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Medicaid Medical Homes Initiatives: Promising Practices to Inform 2703 SPAs


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Medicaid Medical Homes Initiatives: Promising Practices to Inform 2703 SPAs

  1. 1. Medicaid Medical Homes Initiatives: Promising Practices to Inform 2703 SPAs The Power of Integrated Care: Implementing Health Homes in Medicaid February 15, 2011 Mary Takach, MPH, RN Program Director National Academy for State Health Policy 1
  2. 2. NASHP Medical Home Projectsv  The Commonwealth Fund: Advancing Medical Homes in Medicaid n  Round I 2007-2009 (CO, ID, LA, MN, NH, OK, OR, WA) n  Round II 2009-2010 (AL, IA, KS, MD, MT, NE, TX, VA) n  Round III 2011-2012 (RFA released 1/2011)v  Office of the Assistant Secretary for Planning & Evaluation in the US Department HHS n  With RTI, evaluation design for Medicaid State Plan Option for Chronically Ill Health Homes (Section 2703 Affordable Care Act)v  Federal HRSA Bureau of Primary Health Care n  Informing state policymaking as it affects health centers through a National Cooperative Agreementv  Federal HRSA Maternal Child Health Bureau n  Coordinating medical home policies between State Title V & Medicaid 2
  3. 3. Since 2006, most states have new Medicaidor CHIP medical home initiatives WA ME MT ND OR VT ID MN NH MA WI SD MI NY WY RI PA CT IA NV NE NJ UT IN OH IL DE CA CO WV MD VA DC KS MO KY NC TN AZ OK AR SC NM AL GA MS TX LA AK FL HI States with at least one effort that met criteria for analysis SOURCE: NASHP analysis 3
  4. 4. Medicaid medical homes:wide variationn  Several target chronic, complex populationsn  Several participate in >1 initiativen  Several use state plan amendments or Medicaid waivers: MN & NE recent SPAsn  Recognition standards vary p NCQA, modified NCQA, state-grownn  Payment is mainly fee for service plus monthly care coordination fee, often adjusted p Added payment for networks, teams, start-up costs, performance p Plans participate like other payers 4
  5. 5. Enrolling populations Minnesota Health Section 2703 Health Care Homes Homesv  Provider-determined tier v  Two or more chronic assignment conditions; one condition andv  Five tiers based on the the risk of developing number of conditions – another; or at least one groups that are chronic, serious and persistent severe, and requiring a care mental health condition. team for optimal management v  Examples include:v  Two supplemental complexity §  Mental health conditions factors added §  Substance abuse disorders n  Non-English as primary §  Asthma language §  Diabetes n  Significant mental illness §  Heart disease §  Obesity 5
  6. 6. Enrolling populations (cont.) North Carolina Section 2703v  General Medicaid v  No statutory flexibility population to exclude dualv  Aged Blind & Disabled eligibles from health population homes services.v  Dual eligibles: Medicare 646 demonstration 6
  7. 7. Provider infrastructure Vermont AdvancedPrimary Care Practices Section 2703v  Recognized providers form v  Three distinct types of internal teams, and providers from which av  Community Health Teams: beneficiary may receive services: 5-member multidisciplinary teams support providers 1.  Designated providers n  Support patients and families (physician, clinic, etc.) n  Support practices 2.  A team of health care Coordinate care & services n  professionals linked to a n  Referrals and transitions n  Case management designated provider n  Self-management (virtual, based at practice, n  Counseling or other sites) Population management n  3.  Health team (section 3502 of ACA) 7
  8. 8. Provider standards Maine PCMH NCQA + 10 Expectations Section 2703v  Demonstrated leadership v  Culturally effective, patient centered carev  Team-based approach to care v  Evidence-based clinical guidelines v  Preventive & health promotion servicesv  Population risk stratification and management v  Mental health & substance abuse services v  Care management, care coordination, &v  Practice-integrated care transitional care management v  Chronic disease management, includingv  Enhanced access to care self- managementv  Behavioral-physical health v  Individual and family supports integration v  Long-term care supports & servicesv  Inclusion of patients & families v  Person-centered care planv  Connection to community v  HIT to link services, facilitate communication, provide practice feedbackv  Commitment to reducing waste v  Continuous quality improvement program and increasing efficiencyv  Integration of HIT 8
  9. 9. Provider standards (long-term care)Oregon Primary Care Section 2703 Homev  Referral and Specialty v  Coordinate and provide access to comprehensive care Care Coordination management, care n  PCH either: coordination, and transitional 1.  Manages hospital and care across settings. nursing facility care; or v  Transitional care includes appropriate follow-up from 2.  Demonstrates active inpatient to other setting, involvement and including participation in coordination of care when discharge planning and its patients receive care in facilitating transfer from a these specialized settings pediatric to an adult system of health care 9
  10. 10. Provider standards: behavioral healthPennsylvania Chronic Care Initiative Section 2703 NCQA PLUSv  Periodic screenings on all v  Access to a wide range of patients with chronic physical health, mental conditions using an health and substance use evidence-based screening prevention, treatment, and tool, such as the PHQ9 recovery services.v  Practices will provide or v  Examples: arrange for appropriate n  Alcohol/drug screening evidence-based behavioral n  Identifying available therapy to achieve optimal mental health and treatment outcomes. substance abuse services n  Discharge/Care planning n  Continuity of Care services 10
  11. 11. Payment Methodologies Minnesota Health Section 2703 Care Homesv  Medicaid fee-for-service: v  Payment methodology must be $10.14-$79.05 PMPM included in SPA. p  Considerable flexibility in the payment, varying on design. patient complexity and p  Expressly permits states to other factors structure a tiered paymentv  Multi-payer. State methodology that accounts for the regulated payers and severity of each individual’s chronic conditions and the Medicare to adopt payment “capabilities” of the health home. method “consistent” with v  ACA permits States to propose Medicaid fee-for-service alternative models of payment method. that are not limited to per member per month payments for CMS approval. 11
  12. 12. Payment methodologies-state payments to external practice supports Community Care of Vermont Community North Carolina Health Teamsv  General Medicaid v  Insurers currently share the n  $3 per member per costs of CHTs equally. v  This support allows the services month of a CHT to be offered free ofv  Aged, Blind, & Disabled charge to patients and practices, with no co-pay or population prior authorization. n  $13.72 per member per v  Insurers provide a total of month $350,000 per CHT annually.v  Dual-Eligibles n  CHTs serve a general population of 20,000. Shares n  Payment only if there are paid to a single existing shared savings after administrative entity in each meeting certain Hospital Service Area. thresholds 12
  13. 13. Monitoring requirements Maryland Multi-stakeholder Medical Home Pilot Section 2703v Adopted 23 adult and pediatric v  Outcomes: quality measures, including n  Individual-level clinical outcomes seven CMS EHR Meaningful Use n  Experience of care outcomes Core or Alternate Core n  Quality of care outcomes. measures. Outcomes of interest v  Avoidable hospital Readmissions include: v  Cost savings from improved n  Decreased acute care utilization coordination of care and chronic n  Increased preventive care disease management utilization v  HIT use to improve service delivery n  Increased patient and provider and coordination across the care satisfaction continuum v  Emergency room visits v  Skilled nursing facility admissions. 13
  14. 14. State challenges & opportunitiesv Dual eligiblesv New boundaries: behavioral health care and long-term care integrationv Time interval to see outcomesv Financialv Retrofitting existing programs 14
  15. 15. For More Information on State MedicalHome Initiatives: v Please visit: v Contact: 15