Dhcf strategic planfy12-14

D epar tm en t of H e a lt h C a re F i n a n c e

F Y 2 0 1 2 - 2 0 1 4

Str at e g i c P l an

“Partnering to Improve Health Outcomes”

Contents
Letter from the Mayor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Message from the Director. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Agency Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Strategic Goal I: Improve Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Strategic Goal II: Strengthen Program Integrity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Strategic Goal III: Implement Health Care Reform. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Strategic Goal IV: Improve Medicaid Billing with Public Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Strategic Goal V: Develop and Implement a Comprehensive Health Information Technology (HIT) Plan. . . . . . . 27

Strategic Goal VI: Enhance Reporting Capabilities to Improve Outcomes and Performance Management . . . . . . 34

Strategic Goal VII: Enhance DHCF Infrastructure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Appendices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

i Department of Health Care Finance FY2012-2014 Strategic Plan


Message from Mayor Vincent C. Gray
I am pleased to present, along with Director Wayne Turnage, the FY 2012-2014 Strategic Plan for the
Department of Health Care Finance (DHCF) of the Government of the District of Columbia.

DHCF has been at the forefront in providing District residents with access to the most comprehensive,
cost-effective and quality healthcare services they deserve.

The District of Columbia has made significant progress over the years in our efforts to improve the
health status of District residents.

This strategic plan was created based upon the theme, “Be the Change, Focus on the Outcomes,” which
is the underlying focus of DHCF’s efforts. The plan also serves as an essential roadmap for the agency
and stakeholders who can actively participate in the changes that will lead to improved outcomes.

In today’s changing health care environment, I am proud to say that the District of Columbia is on
the cutting edge in achieving key milestones in the implementation of the Patient Protection and
Affordable Care Act (PPACA), which became law on March 23, 2010. DHCF is ensuring that “care”
remains a high priority in any health care reform that will serve the residents of the District.
The District of Columbia is at the vanguard and is poised to become a leader in providing access to
comprehensive, coordinated and quality health care to all District residents.

I applaud the work of Director Turnage and the DHCF staff for developing strategies for the next three
years that will increase access to health care and improve health outcomes for the residents of the
District of Columbia.

Thank you!

1 Department of Health Care Finance FY2012-2014 Strategic Plan


Message from the Director
As the Director of the Department of Health Care Finance (DHCF), I am excited about positioning the agency to
focus more on its mission to improve health outcomes by providing access to comprehensive, cost-effective and
quality healthcare services for residents of the District of Columbia. Our strategic planning theme focuses our next
three years on change. Hence, “Be the Change…..Focus on the Outcomes,” motivates us to think of ourselves as
change agents and what outcomes we want for DHCF. By applying four fundamental questions – who and what are
we; what do we do now and why; what do we want to be and do in the future and why; how do we get from here to
there – we have established the framework to create strategic thought and action within our leadership and staff.

As we move from planning to implementation of the plan, we recognize to reach our goals require the reliance on our
many partners inside and outside of government. Our implementation theme is “Partnering to Improve Health Out-
Wayne Turnage, M.P.A. comes,” which is by far our most important goal.
Director
By asking ourselves these fundamental questions, we came together to identify key department issues and develop
strategies for the next three years. The following seven goals form the basis of this strategic plan:

“….an agency built on n mproving Health Outcomes
I
transparency, integrity, n S
trengthening Program Integrity
accountability, respect n I
mplementing Health Care Reform
and teamwork.” n I
mproving Medicaid Billing with Public Providers
n D
eveloping and Implementing a Comprehensive Health Information Technology Plan
n E
nhancing Reporting Capabilities to Improve Outcomes and Performance Management
n E
nhancing DHCF Infrastructure

We will stay focused as we move forward to improve the health outcomes of the people we serve. It is our respon-
sibility to District residents to partner with our stakeholders to provide the most comprehensive, cost-effective and
quality health care services they deserve.



Introduction
The Department of Health Care Finance (DHCF), formerly the Medical Assistance Administration under
the Department of Health, is the District of Columbia’s state Medicaid agency, as well as the agency
responsible for implementation of certain components within the Health Information Technology for
Economic and Clinical Health Act (HITECH) under the American Recovery and Reinvestment Act of
2009, Pub. L. 111-5, and key components of the Patient Protection and Affordable Care Act of 2010,
Pub. L. 111-148.

DHCF was established on February 27, 2008, under the Department of Health Care Finance Act of 2007,
giving it legal authority to administer a state-wide Medicaid program. It provides health care services to
low-income children, adults, the elderly and persons with disabilities. Over 200,000 District of Columbia
residents (nearly one third of all residents) receive health care services administered by DHCF.

The mission of the Department of Health Care Finance is to improve health outcomes for residents of the
District of Columbia by providing access to a comprehensive and cost-effective array of quality health care
services.

We have established core values to facilitate a culture change within DHCF staff and management that
will better position us to become a premier agency in health care. These core values are: transparency,
integrity, accountability, respect, and teamwork.



Agency Organization Programs
The agency operates under the direction of the Office of the Director, who Medicaid, CHIP and the Alliance Programs
is responsible for executive management, policy direction, strategic and
DHCF is the single state agency responsible
financial planning, public relations, and resource management. The Office
for managing the District’s Medicaid program
of the Director controls and coordinates agency operations to ensure the
which provides health care coverage to over
attainment of the agency’s goals and objectives.
205,000 residents with low-incomes. In FY
2010, the District spent $1.82 billion on health
To carry out the responsibilities of the Department, DHCF has 178 full-
care services for Medicaid beneficiaries. The
time positions organized in eight major areas of administration that are
federal government pays 70 percent of the
designed to carry out the mission of DHCF (Appendix A):
cost of the Medicaid program in the District of
Columbia.
n Office of the Director
n Deputy Director for Finance Linda Elam, PhD, MPH In addition to Medicaid, DHCF also admin-
Deputy Director, Medicaid
n Office of the Chief Operating Officer isters the DC Health Care Alliance program
Heath
n Deputy Director for Medicaid for approximately 24,000 residents who are not eligible for the Medicaid
n Health Care Delivery Management Administration program. Unlike, Medicaid, this program is paid for entirely with local
n Health Care Policy Research Administration dollars. In FY 2010, expenditures on the Alliance program exceeded $63
n Health Care Operations Administration million.
n Health Care Reform and Innovation Administration
DHCF is responsible for ensuring that health care services for residents
Each administration and office has management oversight of its functional served in these two programs are high quality, cost effective, and comply
areas. Currently, there are twenty-four divisions that function under these with District and federal laws. In addition, we also work with other D.C.
administrations (Appendix A). agencies such as the Department of Human Services, the District of
Columbia Public Schools, the Department of Mental Health and others to
coordinate Medicaid-funded services that are delivered to District residents
who receive care through those agencies.



DHCF also works with private industry to ensure that the services we The Health Insurance Exchange will give individuals and small businesses
provide are meeting the needs of our residents, such as health care access to affordable coverage through a new competitive private health
providers, insurance carriers, transportation providers, advocacy groups, insurance market – state-based Affordable Insurance Exchanges. The U.S.
and many other for profit and non-profit organizations. Department of Health and Human Services (HHS) provided $1 million in
grants to States and the District to conduct planning during FY 2011. The
Health Care Reform Initiatives District is using these funds to coordinate background research, capacity,
systems, and infrastructure assessments, and preliminary budget forecast-
On March 23, 2010, President Barack Obama signed the Patient
ing. Quarterly and final reports will be developed and submitted to HHS,
Protection and Affordable Care Act (PPACA) into law, which puts into
and will form recommendations to guide the District’s plans for implemen-
place comprehensive health insurance reforms that will hold insurance
tation of an Exchange by the 2014 federal deadline.
companies more accountable, lower health care costs, guarantee
more health care choices, and enhance the quality of health care for
In August of 2011, the US Department of Health and Human Services
all Americans. The law is intended to provide greater access to quality
(DHHS) awarded the District a Level One Exchange Establishment grant of
affordable healthcare for all Americans. DHCF is coordinating with sister
$8.2 million to continue with its planning and implementation of a Health
agencies and city leadership to develop and implement health care reform
Insurance Exchange for District residents. The funding from this grant will
initiatives. DHCF chairs the District’s Health Reform Implementation
leverage the data, information and indicators gathered in the preliminary
Committee (HRIC) with the Department of Insurance, Securities and
effort into a comprehensive project design.
Banking and the Department of Health serving as co-chairs, and serves as
the lead agency in city-wide committees focused on policy, planning and
communications. Within DHCF, health care reform initiatives are conducted n Health Information Exchange
across administrations, with coordination responsibilities housed in the In January 2010, the Office of the National Coordinator for Health
Director’s Office. Key health reform related goals and responsibilities for Information Technology (ONC) at HHS awarded the District $5.1 million
DHCF include: conducting public forums; analyzing the development of the to facilitate the planning and implementation of a District-wide Health
health insurance exchange; overseeing the necessary regulatory changes; Information Exchange (HIE). HIE is the electronic sharing of clinical,
and providing information to providers and payers. financial, and administrative health care information across care settings
(such as physician offices, hospitals, pharmacies, and payers). The grant
required DHCF to conduct planning initiatives in FY 2010 and FY 2011.
n Health Insurance Exchange
DHCF is focusing on developing five (5) key infrastructure components:
The Patient Protection and Affordable Care Act (PPACA) enables States to
governance; architecture; technical infrastructure; business and technical
establish a Health Insurance Exchange (HIX) through which uninsured resi-
operations; and legal/policy. In FY 2012, DHCF will develop a roll out plan
dents may purchase insurance and receive subsidies depending on income.



for HIE in the District, establish a governance mechanism for the provision Each of the seven subcommittees was chaired by a DHCF staff person. The
of HIE services, and develop and deploy core HIE services. Services to Strategic Planning Steering Committee and Task Force provided guidance and
be established during FY 2012 include: a baseline HIE architecture and leadership to the process. The planning process included the following groups.
implementation of core HIE services, such as e-prescribing, structured lab There were seven sub-committees that addressed key program issues.
reporting, and continuity of care reporting.
n HCF Strategic Planning Steering Committee. The DHCF
D
By implementing a carefully planned and well thought out HIE Strategic Planning Steering Committee was responsible for leading
infrastructure, the District seeks to improve the overall quality of health the change process by providing vision and encouragement to the
care delivery by empowering providers with the most current and accurate planning body, and ensuring that the goals and objectives of the
information about their patients. Ultimately, the HIE will serve to empower process were completed in a timely fashion.
District residents by granting them access to their own health information. n HCF Strategic Planning Task Force. The Planning Task Force
D
was responsible for the integration of the goals, objectives and
activities of the master plan, and provided recommendations for
systemic change to the DHCF Steering Committee.
Strategic Plan Framework n HCF Strategic Planning Sub-Committees and Supports. DHCF
D
strategic planning sub-committees are listed below. The majority
We are excited to share with the public and our stakeholders the first DHCF
of the work took place at this level…this is where the rubber
Strategic Plan. The strategic planning process kicked off at an All Hands
meets the road. The planning sub-committees were responsible
Staff Meeting that was held on June 6, 2011.
for the development of the goals, objectives and activities of the
master plan. Each sub-committee listed below was responsible for
DHCF created a planning structure to serve as the vehicle for change. The
including appropriate stakeholders outside of DHCF to participate
planning process facilitated the development of this three year plan and
in the planning process.
helped to create strategic thought and action within the leadership and
n ealth Outcomes Subcommittee
H
staff to move the agency to a position of excellence.
n Program Integrity Subcommittee
n Health Care Reform Subcommittee
To create and implement the strategic planning process, we obtained ideas
n Public Providers Subcommittee
from our business partners, customers, key stakeholders, and staff through
n omprehensive Health Information Technology Plan
C
planning meetings and by obtaining information through stakeholder surveys.
Subcommittee
We encouraged all DHCF employees to participate in this process.
n Outcomes and Performance Management Subcommittee
n DHCF Infrastructure Subcommittee



Accountability
We will provide quarterly updates to keep the public and our stakeholders
informed of our progress. In addition, performance management
provides DHCF with the mechanism to track our progress to ensure that
we are focusing on outcomes. The Strategic Plan Progress Report will be
disseminated quarterly through our website and through links provided
in various documents and other electronic media. You will also find our
strategic plan available with links that are of interest on the DHCF website.

Stakeholder Survey
Our internal and external stakeholders are important to us and so are their
opinions. We wanted to bring together our business partners, customers,
key stakeholders and staff, as we thought it was critical in major change
efforts to involve all relevant parties in the process. We gave them the
opportunity to rate the agency’s mission, core values, and priorities, as
well as provide their input on more specific issues related to the agency’s
strategic priorities.

We received favorable responses, with the majority coming from our health We asked our stakeholders to rank the agencies priorities and evaluate our
care providers and health care advocates. We found a high percentage of performance. The single most important priority from our stakeholders is
our stakeholders agree with our mission and submitted suggestions on improving patient outcomes with an average rating on performance. We
improving our mission. realize we have a lot of work ahead of us, but we now have confirmed that
our #1 priority is also our stakeholder’s #1 priority. With all of our resources,
Stakeholders provided a favorable response to the core values we talent and efforts focused on the goal, we know that we will be able to
identified as standards for DHCF and its employees, and feel strongly about make a significant impact on the health outcomes of District residents.
transparency, accountability and integrity. We are committed to instilling
all of the core values as we work to improve our delivery of service to Conducting this survey has provided DHCF with evaluation tools to help
District residents. us focus on our mission and core values, and prioritize the objectives and
goals we have established for the agency.



Organization of Strategic Plan
The following sections contain the seven strategic goals that DHCF will
focus on over the next three years. The strategic goal statements align
with the priorities established for the agency. Each of the seven strategic
goals provide a clear vision for the future and identifies objectives for
implementation of DHCF’s three-year strategic plan.

I. Improve Health Outcomes
II. Strengthen Program Integrity
III. Implement Health Care Reform
IV. Improve Medicaid Billing with Public Providers
V. Develop and Implement Comprehensive Health Information
Technology (HIT) Plan
VI. Enhance Reporting Capabilities to Improve Outcomes and
Performance Management
VII. Enhance DHCF Infrastructure



STRATEGIC GOAL I: Improve Health Outcomes


n ub Goal A: dentify priority health outcomes for measurement
S I
and improvement.
n ub Goal B: romote and incentivize evidence-based health care
S P
by DHCF providers.
n Sub Goal C: romote continuity of care among DHCF programs.
P
n ub Goal D: reate a culture of illness self-management through-
S C
out the District of Columbia.
n ub Goal E: ncorporate attention to psycho-social determinants
S I
of health among DHCF programs.

DHCF spends more than one and a half billion dollars every year to pro-
vide health insurance to lower-income District residents. DHCF’s health
insurance programs are critical to the health of District residents, because
research has proven that people without health insurance are: sicker than
people who have health insurance; get poorer quality health care when
they do receive it; and have worse health outcomes even when they re-
ceive health care. In addition, research has shown time and time again that
even when people receive health care, they often don’t receive the right

Results “All health care organizations, professional groups, and private and public
purchasers should adopt as their explicit purpose to continually reduce the
burden of illness, injury, and disability, and to improve the health and
functioning of the people of the United States.”
Institute of Medicine. 2001




