly navigate the many transitions they face in order to ensure they receive the health care services they need.

Proposal Summary

Health Choice submits the following recommendations and proposal:

• Administration. Health Choice would establish a new health plan line of business, specifically tailored to address the needs and interests of CMDP. We have tentatively called this new health plan Health Choice Children’s Specialty Care. The new plan would be led by a dedicated leadership team including an Executive Director, Clinical Services Director, Finance Director, and Managed Services Administrator. This team would be directly responsible for ensuring that CMDP’s contractual expectations are being fully met. The new health plan would be based in Phoenix, but would also have regional offices in Tucson in addition to our existing staff and infrastructure locating in Flagstaff.

• Clinical Services. The new health plan would also have dedicated care management, medical management, and quality management teams, under the direct supervision of the Clinical Services Director. The care management team would be following the same integrated care management model that Health Choice has used since 2105 2015 for our most clinically complex members. Both our care management and medical management teams would follow a unique set of policies and protocols that would be developed in concert with CMDP staff. As noted during our first meeting with CMDP, we would also be willing to provide clinical decision

2 Health Choice Arizona | Narrative Submission makers with direct access to our CareRadius prior authorization approval system to review all services that are set for denial by a medical director.

• Provider Network. The new health plan would develop a provider network of specialty health homes throughout the state that would focus on the whole person health of foster children and their families.

The specialty health home network would he an extension and evolution of Health Choice’s current integrated and behavioral health home network in Northern Arizona. The specialty network would be further supported and supplemented with Health Choice Arizona’s existing statewide provider network, consisting of over 16,000 physical and behavioral health providers. In addition, Health Choice would agree to an extended transition period of a year during which members who have been receiving services from providers who are not in our network could continue to treat members while we work to bring the providers into our network.

• Core Services. Core services needed by the new health plan, including claims adjudication, encounter submission, credentialing, compliance, pharmacy, provider network support and contracting, member and provider call center services, prior authorization, information systems, and grievance and appeals, would be supported through the expansion of Health Choice Arizona’s current teams. However, the new health plan would employ a Managed Services Administrator whose primary role would be to ensure that these core services are being fully responsive to, and meeting the needs of, the new health plan.

• Reporting and Deliverables. As was likely obvious from the slide deck “takeaway” that we left with the CMDP team following our first meeting, Health Choice is moving away from the traditional “static” reporting system, toward a self-service reporting system. This system is already largely in place for all areas of claims history-based cost, utilization, and quality reporting. Health Choice recommends the creation of a custom set of dashboards that would be made directly available to CMDP staff members so that they can see “live” reports on demand. This system would be supplemented by a smaller number of regular deliverables that would serve to document the clinical and operational effectiveness of the health plan at a higher level. Lastly, the new plan would commit to hold regularly scheduled “operating review” meetings with CMDP to discuss clinical and operational results, as well as plans to address collectively identified issues.

• Finance. Health Choice recommends that the contract between CMDP and Health Choice be a modified full risk contract, implementing a phased approach. Given the significant number of changes in the delivery and medical management system anticipate, and the high level nature of the data made available to us, Health Choice recommends that the parties start by employing a modified risk contract that is based on the current AHCCCS arrangement which utilizes AHCCCS’ actuarial team and methodology to certify capitation rates to compensate for medical expense; uses a gain-shared risk corridor similar to that used by AHCCCS’ ACC contracts, but eliminates the risk corridor for the first three years of the contract. This will allow the parties to gather enough cost and utilization data under the new models to be actuarially significant. Health Choice would also propose an administrative rate of 15% for the first three years of the contract.

Detailed Discussion

Administration. As noted above, Health Choice would establish a new health plan line of business with a separate organizational identity and executive level leadership structure. This would ensure that there is a direct line of responsibility and communication between CMDP and the health plan’s decision makers.

The leadership structure would include four primary positions, all of which will be subject to review and approval by CMDP prior to the appointment of an individual to the position. The Executive Director (or “General Manager” in Blue Cross terminology) would be the senior most executive responsible for direction of the new health plan. The position would be directly responsible for ensuring that the health plan’s contractual responsibilities to CMDP are being fully met. The individual would have a minimum of five years of senior level experience in either a government program health plan and/or a state health related agency.

The new health plan would also be supported by a Clinical Services Director. This position would be responsible for management of all clinical operations in the health plan, including the health plan’s dedicated care management, medical management, and quality management teams. The position would work directly with CMDP’s clinical teams to ensure that the agreed-upon policies and protocols are being met, and that care

3 Health Choice Arizona | Narrative Submission management and medical management decisions are being made in a manner that are supported by CMDP. The individual hired for the position would be an Arizona licensed health care professional, with a minimum of five years of senior level experience in either a government program health plan and/or a state health related agency.

The third member of the leadership team would be a dedicated Finance Director. This individual would be responsible for ensuring that CMDP receives timely and transparent financial reporting. Given the significant number of changes in the CMDP system’s provider and administrative structure under this contract, the Finance Director’s responsibilities will be of major importance to CMDP so that, to the full extent possible, financial planning, projections, and reporting help avoid “surprises” that negatively affect either organization. Again, the selected individual for the position would have a minimum of five years of senior level experience in either a government program health plan and/or a state health related agency.

The final member of the leadership team would be the Managed Services Administrator. This position would be responsible for ensure that the “core services” that are supplied by the central Health Choice organization perform in a manner that fully supports the needs of CMDP under the contract. The individual selected for the position would have a minimum of five year of senior level experience as a senior operations director, vice president of operations, or chief operating officer in either a government program health plan and/or a state health related agency.

The new plan’s Executive Director would report to the Chief Executive Officer of Health Choice Arizona, Shawn Nau, and would be further supported by the full Health Choice leadership team which includes several clinical and administrative team members with extensive experience serving foster children and CMDP under the current AHCCCS RBHA contract. By further extension, the executive leadership and professional consultation services offered by Blue Cross Blue Shield of Arizona and NARBHA Institute would also support the new health plan’s organizational and operational efforts.

Lastly, the primary officer of the new health plan would be located in Phoenix in order to provide ready access by CMDP to the leadership and operations teams, however satellite operations would also be located for clinical staff in Tucson and Flagstaff. Locating clinical (and in particular, care management) staff regionally will allow them to quickly travel to remote sites to address member and family support needs. Likewise, it will allow the staff to assist more directly and quickly in immediate resolution of complex issues and build relationships with local DCS staff, which have been important elements of Health Choice’s ability to quickly address challenges in North Arizona.

Clinical Services. The new health plan would have dedicated care management, medical management, and quality management teams, under the direct supervision of the Clinical Services Director. Given that the health services managed by the plan would be heavily weighted toward behavioral health, we currently envision that the position could be a master’s level social worker, psychiatric nurse practitioner, or pediatric psychiatrist.

This position would also receive the full clinical support of Health Choice’s Chief Medical Officer, Dr. Mark Carroll, who is a highly respected pediatrician with over 20 years of experience working with the Indian Health Service, AHCCCS, NARBHA, and Northern Arizona Healthcare, Health Choice’s Pediatric Behavioral Health Medical Director, Dr. Aaron Goldman, a child psychiatrist with extensive experience in addressing the challenges of health care in rural Arizona, and Blue Cross’ Behavioral Health Medical Director, Dr. Sandy Zebrowski, who is also a child psychiatrist, and formerly served as the Chief Medical Officer for the RBHA in Maricopa County. The clinical team would also benefit from the support of Jon Perez, the NARBHA Institute’s Chief Operating Officer and former SAMHSA Region IX Administrator.

Care Management. Health Choice’s integrated care management program (covering both physical and behavioral health services) is unique among the current AHCCCS health plans. It was specifically formulated to provide for “seamless” care coordination across the entire delivery system by offering a single point contact for whole person health care. It was also designed to offer a central point of clinical responsibility for outcomes from a managed care perspective. Our goal would be to replicate this approach, but supplement it with care management staff that is dedicated to the support of CMDP, foster children, and their family members.

Our basic program design starts with the use of the traditional Child & Family Team (CFT), through which the child and family are directly involved in identifying needed services. However, support for the CFT is not

4 Health Choice Arizona | Narrative Submission simply delegated to providers. Instead, Health Choice uses an extended, internal Individual Care Team to directly support the CFT. The Individual Care Team includes the Specialty Health Home’s Case Manager, one or more Integrated Care Managers from Health Choice, and the support of one or more of our Population Care Team.

The basic roles of these functions are:

• Case Manager. The Case Manager is employed by the specialty health home, and serves as the single point of contact for child and family. The Case Manager supports the member and family’s needs by developing a personal relationship with the member and family, and collecting patient information and helps them navigate the system to obtain necessary services and supports. The Case Manager is responsible for monitoring and following-up on interventions in conjunction with the health plan’s Integrated Care Manager and CMDP’s care managers.

• Integrated Care Manager.

Integrated Care Managers will be employed by the new health plan, and will be assigned to specialty health homes throughout the state.

Locating Integrated Care Managers regionally will permit them to learn, understand, and be sensitive to the unique aspects of the location’s cultures, norms, and interests. It will also allow them to build close professional relationships with medical and behavioral providers, case managers, local Peer and Family resources, and each specialty health home’s support team – in spite of Arizona’s expansive geography. Integrated Care Managers will be responsible for convening and leading CFTs, and providing medical expertise and input into the child’s Individual Care Plans with knowledge of chronic co-morbid conditions. The Integrated Care Manager will compile case analyses (in collaboration with the Case Manager and CMDP’s care managers), and manage the process to ensure coordination of both physical and behavioral health care needs through oversight of the Individual Care Plan.

• Population Care Leads. Population Care Leads provide specialized expertise regarding strategies to meet the needs of specific populations, including high risk children. Population Care Leads monitor Care Management Plan content and caseloads, Individual Care Plan interventions and anticipated outcomes, and provide technical assistance to Integrated Care Managers including disease management, case review, ongoing education, and training. Population Care Leads also communicate care management activities across the organization and identify data-driven opportunities to improve care management practices.

To be fully effective, the use of this integrated care management design must start at first contact. We would expand and evolve our existing dedicated 24-hour telephone line which give DCS access to our clinical team to notify us of all removals of children or adolescents from a home. Within 24 hours of removal, a clinician within our Specialty Health Home will complete an in-home comprehensive behavioral health needs assessment to support the child, the child’s family and the new foster family in identifying immediate/unmet needs due to the trauma of the removal. Health Choice will be coordinating ESPDT records for new children in DCS custody so that the newly assigned pediatrician does not duplicate immunizations and is aware of gaps in care. Our care management team will leverage our existing “Pediatric Check-Up” protocol to ensure that the child’s needs are quickly assessed, and immediate needs can be promptly met. Where needed, Health Choice can also deploy our extensive telemedicine system to address immediate needs at locations that present geographic barriers.

Our goal will continue to be promoting a stable, nurturing environment for children in foster care. The new health plan would continue our programing to educate stakeholders regarding the developmental needs of children and the effects of trauma, and ensuring that foster families are prepared to support the children in their care. For high need children, the new health plan will provide significant supports, including in-home services to foster families and children to support the placement. We will also continue to work closely and collaboratively with involved State agencies to successfully develop and utilize Home Care Training to the Home Care Client

5 Health Choice Arizona | Narrative Submission

(HCTC) as an alternative to more restrictive levels of care whenever possible, and continue development of the Families First model that we pioneered along with Family Involvement Centers and MiKid.

If at any time a family or guardian requests an out of home (including an out of state) placement not supported by the CFT, the CFT is required to immediately submit a prior authorization request to Health Choice for medical necessity review, which would be made available for CMDP review through our CareRadius care management and prior authorization system. This step will ensure that the DCS request is addressed promptly. If a child has complex needs, the Clinical Services Director will work closely with the CMDP Medical Director to ensure there are no gaps in services, especially when a child is in an out-of-state placement, based on the child’s medical and behavioral health needs.

Finally, while available space does not allow for much elaboration, our existing care management program is also designed to address the aging out transition process, including foster family support by providing materials and education related to the transition and ongoing to support access to care. We also partnering with DCS on identifying families to provide support before children are removed from the home, and collaboratively work to continue to always improve data flow for various state partners, including DCS, the state courts, AHCCCS, and K-12 schools.

Medical Management. One of the most significant changes that families and providers would experience if CMDP choses to move (even slowly) to a modified full risk manage care model will be implementation of medical management – both in terms of the need for prior authorizing certain services and the intervention involved in medical necessity review. In light of this, Health Choice recommends that the new health plan have its own dedicated medical management team, with a unique set of policies and protocols developed jointly between CMDP and the plan. Having a separate medical management team will be important in order to avoid the confusion that naturally occurs when a single team serves more than one line of business. We recognize and anticipate that, especially at first, these policies and protocols will likely need to use a considerably “lighter touch” as families and providers adapt to the new processes.

As with care management, Health Choice’s medical management design is also somewhat different from that of the other AHCCCS health plans. Like other plans, our medical management function is comprised of two main teams – concurrent review and retrospective review. As with other AHCCCS plans, our retrospective review team conducts a sample review of medical necessity, focused primarily on high dollar claims. If the recommendation is to deny or modify a payment, the claim is forwarded for medical director review. As with prior authorization decisions, we would be willing to provide CMDP’s medical directors with access to our CareRadius system so that they can provide a final review as part of this decision making process.

By contrast, the primary function of our concurrent review team has been different. It typically has focused less on medical necessity, and more on discharge planning. Where the team has concerns regarding the appropriateness of care, they are empowered to escalate the issue for medical director review. However, we typically have not found these issues to predominate. Instead, the concurrent review team is expected to engage with the hospital or residential facility to ensure that the child and family’s post-discharge needs are fully in place so that outpatient services are available immediately following discharge.

Quality Management. Health Choice has made a significant number of changes to our quality management functions over the last two years. With the active and direct support of our executive leadership, including our Chief Operating Officer, Diana Alvarez, we have developed an entire system for monitoring quality progress on individual quality measures on a granular level. Each performance measure is tracked on a weekly basis against an aggressive set of internal monthly performance targets. Actual performance is then reviewed weekly by our internal Quality Leadership Team, and monthly by our full executive team. If performance does not meet the established targets, the Quality Leadership Team is expected to propose pragmatic alternative initiatives to improve performance to reach the monthly goal. An example of our one of our performance tracking charts is included as the accompanying graphic at right. We would replicate this approach within the new health plan’s dedicated quality management department, using an agreed upon set of performance measures established jointly with CMDP. (We have noted that CMDP has some of the best performance in the system and there are opportunities to partner with CMDP to push forward even greater levels of improvement.)

6 Health Choice Arizona | Narrative Submission

In addition, the quality management department would also be responsible for managing all quality of care concerns. Health Choice has historically taken a “no wrong door” approach to quality of care concerns.

Literally anyone, can request the initiation of an investigation of any function within the system – from provider level care all the way through health plan management. Indeed, many of our quality of care concerns are initiated internally. Any material quality of care concerns that are upheld result in the implementation of a corrective action plan. The frequency and results of quality of care concerns are reported to the executive team on a monthly basis as part of our operational review process, and can easily be shared with CMDP.

Provider Network. The new health plan would develop a provider network of specialty health homes throughout the state that would focus on the whole person health of foster children and support for their families. The specialty health home network would be modeled on our Northern Arizona health home network, an extension of which we are already developing in Central Arizona. This model uses a total cost of care, sub-capitated prepayment model to ensure that health homes have sufficient resources to address their member’s needs. These payments must be supported by the health home’s submission of encounters that demonstrate that the health home has either directly or through referrals provided services that justify the prepaid amount. We then also employ a series of specific, quality-focused measures as part of a value based, shared risk/savings model.

As demonstrated by the graphic on page 4, our specialty health home network typically uses established behavioral health providers as a practice base, but then adds physical health services either through a “structurally integrated model” in which the health home directly employs physicians or through an “affiliation model” under which the health home works directly with a major pediatric provider or accountable care organization. An excellent example of a structurally integrated specialty health home is Spectrum Healthcare in Cottonwood which offers both pediatric physical and behavioral health services under a single organizational structure. As an example of an affiliation model would be Southwest Behavioral Health’s affiliation with Phoenix Children’s Care Network (ACO) in the Phoenix metropolitan area.

We strongly believe that a focused specialty health home model is the best way to ensure that a properly staffed, trained, and resourced provider network will be available to address each foster child’s needs from first contact through adolescence. A specialty health home network will fully understand and be able to address the unique needs and circumstances of foster children, including the use of trauma informed care. Even with a fully developed specialty health home network, however, foster children will need the support of additional inpatient, specialty, and support services. To address these needs, Health Choice would make available its entire provider network of over 16,000 providers in Arizona and neighboring states, including all major hospital systems, physical and behavioral health specialists, substance use recovery services, and peer and family support programs.

Core Services. Core managed care services needed by the new health plan, including claims adjudication, encounter submission, credentialing, compliance, dental, vision, pharmacy, provider network support and contracting, member and provider call center services, prior authorization, information systems, and grievance and appeals, would be supported through the expansion of Health Choice’s current teams. These services would report to the Managed Services Administrator to ensure that they perform in a manner that addresses the

7 Health Choice Arizona | Narrative Submission unique needs of CMDP consistent with our contract. Unlike other plans, all of these support services are managed directly from our offices in Arizona.

Our claims adjudication function would be supported by our dual systems, including MedMC for physical health claims and QNXT for behavioral health claims. The data from the two system is then fed into a data warehouse for reporting purposes. Our call center and prior authorization systems are managed on our CareRadius platform, which integrates the information from these functions along with our care management and medical management data. As with most of our systems, CareRadius is a cloud-based application, which would allow CMDP staff to directly see member level data, and potentially participate in the prior authorization decision making process. Our pharmacy benefit management contract is with CVS, which supports an extensive statewide network of pharmacies, including Walgreens, Walmart, CVS, and large number of rural independent pharmacies. CVS also manages our specialty pharmacy network, while our vision network is managed through Nationwide Vision. Unlike other AHCCCS health plans, we directly manage our own dental program and network of pediatric dentists across the state.

Reporting and Deliverables. The key to making certain that core services are actually meeting the needs of the program is having timely and accurate reporting. As was demonstrated in the slide deck “takeaway” that we previously provided to CMDP, Health Choice has moved away from static pre-programmed reporting and “deliverable” systems to a self-serve analytics system called QlikSense. This system allows us (and by extension, would allow CMDP) the ability to observe and analyze cost and utilization data at a “dashboard” level, but then simply “click down” to see provider level data. This data is refreshed on a daily basis, for as close to a “real time” experience as any claims based system can provide. Our QlikSense implementation is available on a remote basis, which means that we can make CMDP program-specific dashboard and data available to CMDP. We believe that the availability of a common set of care management and self-service analytic resources will facilitate a team based approach between CMDP and Health Choice to better serve foster children and their families.

Finance. Health Choice recommends that the contract between CMDP and Health Choice be a modified full risk contract. Given the significant number of anticipated changes in the delivery and medical management systems, and the high level nature of the data made available to us, Health Choice is not currently comfortable agreeing to a full risk arrangement identical to that employed by AHCCCS. We frankly do not believe that CMDP would ultimately find such an arrangement beneficial to it either. However, a straight Administrative Services Organization model also presents significant challenges, including an inability to ensure proper care coordination or having a material impact through quality initiatives. As such, Health Choice recommends that the parties start by employing a risk contract that is based on the current AHCCCS arrangement which utilizes AHCCCS’ actuarial team and methodology to certify capitation rates to compensate for medical expense.

However, given all of the unknowns, Health Choice recommends that the risk corridors be significantly altered.

Health Choice recommends that the upside shared gain corridors used in the AHCCCS contract be retained, but that the downside risk be eliminated for the first three years of the contract. This will allow the parties to gather enough utilization data under the new system to be actuarially significant under the AHCCCS model. Health Choice would also propose that an administrative rate of 15% for the first three years of the contract in light of the significant startup costs associated with standing up a dedicated plan. Administrative costs could then be reassessed by the parties based on actual costs following the completion of the third contract year.

Conclusion. Health Choice sincerely appreciates the opportunity to submit this proposal to CMDP. While the foregoing does not represent a formal offer to contract or response to a request for proposals, we firmly believe that the ideas and concepts included above are capable of being quickly negotiated and reduced to writing if the Department of Children’s Services is in substantial agreement with our overall approach. We look forward to the opportunity to discuss these concepts with you in the near future.