The document summarizes initiatives by several states to implement patient-centered medical homes (PCMHs) and shared care teams through Medicaid programs. It discusses how states like Alabama, Maine, Vermont, and New York have established networks, teams, or "pods" to provide support to primary care practices in order to help them function as medical homes. These support systems receive per-member-per-month payments from Medicaid and other payers. The document also covers initiatives to implement health homes for high-need patients and use of health information technology.

1. 1
Lessons Learned: The Government
Healthcare Transformation Journey
Craig Rhinehart’s Blog
Insights from NASHP Conference in Atlanta
Trick or Treating for State Healthcare
Innovation Treats
http://craigrhinehart.com

2. The Government Healthcare
Transformation Journey
2
Barbara Wirth, MD MS
Program Manager
National Academy for
State Health Policy

3. The Government Healthcare
Transformation Journey
3
Lyn Hohmann, MD PhD MBA
Medical Director
Island Peer Review
Organization
Department of Health

4. Medical Homes and Shared Resource Teams:
State Initiatives Impacting
Healthcare Delivery
Barbara Wirth, MD, MS
IBM Health and Social Programs Summit
Arlington, VA October 20, 2014

5. 5
NASHP
27-year-old non-profit, non-partisan organization
Offices in Portland, Maine and Washington, D.C.
Academy members
 Peer-selected group of state health policy leaders
 No dues—commitment to identify needs and
guide work
Working together across states, branches and
agencies to advance, accelerate and implement
workable policy solutions that address major
health issues
5

6. Where do we
want to go?
Background Image by Dave Cutler,
Vanderbilt Medical Center
(http://www.mc.vanderbilt.edu/lens/article/?
id=216&pg=999)
6

7. Patient Centered Medical Homes
Key model features:
•Multi-stakeholder
partnerships
•Qualification standards
aligned with new
payments
•Practice teams
•Health Information
Technology
•Data & feedback
•Practice Education
Graphic Source: Ed Wagner. Presentation entitled “The Patient-centered Medical Home: Care
Coordination.” Available at: www.improvingchroniccare.org/downloads/care_coordination.ppt
7

9. PCPCC 2013 9 9

10. 10
Medicaid PCMH Payment Activity
WA
OR
TX
CO
NC
WI
★ ★
LA
PA
NY
IA
VA
NE
OK
AL
MD
MT
ID
KS
MN
NH
ME
AZ
VT
MO
CA
WY
NM
IL
MI
WV
SC
GA
FL
UT
NV
ND
SD
AR
IN
OH
KY
TN
MS
DE
RI
NJ CT
MA
HI
AK
Making medical home payments (30)
Payments based on provider qualification standards (28)
Payments based on provider qualification standards, making payments in a multi-payer initiative (18)
Participating in MAPCP Demonstration (8: ME, MI, ★ MN, NY, NC, PA, RI, VT)
Participating in CPC Initiative (7: AR, CO, NJ, NY, OH, OK, OR)
★
★
★
★
★
★
As of June 2014
SOURCE: National Academy for State Health Policy. “Medical Home and Patient-Centered Care.”
Available at: www.nashp.org/med-home-map.

11. 11
Care Coordination Payments
in Multi-Payer Medical Home Initiatives
State Initiative
Per member per
month range
Adjusted for
Patient
Complexity or
Demographic
Adjusted for
Medical
Home Level
Lump Sum
Payment
Financial
Incentive
Based on
Quality
TOTAL (n=9) $1.20 - $79.05 7 3 2 6
Maine* $6.95 - $7.00 ▲
Maryland $3.51 - $11.54 ▲ ▲ ▲
Massachusetts $2.10 - $7.50 ▲ ▲ ▲
Michigan* $4.50 - $6.50 ▲ ▲
Minnesota $10.14 - $79.05 ▲
North Carolina $2.50 - $5.00 ▲ ▲
Pennsylvania $2.10 - $8.50 ▲ ▲ ▲
Rhode Island $5.00 - $6.00 ▲
Vermont $1.20 - $2.39 ▲
* Michigan: Payments to Provider Organizations; pass-through to practices that employ care coordinators.
Maine: Commercial insurer PMPM rates unavailable.

12. Medical Homes vs. Health Homes
Medical Homes
• Designed for everybody
• Primary care provider-led
• Primary care focus
• No enhanced federal
Medicaid match
2703 Health Homes
• Designed for eligible
individuals with a serious
mental illness and/or specific
chronic physical conditions
• Primary care provider is key,
but not necessarily the lead
• Focus on linking primary care
with behavioral health and
long-term care
• Eight-quarter 90 percent
federal Medicaid match
• Significant increase in
financial support to providers

13. Expanding Medical Home Capacity through
Multi-disciplinary Teams
Key model features:
•Practice teams—often
shared among practices
•Payments to teams and
qualified providers
•Teams are based in a
variety of settings
•Community developed,
teams vary from region to
region
13

14. 14
Whose on the team?
•New or Expanded Roles for:
• Nurses
• Behavioral Health Specialists
• Community Health Workers
• Social Workers
• Peer Specialists
• Pharmacists
• Health Coaches

15. 15
Shared Support Teams
RI
IA
MT
ME
NY
AL
OK
MN
NC
MI
VT
Making Payments to Shared Support Teams
Pursuing similar models through State Innovation Model Grants
MD
ID
IL
PA

16. 16
Shared Community Care Team Michigan
Snapshot
Scope Payer(s) Payment Strategy Core Team Composition
Alabama Maine
Alabama:
Patient Care
Networks of
Alabama
4 networks,
170,000 eligible
patients.
Medicaid (Health
Home SPA)
Networks receive $9.50
PMPM for each Health
Home patient
Must include clinical director or
medical director, clinical
pharmacist, chronic care clinical
champion (nurse), care managers
(nurse or social worker)
Maine:
Community
Care Teams
10 care teams,
130,000 eligible
patients.
Medicaid (Health
Home SPA),
Medicare, private
plans, some self-insured
employers
including state
employees.
Teams receive $129.50
PMPM for Medicaid Health
Homes; $2.95 Medicaid non
Health Home; $2.95 PMPM
for Medicare; $0.30 PMPM
for privately insured.
Must include part-time clinical
leader; team composition based
on each entity’s care
management strategy
Vermont:
Community
Health Teams
14 teams;
514,000 eligible
patients.
Medicaid, Medicare,
private plans, some
self-insured.
Teams receive $350,000 for
5 FTE team; costs divided
proportionately among
payers
Staffing structures are flexible;
most include nurse care
managers, behavioral health
specialists/social workers, health
coaches, panel managers, and
tobacco cessation counselors
New York:
Adirondack
Region Medical
Home Pilot Pods
3 pods,
106,000 eligible
patients.
Medicaid, Medicare,
private plans, some
self-insured employers
including state
employees.
Pods receive $7 PMPM
payment to providers who
contract with pods for
support services. Average
payment to pod
approximately $3.50 PMPM.
No specific staffing requirements;
structures vary across pods.

17. 17
Patient Care Networks of Alabama
• Four new 501(c)(3) organizations
• Support Patient 1st Medicaid providers
• Focus on high risk, high acuity patients
• Providers who partner with networks receive
$1.60 - $2.10 PMPM + $1 PMPM from Patient 1st
• Total PMPM rate for Patient 1st patients in
network areas decreased by 7.7% vs. 0.6% for
the rest of the state, after 1st 6 months
• 3 network areas had a 15% decrease in their ER Use vs. non-network
areas that had a 2 % during same time
(http://medicaid.alabama.gov/news_detail.aspx?ID=6608)

18. 18
Maine Community Care Teams
• Multi-payer support: PMPM varies by payer
• Community care teams based in wide variety
of organizations
• Support providers meeting “NCQA Plus”
including:
• Behavioral health integration
• Population risk-stratification and management
• Team-based care
• Connection to community resources
• Focus on High Costs utilizers aka “Super Utilizers”
• No outcome data available

19. Vermont Blueprint for Health:
Community Health Teams
• Statewide, multi-payer support
• Provider reimbursement tied to NCQA PCMH
recognition and CHTs help practices meet NCQA
PCMH recognition
• CHTs focus on public health helping patients engage in
preventive services and adopt healthier lifestyles
• Specialized care coordinators added to teams to care
for elderly patients and substance abusers added
• 2013 Vermont Annual Report found that people cared
for in PCMH + CHT setting had favorable outcomes vs.
comparison groups including reductions in annual
expenditures, more than offsetting payer investments in
PCMHs and CHTs
19

20. 20
Adirondacks Regional Pods
• Three “pods” in upstate NY supported by a central
entity (Adirondack Health Institute)
• Regional, Multi-payer support
• Workforce shortages was primary reason for
development of PCMH initiative
• Support affiliated practices and smaller independent
practices in region
• PMPM reimbursement passed through by providers
• From 2006 to 2007 the region lost 24 PCPs. Since the
pilot began, primary care has stabilized and grown;
total costs of care has been trending downward for
commercial payers and Medicaid
(http://www.adkmedicalhome.org/wp-content/uploads/2013/10/Dennis-Weaver-
Medical-Home-Summit-Presentation.pdf)

21. 21
Key Takeaways
• Team-based care is a key feature of a medical
home
• Meeting medical home criteria, including team-based
care, is hard work for practices—particularly
small & rural practices
• Shared community-based support teams offer
providers of all types the opportunity to participate
in value-based health care delivery models
• Community-based teams can extend their reach by
leveraging social, public health and other services
• Community based teams provide infrastructure for
ACOs
21

22. 22
For More Information
Please visit:
• www.nashp.org
• www. nashp.org
/med-home-map
• www.nashp.org
/state-accountable-care-• www.statereforum.org
Contact:
bwirth@nashp.org

23. Transforming The Medicaid
Health care system
In New York State
Lyn Karig Hohmann, MD, PhD, MBA (IPRO)
Division of program Management and Development
Office of health Insurance Programs
NYS Department Of Health
23

24. Where We Were:
o In 2010 Medicaid reform was not
on the agenda.
o Program was stuck in neutral,
reform derailed by a harsh
political climate and a deep
recession.
o In 2011, Governor Cuomo
changed the game by creating the
Medicaid Redesign Team (MRT).
o The MRT developed a multi-year
action plan – we are still
implementing that plan today.
24

25. Major MRT Reforms Implemented
 Cost Control: Reduced Medicaid’s annual spending growth rate
from 13% to less than 1%.
 Global Spending Cap: Introduced fiscal discipline to an out of
control government program; focus on transparency with
monthly report on spending.
 Care Management for All: Expanded existing and created new
models of improved primary/coordinated care that will both
improve outcomes and lower costs, moving Medicaid members
from fee-for-service to managed care.
 PCMH and Health Homes: Investments in high-quality primary
care and care coordination through major MRT reforms such as
Patient Centered Medical Homes and the creation of Health
Homes.
25

26. Where We Have Been:
 At its core, MRT was about trying to ensure that the Medicaid
program was financially sustainable.
 After years of out of control cost growth the state budget was no
longer able to afford Medicaid driven budget problems.
 MRT and its approach to cost containment was to launch many
initiatives simultaneously with the goal being to both generate
immediate cost savings while also launching multiple systemic
reforms designed to generate future cost savings.
 To date, the MRT fiscal impact has been staggering – billions of dollars
have been saved.
Fiscal Impact of MRT
26

27. Total Medicaid Spending Over
Time (SFY 03-13)
27

28. NYS Statewide Total Medicaid Spending (CY2003-
2013)
Calendar
Year
2011 MRT
Actions
Implemented
Projected
Spending
Absent
MRT
Initiatives
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
# of
Recipients
4,267,57
3
4,594,66
7
4,733,61
7
4,730,16
7
4,622,78
2
4,657,24
2
4,911,40
8
5,212,44
4
5,398,72
2
5,598,23
7
5,792,56
8
Cost per
Recipient $8,469 $8,472 $8,620 $8,607 $9,113 $9,499 $9,574 $9,443 $9,257 $8,884 $8,504
*Projected Spending Absent MRT Initiatives was derived by using the average annual growth rate
between 2003 and 2010 of 4.28%.
*
Excluded from the 2013 total Medicaid spending estimate is approximately $5 billion in "off-line
spending (DSH, etc.)
28

29. NYS Statewide Total Medicaid Spending per
Recipient
(CY2003-2013)
Calendar
Year
2011 MRT
Actions
Implemented
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
# of
Recipients
4,267,57
3
4,594,66
7
4,733,61
7
4,730,16
7
4,622,78
2
4,657,24
2
4,911,40
8
5,212,44
4
5,398,72
2
5,598,23
7
5,792,56
8
Cost per
Recipient $8,469 $8,472 $8,620 $8,607 $9,113 $9,499 $9,574 $9,443 $9,257 $8,884 $8,504
29

30. MRT: Development of
Health Homes
Care management for high cost, high risk Medicaid
Members
30

31. NYS Medicaid Health HOmes
• New Medicaid program from the ACA
• Care management model that supports coordination of care across medical,
behavioral health and social needs.
• Health Home services include:
comprehensive care management,
health promotion;
transitional care including appropriate follow-up from inpatient to other
settings,
patient and family support,
referral to community and social support services,
use of health information technology to link services.
• New York State's Health Home eligibility definition is as follows:
Two (2) chronic conditions; or
One (1) single qualifying condition (HIV/AIDS or SMI)
• State has specific metrics to measure the impact of Health Homes
31

32. NOTE: Health information technology is a key component
of Health homes!
• New York State has invested heavily in HIT infrastructure through
development of RHIOs with HIEs, partnership with NYeHealth
Collaborative with the SHIN-NY, and support of electronic medical
records within the Patient Centered Medical Home projects.
• Health Homes were required to implement electronic clinical care
management records exchangeable with down stream care
management agencies and to connect with the local RHIO’s HIE for
exchange of medical/clinical information.
BUT:
Connectivity to the NYS DOH through the Health Home portal on
the NYS Health Commerce System was generally by file transfer,
not real time, and not user friendly. The limitations forced policy,
rather than responding to policy.
New York Department of Health needed a connectivity solution to
meet the growing needs of the Health Home Program….
32

33. Building the concept ….
The DOH with its partner agencies - OHITT, OMH, OASAS, AI
and several Health Homes and MCOs - participated in a
series of end-user innovation workshops to develop key
IT concepts and capabilities for the Health Home
program, from which came the Health Homes Analytics
Platform (the Portal).
These Health Home workshops focused on defining use
cases and supporting workflows. The use cases were the
basis for the Health Home system and portal concepts
and capabilities.
33

34. NY Health HHoommeess UUssee CCaasseess
Identification … Assignment … Outreach
…
Consent …
Referral …
Care Planning … Care
Coordination
…
Performance
Mgmt ...
Conceptual
Solution
Architecture
34

35. Building the concept….
The Department decided to build a flexible and scalable architecture
with robust data, analytics, and care management capabilities.
The goal was to deliver a solution which supports interoperability across
systems, users and business functions – allowing for the collection, use
and sharing of information critical to the processing, monitoring, and
coordinated care of the program.
Based on assessment of best in class, the decision was made to built
using Cúram Software on the Medicaid Data Warehouse and linked
with Salient for analytic capability.
Within the portal will be an optional Care Management Lite component,
similar to RHIOs that provide a portal to access EMRs.
90:10 Federal funding has been approved through the APD process.
Initial goal was to use this capability for Health Homes now and other
state care management programs over time.
35

36. Health Homes AAnnaallyyttiiccss PPoorrttaall ((HHHHAAPP))
Conceptual Solution Architecture Capabilities
Health Homes Portal Facility
sync
Medicaid Data Warehouse
Information
Sources
HH-PF
HH-MR HH-CI
Health Homes
Master Records
Health Homes
Care Intelligence
Information
Consumers
Operational
Systems
(e.g., Care
Mgmt
Lite)
• Service Bus HH-IS
• Data Staging / Integration
• Data Quality
• Data Harmonization
• Portal
• Security
• Privacy
• Audit & Logging
• Person Master
• Provider Master
• Relationship Mgmt
• Data Stewardship
• Care Metrics
• Analytics / Reporting
• Predictive Models
• Text Mining
• Claims &
Encounters
• Provider
Sources
(e.g.,
CMART,
Card Swipe)
• Criminal
Justice
• Social
Services
• RHIOs
• DOH
• MCO
• Lead HH
• Downstream
Care Mgmt
Provider
• Clinicians
• Community
• Patient /
Family
• Care • RHIOs
Planning
• Care
Coordin-ation
36
Salient
Analytics

37. 37
Health Home Analytics Portal

38. Then came the NYS Delivery system Reform
Incentive Payment Program (DSRIP)
• DSRIP is the culmination of the MRT action plan.
• DSRIP creates the opportunity to fundamentally restructure delivery to
achieve the system we need while also ensuring its long term sustainability.
• The health care delivery system we have is a direct result of how we purchase
and regulated health care services. DSRIP changes that.
• The NYS Waiver Amendment to the State Partnership plan has been approved
for $ 8 billion to implement changes in the NYS Medicaid delivery system.
• $ 6.42 billion will be used for the DSRIP program
• Other dollars will go to stabilize the safety net system, support
infrastructure development for Health Homes and be investments in long
term care workforce and enhanced behavioral health services.
38

39. NYS DSRIP Program: Key Goals
o Transformation of the health care safety net at both the
system and state level.
o Reducing avoidable hospital use and improve other health
and public health measures at both the system and state
level.
o Ensure delivery system transformation continues beyond the
waiver period through leveraging managed care payment
reform.
o Near term financial support for vital safety net providers at
immediate risk of closure.
39

40. DSRIP Program Principles
Better care, less cost
40

41. NYS DSRIP Plan: Key Components
o Key focus on reducing avoidable hospitalizations by 25% over
five years.
o Statewide initiative open to large public hospital systems and a
wide array of safety-net providers.
o Payments are based on performance on process and outcome
milestones.
o Providers must develop projects based upon a selection of
CMS
approved projects from each of three domains.
o Key theme is collaboration! Communities of eligible providers
are required to work together to develop DSRIP Project Plans.
41

42. DSRIP is Performance based…..
• Performing provider systems need access to information about their
population in order to understand how the system needs to change to meet
these needs.
• Performing provider systems need access to data to monitor how they are
meeting their process and outcome metrics.
• The state needs a robust platform to exchange real time data with the
Performing Provider Systems to ensure they are acting on most current data.
• The state needs a robust platform that will allow them to maximize the
benefits of the robust analytics of the Salient system that we use in
conjunction with the Medicaid Data Warehouse (MDW) and to share these
analytics with the Performing Provider Systems.
• The portal must have the capability for PPSs to enter either directly or through
the SHIN-NY and RHIOs’ HIE platforms.
• The portal must be secure, capable of role restrictions/permissioning, be
flexible and expandable.
42

43. Medicaid Analytics Performance Portal
(MAPP)
• Based on the service capability of the already in process Health
Home Information Portal, the Department of Health in
conjunction with various technology staff and consultants
determined that this portal would be able to provide the service
needs for both Health Homes and DSRIP.
43

44. What is MAPP
o MAPP: Medicaid Analytics Performance Portal
o MAPP supports both Health Homes and DSRIP performance
management technology needs
o MAPP Technology:
o Serve as retail front-end to the Medicaid Data Warehouse for
PPS / Health Home community
o Robust dashboard capabilities provided by Salient
o Online tools available in portal technology to support DSRIP
o Health Homes Business and Care Management Functionality
o Data management and analytics to drive performance
44

45. MAPP High Level Conceptual Diagram
45

46. The DSRIP Vision: Five Years in the Future
How The Pieces Fit Together: MCO, PPS & HH
Role:
-Insurance Risk Management
-Payment Reform
-Hold PPS/Other Providers Accountable
-Data Analysis
-Member Communication
-Out of PPS Network Payments
-Manage Pharmacy Benefit
-Enrollment Assistance
-Utilization Management for Non-PPS Providers
-DISCO and Possibly FIDA/MLTCP Maintains Care
Coordination
Role:
-Care Management for Health Home Eligibles
-Participation in Alternative Payment Systems
Role:
-Be Held Accountable for Patient Outcomes and
Overall
Health Care Cost
-Accept/Distribute Payments
-Share Data
-Provider Performance Data to Plans/State
-Explore Ways to Improve Public Health
-Capable to Accept Bundled and Risk-Based
Payments
*Mainstream, MLTC, FIDA, HARP & DISCO
Supported by
the data and
analytics
capabilities of
MAPP.
46

47. We want to hear from you!
DSRIP e-mail:
dsrip@health.ny.gov
‘Like’ the MRT on
Facebook:
http://www.facebook.com/NewYor
kMRT
Follow the MRT on Twitter:
@NewYorkMRT
Subscribe to our listserv:
http://www.health.ny.gov/health_care/medicaid/redesign/listserv.htm
47

48. Q&A
Craig Rhinehart
Dr. Barbara Wirth
Dr. Lynda Karig Hohmann