- How can counties and HCA/DSHS work together to prepare for healthcare reform?
- What is a regional health alliance (RHA)?
- Why do we need a regional health alliance?
- Doesn’t the RHA just add another layer of cost, making the overall system more expensive?
- Are all funding sources pooled together, with the RHA becoming the contract holder of dollars from MPA, DSHS, counties, and other funding sources?
- What do health plans think of this idea and why would they be interested in adding another lay of complexity to their environment?
- How does the RHA work with health plans?
- What does the risk sharing arrangement look like at RHA and ACO levels?
- How does RHA plan to integrate across systems? Are AAA, DDD, Home & Community Services, DCFS, etc., part of the governing structure of RHA?
- How are partners within the RHA held accountable?
- What does a shared governing structure look like? What is the role of a shared governing body?
- If the RHA concept moves forward, does every corner of Washington need to have an alliance? How will startup and operations of RHAs be funded?
- How will startup and operations of RHAs be funded?
1. How can counties and HCA/DSHS work together to prepare for healthcare reform?
Stakeholders in Southwest Washington including Clark, Cowlitz, Skamania, Wahkiakum counties, RSNs, Cowlitz Tribe and health plans studied the Regional Health Alliance (RHA) that is being developed in the Bend, Oregon area and determined that this approach has the potential to address a key question – How can local communities support Healthcare Reform the Washington Way?
Counties working on the RHA concept see three levels of mission-critical healthcare reform effort. The federal government is providing the national framework via the Affordable Care Act and the Federal Parity Law. States will do much of the heavy lifting regarding Medicaid Expansion, implementation of Federal Parity, Health Insurance Exchanges, Accountable Care Organization Design and Standards, Medical/Health Home Design and Standards and Payment Models, Medicaid Home and Community-Based Services (HCBS) Option, and Dual Eligible and Special Needs Plan Design. Communities will need to customize these designs to address the particulars of their local healthcare ecosystems.
Empowering local communities to identify local needs and help redesign the delivery systems for the safety net deepens the involvement and commitment as we attempt to use the tools of healthcare reform to improve the healthcare system in Washington.
2. What is a regional health alliance (RHA)?
A Regional Health Alliance (RHA) is a public-private partnership that is being developed as a new approach to supporting Accountable Care Organizations and other providers that serve Medicaid enrollees and other individuals and families in the safety net in a defined geographic area. The purpose of the RHA is to organize the payors of care to create a supportive payment, structural, and regulatory environment along with a regional health information exchange that best facilitates clinical integration among the providers of safety net care.
This includes standardizing payment models, performance measures, and contract requirements across all payors – health plans (both Medicaid and health exchange plans), counties, health departments, state agencies, other private funders, etc. – in order to facilitate regional health planning across health delivery structures, reduce existing and future administrative burdens, and implement new payment models that will aid provider groups in achieving better health for the regional population, better care for individuals, and reduced cost through health status improvement - not rationing or fee reductions (the Triple Aim).
3. Why do we need a regional health alliance?
Once a community understands that it cannot achieve the Triple Aim for individuals and families in the safety net without addressing the social determinants of health, all services in the Healthcare Neighborhood (public health, behavioral health, housing, social services, education, employment, oral health, etc.) take on a new level of importance. For many in the safety net, a typical care plan will require multiple services and supports across what are now multiple funding silos. Even if the health and behavioral health silos are merged, there will continue to be several other silos, each with their own payment models, performance standards, and contract terms. If Accountable Care Organizations (ACOs) serving the safety are subjected to this fragmentation of payor rules, they will be set up for burdensome administrative costs (at best) and potential failure. The purpose of an RHA is to solve this problem.
A second major RHA purpose is to organize a community-wide health assessment and health improvement planning process that brings a comprehensive approach to planning and budgeting. How many people are in the safety population? How much of what types of services and supports are needed to move the community to the Triple Aim? How many of what types of providers are needed, at what cost? How does a community with multiple ACOs handle behavioral health crisis, crisis respite, housing, and other essential services that will be the needed by multiple ACOs and multiple payors? How do payors braid and blend funds to maximize everyone’s dollars?
4. Doesn’t the RHA just add another layer of cost, making the overall system more expensive?
The intent of the RHA is to support the payors in streamlining and eliminating waste, duplication, and conflicting rules/payment models. An individual in the safety net should never have more than one care plan or one care manager/case manager. This is not the case now throughout Washington State. If an ACO in a community is being paid by more than one Medicaid health plan, multiple plans in the Exchange, and other payors of services and supports, there is a great risk that the ACO will have an unsupportive and confusing payment and regulatory system, especially for ACOs serving the safety net population. If the RHA is not able to achieve cost savings it should not exist.
5. Are all funding sources pooled together, with the RHA becoming the contract holder of dollars from MPA, DSHS, counties, and other funding sources?
No. We anticipate that health plans, counties and other payors of services and supports will continue to hold contracts directly with service providers. The RHA is a public-private partnership that coordinates these payors of safety net services and supports within a geographic region.
Under the RHA model, these payors will work together, using agreed upon payment models, performance measures and contract terms that provide consistent messages to the service delivery system across all payors. Without an RHA structure there is no forum or vehicle for coordinating “the rules” across multiple payors.
It is also possible that payors will want to jointly fund a specific program or service through a single contract (such as a mobile crisis team that services multiple payors). The RHA could become the fiscal intermediary or this could be delegated to one of the existing payors.
6. What do health plans think of this idea and why would they be interested in adding another lay of complexity to their environment?
Although we cannot speak for Washington State’s Medicaid health plans, they have been vocal in meetings in King County, Southwest and Northeast Washington. If a health plan is serving a TANF mom with two kids who is the victim of domestic violence and about to be homeless, the health plan will not succeed in helping her and her kids move toward health if they don’t address her unstable housing and safety issues. Health plans have made public statements that by working closely with other payors they will have a much better chance of achieving their goals and objectives.
We anticipate that health plans, as members of the RHA, will participate in the development of the public private partnership, support the community needs assessment and improvement planning process, and provide leadership in the development of standardized payment models, performance measures and contract terms. This public-private partnership builds on the efforts of existing Medicaid health plans to deepen their ties to the communities in which they operate. This includes the Molina partnerships to embed primary care into community mental health centers and Community Health Plan’s spread of the Disability Lifeline clinical and financial model throughout the RSN system.
8. What does the risk sharing arrangement look like at RHA and ACO levels?
Because the RHA is not expected to be a direct payor of services and supports, they will only serve to provide a forum for designing common payment models and risk sharing arrangements between all payors that are members of the RHAs and ACOs and other providers of services and supports that are not members of an ACO.
9. How does RHA plan to integrate across systems? Are AAA, DDD, Home & Community Services, DCFS, etc., part of the governing structure of RHA?
The intent is to integrate all payors of safety net services in a community/region, bringing those payors in as members of the RHA. Having all payors participate in the community-wide needs assessment and improvement plan helps each better understand the part they play in addressing the needs of the community. Participating in the development of a regional safety net budget deepens this understanding and is expected to influence how payors prioritize their dollars. Remember that, because dollars are not flowing through the RHA, final budget decisions remain with each payor.
10. How are partners within the RHA held accountable?
The RHA represents a significant innovation because it creates a forum for state, regional and local payors to work together in ways that have not occurred in the past. Each RHA will develop a “virtual budget” based on the needs of the community and payors will agree to transparency through utilization and expenditure reporting that compares actual with projected dollars and data. There will most likely not be specific contractual agreements to adhere to a projected spending plan. But if, for example, a member of the RHA has agreed to spend XX dollars on prevention services and does not do so, this will become known through the reporting process, establishing a horizontal accountability process.
11. What does a shared governing structure look like? What is the role of a shared governing body?
We are beginning to explore how an RHA public-private partnership can be developed in Washington and whether enabling legislation will be needed. This research will provide the details of how the RHA model can be created.
In 2004, the King County Task Force on Regional Human Services explored this question and identified four models: 1) Nonprofit Lead Agency; 2) Government Lead Agency; 3) United Way Lead Agency; and 4) Public Development Authority. Many ACOs are using a fifth model – a Limited Liability Company. What is possible, what can be possible with enabling legislation, and the pros and cons of each approach will be explored as the design effort moves forward.
12. If the RHA concept moves forward, does every corner of Washington need to have an alliance? How will startup and operations of RHAs be funded?
Not necessarily. A group of payors in a region could create a RHA tomorrow and begin defining and working on the tasks of the Alliance. As the Healthy Options procurement unfolds, it is anticipated that there may be additions or changes in health plans operating in a region and it is hoped that new plans would become members of an RHA.
If not every region organized an RHA in the near term, Washington State would be able test the comparative ability of regions with RHAs to achieve better health for the population, better care for individuals and reduced cost growth, compared with regions that do not develop an RHA.
13. How will startup and operations of RHAs be funded?
Stakeholders have begun to explore obtaining startup grants from Washington State’s health foundations. Counties in California that manage child welfare, mental health and drug and alcohol services have developed several Joint Power Authority (JPA) agreements that include funding formulas to fund modest infrastructure requirements. These issues will need to be addressed, but it’s very clear that if an RHA is not able to achieve cost savings greater than the cost of operating the organization, it should not exist.