medicaid medical homes initiatives: promising practices to inform 2703 spas
TRANSCRIPT
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Medicaid Medical Homes Initiatives: Promising Practices to
Inform 2703 SPAs
Mary Takach, MPH, RN Program Director
National Academy for State Health Policy
The Power of Integrated Care: Implementing Health Homes in Medicaid
February 15, 2011
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NASHP Medical Home Projects v 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 Agreement
v Federal HRSA Maternal Child Health Bureau n Coordinating medical home policies between State Title V & Medicaid
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Since 2006, most states have new Medicaid or CHIP medical home initiatives
AK
NH MA
ME
NJ CT
RI
DE
VT
NY
DC MD
NC
PA
VA WV
FL
GA
SC
KY
IN OH
MI
TN
MS AL
MO
IL
IA
MN
WI
LA
AR OK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AZ
NM
ID OR
WA
NV
CA
States with at least one effort that met criteria for analysis
SOURCE: NASHP analysis
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Medicaid medical homes: wide variation
n Several target chronic, complex populations n Several participate in >1 initiative n Several use state plan amendments or
Medicaid waivers: MN & NE recent SPAs n Recognition standards vary
p NCQA, modified NCQA, state-grown n 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
Enrolling populations Minnesota Health
Care Homes v Provider-determined tier
assignment v Five tiers based on the
number of conditions – groups that are chronic, severe, and requiring a care team for optimal management
v Two supplemental complexity factors added n Non-English as primary
language n Significant mental illness
Section 2703 Health Homes
v Two or more chronic conditions; one condition and the risk of developing another; or at least one serious and persistent mental health condition.
v Examples include: § Mental health conditions § Substance abuse disorders § Asthma § Diabetes § Heart disease § Obesity
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Enrolling populations (cont.) North Carolina
v General Medicaid population
v Aged Blind & Disabled population
v Dual eligibles: Medicare 646 demonstration
Section 2703
v No statutory flexibility to exclude dual eligibles from health homes services.
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Provider infrastructure Vermont Advanced
Primary Care Practices v Recognized providers form
internal teams, and v Community Health Teams: 5-member multidisciplinary
teams support providers n Support patients and families n Support practices n Coordinate care & services n Referrals and transitions n Case management n Self-management n Counseling n Population management
Section 2703
v Three distinct types of providers from which a beneficiary may receive services:
1. Designated providers (physician, clinic, etc.)
2. A team of health care professionals linked to a designated provider (virtual, based at practice, or other sites)
3. Health team (section 3502 of ACA)
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Provider standards Maine PCMH
NCQA + 10 Expectations Section 2703
v Culturally effective, patient centered care v Evidence-based clinical guidelines v Preventive & health promotion services v Mental health & substance abuse services v Care management, care coordination, &
transitional care v Chronic disease management, including
self- management v Individual and family supports v Long-term care supports & services v Person-centered care plan v HIT to link services, facilitate
communication, provide practice feedback v Continuous quality improvement program
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v Demonstrated leadership v Team-based approach to care v Population risk stratification and
management v Practice-integrated care
management v Enhanced access to care v Behavioral-physical health
integration v Inclusion of patients & families v Connection to community v Commitment to reducing waste
and increasing efficiency v Integration of HIT
Provider standards (long-term care)
v Referral and Specialty Care Coordination n PCH either: 1. Manages hospital and
nursing facility care; or 2. Demonstrates active
involvement and coordination of care when its patients receive care in these specialized settings
Section 2703
v Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings.
v Transitional care includes appropriate follow-up from inpatient to other setting, including participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care
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Oregon Primary Care Home
Provider standards: behavioral health Pennsylvania Chronic
Care Initiative NCQA PLUS
v Periodic screenings on all patients with chronic conditions using an evidence-based screening tool, such as the PHQ9
v Practices will provide or arrange for appropriate evidence-based behavioral therapy to achieve optimal treatment outcomes.
Section 2703
v Access to a wide range of physical health, mental health and substance use prevention, treatment, and recovery services.
v Examples: n Alcohol/drug screening n Identifying available
mental health and substance abuse services
n Discharge/Care planning n Continuity of Care services
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Payment Methodologies Minnesota Health
Care Homes v Medicaid fee-for-service:
$10.14-$79.05 PMPM payment, varying on patient complexity and other factors
v Multi-payer. State regulated payers and Medicare to adopt payment method “consistent” with Medicaid fee-for-service method.
Section 2703
v Payment methodology must be included in SPA. p Considerable flexibility in the
design. p Expressly permits states to
structure a tiered payment methodology that accounts for the severity of each individual’s chronic conditions and the “capabilities” of the health home.
v ACA permits States to propose alternative models of payment that are not limited to per member per month payments for CMS approval.
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Payment methodologies-state payments to external practice supports
Community Care of North Carolina
v General Medicaid n $3 per member per
month v Aged, Blind, & Disabled
population n $13.72 per member per
month v Dual-Eligibles
n Payment only if there are shared savings after meeting certain thresholds
Vermont Community Health Teams
v Insurers currently share the costs of CHTs equally. v This support allows the services
of a CHT to be offered free of charge to patients and practices, with no co-pay or prior authorization.
v Insurers provide a total of $350,000 per CHT annually. n CHTs serve a general
population of 20,000. Shares paid to a single existing administrative entity in each Hospital Service Area.
