The Health Care Authority.  The Health Care Authority (HCA) is a state government agency that purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, the School Employees Benefits Board (SEBB) Program, and other programs.  HCA has undertaken numerous health care transformation projects in pursuit of its stated mission to provide equitable, high-quality health care through innovative health policies and purchasing strategies.

The Multi-Payer Primary Care Transformation Model.  The Multi-Payer Primary Care Transformation Model (Model) is an initiative proposed by HCA in 2020, with the stated purpose to create better health and better care through multi-payer payment reform and care delivery transformation.  Primary care clinics certified as ready would accept a value-based payment, based on the number of enrolled clients served, to replace patient billing systems that incentivize volume of patient services over outcomes and quality.  In exchange, the clinic would agree to provide a range of services falling under the umbrella of whole-person integrated healthcare, report data, and be evaluated under a centralized evaluation and quality measurement system.  The Model has undergone a public comment period and two stakeholder surveys, with the last survey completed in December 2021.

HCA must work with stakeholders to complete development of its Model and begin phasing in value-based payments and accountability requirements for top-tier readiness certification clinics for clients of the Medicaid program, PEBB, and SEBB by January 1, 2023.  The Model must to the extent practicable be designed to achieve cost neutrality when fully phased in for participating clinics.  The Model must include the following components:

• a coordinated service payment that removes incentive to bill for a high volume of services;
• coordination of payer functions, such as standardized and centralized contracting, compliance standards, and performance evaluation;
• standardization of accountability for the standard of care and practice capability expectations, which must include, but not be limited to, use of behavioral health screening tools annually with documented follow-up protocols and access to team-based care strategies including patient support services provided by health navigators;
• a transformation fee to support practices building capacity to satisfy provider accountabilities; and
• increased increments of payment for value based on performance across several quality measures. 

Medicaid managed care organizations must make reimbursement for care coordination services performed by non-licensed staff acting in the role of a health navigator available to primary care clinics by January 1, 2023, excluding clinics that have fully transitioned to the Model, using funding provided for Medicaid administrative services.

HCA must report to the Governor and appropriate committees of the Legislature by December 1, 2023, describing the Model, its progress with implementation, and a strategy and timeline to complete implementation in primary care clinics across the state.

A health navigator is defined as an unlicensed member of a health care team who helps individuals overcome barriers and facilitates access to services by increasing health knowledge and self-sufficiency through a range of evidence-based activities, and who is typically a trusted member of the community with an unusually close understanding of the community served.

The Department of Health must contract with an organization that represents pediatric primary care needs to convene community-based organizations dedicated to children's mental health to establish and implement an equity-focused curriculum to prepare health navigators to meet the unique needs of children, adolescents, and their families by January 1, 2023.