kind of health care. Poor quality health care Like other leading purchasers of health care, DHCF also is committed to
keeps people from staying healthy, getting bet- using its purchasing dollars not just to pay for health care, but to improve
ter when they are sick, and being healthy in the health outcomes by paying for high quality health care. DHCF aims to do
face of chronic illnesses like diabetes or high this by: 1) measuring the quality of health care provided through its health
blood pressure. Poor quality health care also insurance programs; 2) promoting the provision of evidence–based health
can make people sicker. care; 3) promoting continuity of care across providers; 4) creating a culture
of Illness Self-Management throughout the District of Columbia; and 5)
Because this is so well known, many organiza- incorporating attention to psycho-social determinants of health among
tions that purchase health care for other peo- DHCF programs. These goals, accompanying objectives and strategies to
ple (like the federal government’s Medicare accomplish them are described below.
Ann E. K. Page, RN, MPH program does for the elderly, and private busi-
Director
Health Care Delivery nesses do for their employees) are adopting Sub Goal A: Identify priority health outcomes for measurement and
Management Administration approaches to paying for health insurance that improvement.
promote the delivery of high quality health
A well-known maxim in the field of quality improvement is that “You can’t
care; i.e., care that is:
improve what you can’t measure.” However, as there are thousands of
human illnesses and health care conditions, it is not feasible to measure the
n afe: avoids injuries to patients;
S
quality of health care delivered to every person for each illness and health
n Effective: provides health care services based on scientific
condition they experience. Because of this, DHCF has identified priority
knowledge.
conditions for health care quality measurement and improvement.
n Patient-centered: provides care that is respectful of and responsive
to individual patient preferences, needs, and values, and ensuring
that patient values guide all clinical decisions.
n Timely: reduces waits and sometimes harmful delays for both
those who receive and give care.
n fficient: avoids waste, including waste of equipment, supplies,
E
ideas, and energy. 1
These six characteristics have been embraced nationally as the aims of good quality health care
n Equitable: provides care that does not vary in quality because towards which all involved in health care should focus their efforts. (See IOM. 2001. Crossing the
Quality Chasm. A new health system for the 21st century. National Academy Press. Available online at:
of personal characteristics such as gender, ethnicity, geographic http://www.nap.edu/catalog.php?record_id=10027)
location, and socioeconomic status.1




n bjective 1 – dentify criteria to be utilized in priority-setting
O I n bjective 1 – ecruit top providers to participate in DHCF
O R
including the epidemiological impact on District programs, by:
residents, strength of evidence an associated a) eveloping customized outreach, communica-
D
health outcome can be improved, availability of tion and provider agreements for specific pro-
data source for measurement, and other District vider types.
resources available to leverage in improving the b) trengthening linkages with District provider
S
outcome. regulatory bodies to prevent enrollment of “bad
n bjective 2 – dentify priority health outcomes for the managed
O I apples.”
care and fee-for service populations. Because the c) dentifying gaps in DHCF provider community,
I
demographic profiles and health status and needs including geographic and provider-type gaps.
of these two populations are likely to be different, n bjective 2 – etain high performing providers, by:
O R
targeting of health outcomes for improvement may a) Improving communication mechanisms with

need to be done separately for these populations. existing providers.
n Objective 3 – Leverage technology to accomplish this goal.
b) ncreasing reimbursement rates, in part by
I
decreasing Medicaid expenditures due to fraud,
waste and abuse.
Sub Goal B: Promote and incentivize evidence-based health care by

n bjective 3 – easure the extent to which DHCF providers
O M
DHCF providers.
provide evidence-based health care, by:
Once priority conditions are identified, strategies for health care quality a) eveloping performance measures for the
D
measurement and improvement must be developed and implemented. Health Alliance and fee-for-service programs.
care quality improvement can be incentivized in different ways, including; b) easuring and analyzing claims data for the fee-
M
redesigning health care systems to make high quality care easier to deliver, for-service program.
providing decision-making support to providers and consumers of health c) ncorporate National Committee for Quality
I
care, and aligning payment policies with quality improvement. DHCF will Assurance Health Care Effectiveness Data and
partner with health care providers to develop and implement such strategies. Information Set (HEDIS) measures for the Med-
icaid managed care program.




n Objective 4 – Identify incentives for all provider types, by:
n bjective 1 – mprove accuracy of initial beneficiary contact
O I
a) rioritizing provider types for both positive and
P information by data-matching with the Income
negative incentives. Maintenance Administration, DHCF fiscal agent, and
b) mplementing Health Care Reform requirement
I providers.
to deny claims for hospital-acquired conditions. n bjective 2 – evelop mechanism for continued accuracy of
O D
c) efine “pay-for-performance” provisions in the
R beneficiary contact information utilizing both
managed care contracts. beneficiaries and providers.
d) eploy Nursing Home Quality of Care Fund
D n bjective 3 – mprove communication among providers serving
O I
to provide incentives to nursing homes for the same beneficiary by implementing the Patient
improved health outcomes. Data Hub.
n bjective 4 – evelop strategic plan for long term care to promote
O D
Sub Goal C: Promote continuity of care among DHCF programs. continuity of care across long term care benefits.
n bjective 5 – eform Medicaid policy requiring Alliance managed
O R
Research has found that many errors in health care occur when patients
care mothers to convert to Medicaid Fee-for-Service
are transferred from one health care provider to another or from one part
at delivery.
of a health care system to another. Gaps in care can occur and important
n bjective 6 – xplore health registries as a source of information.
O E
patient information is sometimes lost or not shared. Continuity of care is
the opposite, and a characteristic of good quality health care. All health
care providers and parts of the health care system know about and act on
patient information that helps them prevent gaps in care or errors due to “The American health care system is fragmented and difficult for many
lack of information that is held by another provider. DHCF has identified patients to navigate. . . . It’s easy for important aspects of a patient’s medical
the following ways to improve continuity in care: history or personal care preferences to fall through the cracks. A lack of care
coordination leads to medical errors, higher costs, and unnecessary pain for
patients and their families.”
National Quality Forum, 2011




Sub Goal D: Create a culture of illness self-management throughout
n bjective 4 – evelop performance measures for the utilization
O D
the District of Columbia. of illness self-management programs by benefi-
ciaries.
Illness self-management is defined as an individual’s “ability to manage
n bjective 5 – ncentivize ongoing support of illness self-man-
O I
the symptoms, treatment, physical and psychosocial consequences and
agement programs by managed care organiza-
lifestyle changes inherent in living with a chronic condition” (Barlow et al.,
tions.
2002:178). In general, interventions to support illness self-management
n bjective 6 – ncentivize utilization of illness self-management
O I
include providing information about an illness and its treatment;
programs by both managed care and fee-for-ser-
education and coaching in skills needed to manage the illness, control
vice beneficiaries.
symptoms, and interact with the health care system; and increasing
n bjective 7 – reate a social marketing campaign to promote
O C
patients’ belief in their ability to manage their illness – an essential
illness self-management throughout the District of
ingredient in individuals’ success in managing their illnesses. There is
Columbia.
considerable evidence for many chronic diseases that improving patient
knowledge, skills, and confidence in managing the illness improves their
Sub Goal E: Incorporate attention to psycho-social determinants of
health outcomes (Chodosh et al., 2005). Barlow, J., C. Wright, J. Sheasby, A.
health among DHCF programs.
Turner, and J. Hainsworth. 2002. Self-management approaches for people with
chronic conditions: A review. Patient Education and Counseling 48(2):177–187. “A significant body of research shows that the psychological and social
Chodosh, J., S. C. Morton, W. Mojica, M. Maglione, M. J. Suttorp, L. Hilton, S. stressors—such as depression and other mental health problems, limited
Rhodes, and P. Shekelle. 2005. Meta-analysis: Chronic disease self-management financial and other material resources, and inadequate social support—
programs for older adults. Annals of Internal Medicine 143(6):427–438. are associated with increased morbidity and mortality and decreased
functional status. These effects have been documented both for health
n bjective 1 – dentify existing and develop more illness self-
O I generally and for a variety of individual health conditions and illnesses,
management programs within the District of including heart disease, HIV/AIDS, pregnancy, and cancer. . . Psychosocial
Columbia.
n bjective 2 – evelop a strategy to support current illness self-
O D “All patients with chronic illness make decisions and engage in behaviors
management programs for DHCF beneficiaries. that affect their health (self-management). Disease control and outcomes
n bjective 3 – evelop interactive website that links beneficiaries
O D depend to a significant degree on the effectiveness of self-management.”
to online illness self-management resources. 2006-2011 Improving Chronic Illness Care




health services are psychological and social services and interventions n bjective 1 – onduct an education campaign on the effect of
O C
that enable patients, their families, and health care providers to optimize psycho-social determinants of health and clarify
biomedical health care and to manage the psychological/behavioral DHCF’s role and capabilities in addressing psycho-
and social aspects of illness and its consequences so as to promote social determinants of health.
better health.” Institute of Medicine. 2008. Cancer care for the whole n bjective 2 – onvene providers and stakeholders to identify
O C
patient: Meeting psychosocial health needs. Washington, DC: The National strategies to better address psycho-social risk
Academies Press. factors in medical settings.
n bjective 3 – dentify opportunities to screen beneficiaries for
O I
psycho-social risk factors.
n bjective 4 – evelop interactive website linking web-based
O D
resources for beneficiaries and providers regarding
psycho-social determinants of health.
n bjective 5 – dentify and deploy incentives to providers to get
O I
them to address psycho-social risk factors.
n bjective 6 – evelop performance measures to gauge psycho-
O D
social interventions by providers.



STRATEGIC GOAL II: Strengthen Program Integrity


Improve compliance with DHCF Medicaid rules and regulations internally
and externally.
n ub Goal A: ncrease knowledge-base of DHCF employees and
S I
external stakeholders on federal and state rules and
regulations governing DHCF programs.
n ub Goal B: mprove effectiveness of compliance activities
S I
through successful implementation.
n ub Goal C: nhance documentation to support continued
S E
compliance across all areas of DHCF.
n ub Goal D: mprove oversight of DHCF programs to identify
S I
program integrity concerns and promote continued
compliance.

The Division of Program Integrity is responsible for ensuring that
DHCF employees and stakeholders adhere to District and federal rules,
regulations and procedures governing Medicaid. We find that lack of
knowledge, ineffective/incomplete implementation of policies and
procedures, insufficient documentation and inadequate oversight are
reasons for inefficient operations. Therefore, the overarching focus must

Integrity
be educating DHCF employees and external stakeholders on Medicaid
rules and regulations to improve compliance. In addition, DHCF should
establish an internal self-audit program for DHCF staff and an external self-
auditing program for certain key stakeholders to assess how both DHCF
staff and stakeholders measure on certain key indicators on a regular
basis, in terms of complying with Medicaid rules and regulations. Finally




DHCF should establish an annual report card n bjective 1 – evelop comprehensive training strategies for
O D
with certain key indicators by which the DHCF incoming and current staff that will
Department can measure the progress that incorporate presentations, training curriculum, and
both DHCF and certain stakeholders make in written materials that will be dynamic in nature.
terms of complying with Federal and State n bjective 2 – stablish a multi-disciplinary “Compliance Team”
O E
Medicaid rules and regulations. consisting of DHCF staff that will promote
compliance issues related to program integrity,
Health Insurance Portability and Accountability
Act (HIPAA) and other vulnerable areas.
Karen Shaw, J.D., MPH n bjective 3 – dequately support and resource internal subject-
O A
Program Manager
matter experts through the budget formulation and
Division of Program Integrity
Health Care Operations Administration execution processes to ensure external and internal
training opportunities, publication subscriptions,
Sub Goal A: Increase knowledge-base of DHCF employees and
conference attendance and professional member-
external stakeholders on federal and state rules and ships.
regulations governing DHCF programs. n bjective 4 – ncrease knowledge of public and private providers
O I
regarding federal and state rules and regulations
When DHCF and external stakeholders increase their knowledge of through facilitated training.
federal and District of Columbia Medicaid rules and regulations, this n bjective 5 – onduct annual Contract Officer Technical Repre-
O C
should result in: sentative (COTR) training.

n DHCF staff participating in increased oversight of Medicaid public and
private providers.
“It is critical that individuals furnishing services to the program do not
n DHCF staff working with external stakeholders to educate stake-

engage in fraudulent or abusive practices that degrade Medicaid fiscal
holders on the importance of complying with federal and state
integrity…”
Medicaid rules and regulations.
n HCF staff strategizing with each other in terms of strategizing on
D Comprehensive Medicaid Integrity Plan of the Medicaid Integrity Program,
FY 2006-2010, Center for Medicare Medicaid Services, Center for
various challenges that arise with both DHCF and stakeholders falling
Medicaid State Operations, Medicaid Integrity Group, July 2006.
out of compliance with federal and District rules and regulations.




Sub Goal B: Improve effectiveness of compliance activities through
n bjective 5 – equire bi-annual recertification of Health
O R
successful implementation. Insurance Portability and Accountability Act
(HIPAA) training among DHCF employees.
Our goal is to improve the effectiveness of compliance activities in order to
n bjective 6 – omplete Management Medicaid Information
O C
reduce waste and fraud. It is important that DHCF engages in a continuous
Systems (MMIS) certification process.
self-auditing process on knowledge of new federal and District rules and
n bjective 7 – evelop standard operating procedures from
O D
regulations that impact program areas and daily work, and incorporate
policy to operations for each new policy that is
standards for compliance in performance plans to improve the efficiency
developed.
and effectiveness of what we do. In addition, funding will provide the tools
n bjective 8 – evelop edit review process and remediation
O D
to assist in developing more complex cases that will, in turn, assist law
protocol.
enforcement in addressing fraud and abuse concerns.
n bjective 9 – eview all current external audits and develop
O R
corrective action plans for findings.
n bjective 1 – evelop three year plan for a DHCF self-audit of
O D
n bjective 10 – everage all resources in compliance implemen-
O L
each program to ensure compliance from policy to
tation efforts including external stakeholders
operations, reconciling with federal and state rules
and contractors.
and regulations, including corrective action steps to
n bjective 11 – ncrease the accountability of providers in the
O I
bring the program into compliance.
claims submission process by strengthening the
n bjective 2 – stablish criteria by which program integrity efforts
O E
claims submission process.
are prioritized to consider financial impact, political
impact, and return on investment.
Sub Goal C: Enhance documentation to support continued compli-
n bjective 3 – atch funding and full-time employee resource
O M
ance across all areas of DHCF.
allocation to program integrity priorities in a
clear and transparent fashion during the budget Reviewing current operating protocols will enable us to revise and/or
formulation process. establish new procedures and develop handbooks for each department,
n bjective 4 – ncorporate “compliance” concerns into each
O I which will send the message that adhering to rules and regulations are a
DHCF employee’s individual performance plan by part of doing business.
mandating its inclusion as a SMART goal or individual
development factor, the specifics of which will be
negotiated between employee and supervisor.




n bjective 3 – omplete all audit plans with issue, action,
O C
timeframe, responsible party and status clearly
identified to increase accountability.
n bjective 4 – reate an annual report, for internal distribution
O C
only, on accomplishments, lessons-learned and
active corrective action plans for compliance
concerns. The report should include measurements
of progress and giving credit to outstanding efforts
by DHCF employees.
n bjective 5 – eview provider agreements and revise if necessary
O R
to incorporate “pay for performance” and compliance
matters.

Investigators/Audit Team Picture

“The Fraud control game is dynamic, not static. Fraud control is played
Establishing corrective action plans for internal and external use will send the
against components: opponents who think creatively and adapt continuously
message that DHCF has established a standard for measuring progress or the
and who relish devising complex strategies; this means that a set of fraud
lack thereof. Both internal and external parties will have a written standard that
controls that is perfectly satisfactory today may be of no use at all tomorrow,
sets forth expectations of how the parties can improve their performance.
once the game has progressed a little…”
License to Steal: How Fraud Bleeds America’s Health Care System
n bjective 1 – stablish federal and state regulations employee
O E – Updated Edition, Malcolm K. Sparrow, Westview Press, Boulder, CO, 2000, p.126

handbook for each part of the agency including
standard operating protocol.
n bjective 2 – ormalize all actions in corrective action plans for
O F
internal self-audits and external audits through
new and/or revised policies and procedures, and
standard operating protocol.




Sub Goal D: Improve oversight of DHCF programs to identify

program integrity concerns and promote continued
compliance.
We must have the ability to assess the value of the dollars DHCF spends,
not only with our contractors but subcontractors as well. We will review
contracts, investigate problem providers identified and take proactive
steps to audit sample providers for license and exclusion list exceptions.

n bjective 1 – tilize the “Compliance Team” for spot-checks on
O U
compliance concerns in order to best identify
chronic concerns that should be addressed agency-
wide.
n bjective 2 – nsure COTRs complete annual contract perfor-
O E
mance evaluations.
n bjective 3 – ample audit selected providers and provider
O S
groups for license and exclusions list exceptions,
including data-bumps with external data sources.
n bjective 4 – Reconsider provider recertification process.
O



STRATEGIC GOAL III: Implement Health Care Reform


Maximize opportunities presented by the Patient Protection and
Affordable Care Act of 2010 (ACA), through its various provisions such as
the establishment of a Health Insurance Exchange (HIX), the expanded use
of Health Information Technology (HIT) and Health Information Exchange
(HIE), to expand health care service delivery and improve access so as to
achieve better health outcomes for District residents.

n
Sub Goal A: nsure stakeholder engagement in planning efforts.
E
n ub Goal B: ollaborate effectively with sister agencies and Center
S C
for Consumer and Insurance Information Oversight
(CCIIO) to ensure successful implementation of the
District’s Health Insurance Exchange.
n ub Goal C: se health outcomes to support applications for
S U
funding and waivers/demonstrations focused on
preventive, comprehensive health care and manage-
ment of chronic diseases.
n ub Goal D: ake advantage of incentives for quality improve-
S T
ment and collaborate with providers on ways to

Reform
gain and sustain improved patient outcomes.
n ub Goal E: nsure sustainability of innovations and other
S E
projects implemented using ACA funding.
n ub Goal F: ommunicate effectively from the perspective of all
S C
stakeholders, including health care payers, public
agencies, Ombudsman and lead agencies for ACA
implementation.




DHCF’s Strategic Plan for 2012-2014 Sub Goal A: Ensure stakeholder engagement in planning efforts.
addresses the agency’s role in successfully
Stakeholder engagement is a key component to an inclusive and
implementing health care reform in the
transparent health reform implementation process. The ACA requires States
District of Columbia. Through compliance
to consult with a variety of stakeholders during the planning, establishment
with the ACA, DHCF will maximize
and development of ongoing operations of the HIX. Further, the buy-in of
opportunities to improve the District’s
stakeholders – consumer advocates, patients, employers, small businesses,
service delivery systems and enhance
and providers – is essential to successful program implementation and
access to affordable, quality health care.
long-term sustainability of the current health reform initiatives.
Critical infrastructure considerations for
health care reform implementation include
Jennifer B. Campbell, DrPH, n bjective 1 – ake stakeholders (i.e., small businesses, providers,
O M
the Health Insurance Exchange (HIX) and
MHSA, FACHE Advisory Neighborhood Commissioners) aware of
Director Health Information Technology (HIT). The
Health Care Reform Innovation planning and implementation.
most critical mandates for DHCF include:
Administration n bjective 2 – esign and deploy a webinar for stakeholder
O D
1) expanding health care coverage for all
education and awareness.
District residents; 2) enhancing preventive services and quality of care;
n bjective 3 – ngage and inform District of Columbia Council
O E
and 3) reducing the incidence of fraud and abuse. The agency’s priority is
constituent staff.
to improve health outcomes for District residents by working towards an
n bjective 4 – ngage the Offices of Religious Affairs, Asian Affairs,
O E
integrated system of health care intended to meet the specific needs of
Latino Affairs, African Affairs, Gay, Lesbian, Bisexual
our beneficiaries. Overall, by taking advantage of opportunities presented
and Transgender Affairs, and Office on Aging.
in the ACA, DHCF will ensure that the District continues to be a leader in
providing access to high-quality and innovative health care services.

“Since it’s enactment nearly two years ago, the Affordable Care Act has
already provided a large number of health benefits for District of Columbia
residents.”
Jennifer B. Campbell, DrPH, MHSA, FACHE




Sub Goal B: Collaborate effectively with sister agencies and CCIIO to
Sub Goal C: se health outcomes to support applications for funding
U
ensure successful implementation of the District’s HIX. and waivers/demonstrations focused on preventive,
comprehensive health care and management of chronic
The HIX is an innovative solution to increase access to health care for
diseases.
District residents. The ACA provides for the establishment of an HIX that
will serve as a market place where small businesses, families and individuals Health care data reflecting the District’s unique demographics will drive
can shop for health insurance products. The Exchange would provide policy priorities and efforts to secure resources and funding opportunities
District residents with consumer protections, easily accessible information available through health reform. For example, outcomes data would be
regarding health insurance plans (such as price, benefits coverage, and cost used to support applications for waivers and demonstration projects
sharing), premium tax credits, and consumer assistance services. focused on comprehensive and preventive health care, management of
chronic disease and uniform service delivery.
n bjective 1 – urvey 100% of sister agencies implicated in health
O S
care reform implementation to determine awareness n bjective 1 – ubmit four options/proposals for subsets of DC
O S
of resources and participation in effort. population most in need of excepted eligibility to
n bjective 2 – rovide 100% of sister agencies with executive
O P agency’s Medicaid Director, then HRIC.
briefings summarizing major developments. n bjective 2 – evelop one slide presentation of DC’s top 10
O D
n bjective 3 – ecommend four workgroup sub-committees
O R morbidity and mortality conditions and potential
of sister agency staff to address cross agency savings from timely interventions.
implementation issues. n bjective 3 – easure and publicize data from the Ombudsman
O M
n bjective 4 – ecure CCIIO technical assistance to work with local
O S quarterly.
cross-agency workgroups. n bjective 4 – onduct research of 75% of DC agencies’ research
O C
n bjective 5 – dentify inter-agency work plans for implementa-
O I environmental scan to collect data, tools and
tion and completion. assessments.




Sub Goal D: Take advantage of incentives for quality improvement
n bjective 2 – easure, fund, and report on innovations to CMS
O M
and collaborate with providers on ways to gain and and throughout the government.
sustain improved patient outcomes.
Sub Goal F: ommunicate effectively from the perspective of all
C
The ACA requires all qualified health plans participating in the Exchange to stakeholders, including health care payers, public
have adequate networks of health care providers. Along with this mandate, the agencies, Ombudsman and lead agencies for ACA
law provides funding opportunities for research on provider incentives and rate implementation.
structures that are sufficient to support efforts to expand provider networks.
Communication is the vehicle to ensure District residents and stakeholders
n bjective 1 – evelop grant scanning process to identify new grant
O D are actively engaged and informed about the health reform implementation
funding for comparative effectiveness research. process. DHCF’s goal is to interpret and communicate the various aspects
n Objective 2 – Identify three incentives for providers. of health reform. Meeting this goal will ensure that stakeholders are
informed participants and decision-makers.
Sub Goal E: Ensure sustainability of innovations and other projects

implemented using ACA funding. n bjective 1 – evelop a formal communications plan in
O D
conjunction with the public information officers
Once the health care delivery system is re-tooled, the District will assume of the public partners in ACA planning and
financial responsibility for sustaining the progress made under the implementation.
auspices of the ACA. With such a significant role in financing health care n bjective 2 – onduct regular briefings on progress in ACA
O C
for a large number of District residents, DHCF has a responsibility to ensure implementations and innovations.
sustainability of the innovations developed through health reform. n bjective 3 – reate streaming cable updates, archived and dated.
O C
n Objective 4 – Provide updates on meetings monthly.
n bjective 1 – stablish one cross-agency review group to look
O E
broadly at sustainability opportunities, not just for
ACA but for all IT-related projects.

“Translate Health Care Reform in simple language to
“Sustain the change through innovation…” District residents…”



STRATEGIC GOAL IV: Improve Medicaid Billing with Public Providers

STRATEGIC GOAL IV: Improve Medicaid Billing with

Public Providers

Strengthen the health care system for Medicaid beneficiaries served
through the Public Provider agencies.

n ub Goal A:
S Improve oversight of the public providers.
n ub Goal B:
S Strengthen Medicaid service delivery.
n S
ub Goal C: Maximize Medicaid coverage.
n S
ub Goal D: nhance communication between public providers,
E
stakeholders and DHCF.

DHCF aims to improve key components of health care services provided
by the public providers. The public provider agencies are integral to
the delivery of Medicaid-eligible services for District residents. With an
Department of Mental Health emphasis on service delivery, provider capacity, policies/regulations,
billing and communication, DHCF works in conjunction with the public
provider agencies and stakeholders to improve health outcomes for
Medicaid beneficiaries. It is vital DHCF identifies opportunities to improve
reimbursement procedures of each agency, as well as maximize federal
funding and assure accurate claims processing. The strategic goals and

Partnerships
objectives lay the framework for a stronger partnership with the District’s
public provider agencies to benefit the city’s vulnerable populations.

“Technical support, training and capacity building are utilized as a means
of strengthening our public provider network. These are the building
blocks that will ensure integrated service delivery and improved health
outcomes...”



STRATEGIC GOAL IV: Improve Medicaid Billing with Public Providers

Sub Goal A: Improve oversight of the public providers. n bjective 1 – oordinate annual public provider training on
O C
As the single state agency for the administration of the Medicaid Medicaid-reimbursable services.
program, DHCF is responsible for ensuring that DC government agencies, n bjective 2 – urvey enrolled providers to determine capacity of
O S
which provide Medicaid-covered services, are informed of the rules and provider network.
regulations. DHCF also has the responsibility to monitor and evaluate
the service delivery provided by these public providers. The objectives Sub Goal C: Maximize Medicaid coverage.
presented below will help us to demonstrate improvement in the manner It is important for DHCF to work with public providers on identifying areas
by which the public providers bill, document and most importantly deliver in which coverage is not being fully utilized. Therefore, DHCF plans to work
care to our Medicaid population. with public providers on effectively communicating best practices which
can help them expand the number of services they currently provide. The
n bjective 1 – ssess the needs of each public provider.
O A following objectives were developed to support the need for greater inter-
n bjective 2 – raft and implement policies and procedures related
O D agency collaboration and data mining in order for us to achieve a greater
to public provider oversight. scope of services.
n bjective 3 – onduct quarterly review of billing patterns and
O C
procedure codes. n bjective 1 – stablish inter-agency committee tasked with setting
O E
n bjective 4 – stablish inter-departmental committee to meet on a
O E policies to enforce Medicaid rules and regulations.
monthly basis regarding relevant topics and issues. n bjective 2 – rovide monthly reports to District-wide agencies
O P
n bjective 5 – ntegrate Medicaid rules with the State Plan search
O I on Medicaid service-related data.
function on the DHCF website.

Sub Goal B: Strengthen Medicaid service delivery. “Insightful collaboration with our community partners is necessary in the
In order for public providers to be successful in providing Medicaid- review and assessment of current Medicaid programs. This strategy places
reimbursable services, all providers must have sound knowledge of the emphasis on the review of Medicaid services currently offered, draws from
program and services they are required to provide. Also of importance the experience of our partners, and aids in the development and expansion
is the need of a provider network not only capable of providing these of value-added health coverage…”
services, but also one that is expansive in scope to handle the volume of
recipients. DHCF created the following objectives as a method to identify
gaps in training and network capacity to effectively address systemic
challenges in providing Medicaid service delivery.


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