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Monitoring requirements Maryland Multi-stakeholder Medical Home Pilot
v Adopted 23 adult and pediatric quality measures, including seven CMS EHR Meaningful Use Core or Alternate Core measures. Outcomes of interest include:
n Decreased acute care utilization n Increased preventive care
utilization n Increased patient and provider
satisfaction
Section 2703
v Outcomes: n Individual-level clinical outcomes n Experience of care outcomes n Quality of care outcomes.
v Avoidable hospital Readmissions v Cost savings from improved
coordination of care and chronic disease management
v HIT use to improve service delivery and coordination across the care continuum
v Emergency room visits v Skilled nursing facility admissions.
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State challenges & opportunities
v Dual eligibles v New boundaries: behavioral health
care and long-term care integration v Time interval to see outcomes v Financial v Retrofitting existing programs
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A State Policymakers’ Guide to Federal Health Reform - Part I: Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states. Through program design, regulations, policies and practices, state decisions and actions already play a profound role in shaping the American health care system. Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates. Part I of this State Policymakers’ Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles. Download the file: Policymakers Guide Part 1 November 2009 •
State Policymakers’ Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHP’s state leadership as their most significant priorities for improving their health systems. As Academy members discussed their priorities, a set of broader themes emerged. These larger policy goals are: Connect People to Needed Services; Promote Coordination and Integration in the Health System; Improve Care for Populations with Complex Needs; Orient the Health System toward Results; Increase Health System Efficiencies. This briefing also provides a more detailed list of states’ priorities presented in four major categories of state health policy: Coverage and Access; Health Systems Improvement; Special Services and Populations; and Long Term and Chronic Care. Download the file: Policymakers' Priorities November 2009 •
Supporting State Policymakers’ Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation. Significant federal and private resources to support state-level implementation will be necessary. Implementation support must be defined and coordinated quickly. Technical assistance must be provided in a manner that corresponds with state needs. State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances, needs, and capacities. Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance. Download the file: Supporting Implementation of Federal Reform November 2009
Will Medicare Join State Multi-Payer Medical Home Initiatives? A Conversation with States Regarding Medicare’s Proposed Advanced Primary Care Demonstration ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children •
RWJF Blog: Preparing for health reform in the states, with Alan Weil
•
Home | •
About NASHP | •
Newsroom | •
E-News signup | •
Employment | •
Contact Us
Search this site: •
Chronic & Long Term Care •
Comprehensive Health Reform •
Coverage & Access •
Health System Improvement •
Specific Services & Populations
•
ABCD Resource Center •
Maximizing Enrollment for Kids •
Medicaid and the DRA •
Patient Safety Toolbox •
State Quality Improvement Partnership Toolbox
•
NASHP Projects & Programs •
NASHP Publications by Category •
NASHP Publications by Date •
NASHP Authors' Publications •
NASHP Publications by Related Topics
•
Preconference Sessions •
Conference Sessions •
Conference Speakers •
Session Speakers
New NASHP Publications •
A State Policymakers’ Guide to Federal Health Reform - Part I: Anticipating How Federal Health Reform will Affect State Roles Many critical aspects of federal health reform will be implemented by the states. Through program design, regulations, policies and practices, state decisions and actions already play a profound role in shaping the American health care system. Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates. Part I of this State Policymakers’ Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles. Download the file: Policymakers Guide Part 1 November 2009 •
State Policymakers’ Priorities for Improving the Health System This State Health Policy Briefing presents the issues identified by NASHP’s state leadership as their most significant priorities for improving their health systems. As Academy members discussed their priorities, a set of broader themes emerged. These larger policy goals are: Connect People to Needed Services; Promote Coordination and Integration in the Health System; Improve Care for Populations with Complex Needs; Orient the Health System toward Results; Increase Health System Efficiencies. This briefing also provides a more detailed list of states’ priorities presented in four major categories of state health policy: Coverage and Access; Health Systems Improvement; Special Services and Populations; and Long Term and Chronic Care. Download the file: Policymakers' Priorities November 2009 •
Supporting State Policymakers’ Implementation of Federal Health Reform States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation. Significant federal and private resources to support state-level implementation will be necessary. Implementation support must be defined and coordinated quickly. Technical assistance must be provided in a manner that corresponds with state needs. State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances, needs, and capacities. Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance. Download the file: Supporting Implementation of Federal Reform November 2009
Will Medicare Join State Multi-Payer Medical Home Initiatives? A Conversation with States Regarding Medicare’s Proposed Advanced Primary Care Demonstration ABCD III Using Data Integration and Information Technology to Improve Care Coordination for Young Children •
RWJF Blog: Preparing for health reform in the states, with Alan Weil
v Please visit: www.nashp.org
v Contact: [email protected]
For More Information on State Medical Home Initiatives: