Medicaid Redesign Proposals

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Transcript Medicaid Redesign Proposals

Supportive Housing Network
September 23, 2011
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NYSDOH submitted two draft SPAs to CMS on June 30, 2011
One SPA targeted the Managed Long Term Care population; the
other targeted the chronic medical/behavioral health population
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The focus of today will be on the SPA targeting the chronic
medical/behavioral health population
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Available on the NYSDOH Health Home Website at:
http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/index.htm
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At least two chronic conditions, one chronic condition and at risk for
another, or one serious and persistent mental health condition.
Chronic conditions include but are not limited to:
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mental health condition
substance abuse disorder
asthma
diabetes
heart disease,
being overweight (BMI over 25)
HIV/AIDS
Hypertension
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Enrollees in the behavioral health category will be identified through claims and
encounter data. They often have co-morbid chronic, medical conditions and unmet
social needs such as a lack of permanent housing
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Enrollees in the chronic medical condition category will be identified through claims
and encounter data as having two or three chronic medical conditions – including
HIV/AIDS.
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The State will use a combination of clinical risk groups (CRG), an algorithm that
predicts hospitalizations, and behavioral health indicators to select Medicaid
enrollees for health homes.
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• Developmental
Disabilities
• Long Term Care
• 209,622 Recipients
• $4509 PMPM
• 52,118 Recipients
• $10,429 PMPM
Total Complex
N=976,356
$2,338 PMPM
32% Dual
51% MMC
$6.5 Billion
50% Dual
10% MMC
$25.9 Billion
$6.3 Billion
16% Dual
61% MMC
• Mental Health and/or
Substance Abuse
• 408,529 Recipients
• $1,370 PMPM
$10.7 Billion
77% Dual
18% MMC
$2.4 Billion
20% Dual
69% MMC
• All Other Chronic
Conditions
• 306,087 Recipients
• $698 PMPM
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“Medical Home” for Patients with Risk Score ≥50
Based on Prior 2-Years of Ambulatory Use
"Medical Home" Status
51%
Loyal
OPD/Satellite
D&TC
MD
Shopper
Occasional User
No PC/Spec/OB
Total
All
NYS
48.9%
25.1%
15.0%
8.8%
18.8%
13.3%
19.0%
100.0%
Number of
PC/Spec/OB
Providers
Touched
2.80
2.97
2.55
2.71
5.39
1.18
0.00
2.54
Source: NYU Wagner School, NYS OHIP, 2009.
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NY will use “designated providers” for the Health Home Program
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Designated providers can be:
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Managed Care Plans
Hospitals
Medical, mental and chemical dependency treatment clinics
Federally Qualified Health Centers (FQHCs)
Targeted Case Management (TCM) programs
Primary care practitioner practices
Patient Centered Medical Homes (PCMHs)
Any other Medicaid enrolled entity that meets NY’s health home requirements
Considering adding other long term care providers
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Section 2703 of the Patient Protection and Affordable Care Act (ACA)
provides states, under the state plan option or through a waiver, the
authority to implement health homes.
• opportunity to address and receive additional federal support for
the enhanced integration and coordination of primary, acute,
behavioral health (mental health and substance use), and longterm services and supports for persons with chronic illness.
• provides 90 percent FMAP rate for health home services for the
first eight fiscal quarters that a health home state plan amendment
is in effect; multiple SPAs permitted.
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NY is seeking applicants that :
◦ have strong medical, behavioral, and social service community providers connections
◦ use multi-disciplinary teams of medical, behavioral , TCM, and social services providers that can
assure appropriate and timely access to services.
Each patient enrollee will be assigned a single care manager who is responsible for
managing and coordinating their care. There will be only one care plan for each patient
enrollee. All members of the health home team will report back to the care manager on
patient status, treatment options, actions taken, and outcomes.
Health homes will be responsible for reducing or eliminating costs associated with avoidable
inpatient and emergency room visits and improving patient outcomes.
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Must be enrolled (or be eligible for enrollment) in the NYS Medicaid program and
agree to comply with all Medicaid program requirements.
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Can either directly provide, or subcontract for the provision of, health home
services. Responsible for all health home program requirements, including services
performed by the subcontractor.
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Care coordination and integration of heath care services will be provided to all health
home enrollees by an interdisciplinary team of providers, where each individual’s care is
under the direction of a dedicated care manager who is accountable for assuring
access to medical and behavioral health care services and community social supports
as defined in the enrollee care management plan.
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Must meet standards for delivery of six core health home services as described in
following slides. Must provide written documentation that clearly demonstrates how
the requirements are being met.
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Health home providers will be required to provide the following health home
services in accordance with federal and State requirements:
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Comprehensive care management
 An individualized patient centered care plan based on a comprehensive health risk assessment – must
meet physical, mental health, chemical dependency and social service needs.
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Care coordination and health promotion
 One care manager will ensure that the care plan is followed by coordinating and arranging for the provision
of services, supporting adherence to treatment recommendations, and monitoring and evaluating the
enrollee’s needs. The health home provider will promote evidence based wellness and prevention by
linking patient enrollees with resources for smoking cessation, diabetes, asthma, hypertension, self-help
recovery resources, and other services based on need and patient preference.
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Comprehensive transitional care
 Prevention of avoidable readmissions to inpatient facilities and oversight of proper and timely follow-up
care.
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Patient and family support
 Individualized care plan must be shared with patient enrollee and family members or other caregivers.
Patient and family preferences are considered.
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Health home providers will be required to provide the following health home
services in accordance with federal and State requirements:
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Referral to community and social support services
 Provider will identify and coordinate community and social supports
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Use of health information technology (HIT) when feasible
 Health home providers will be encouraged to utilize RHIOs or a qualified entity to access
patient data and to develop partnerships that maximize the use of HIT across providers.
Health home provider applicants must submit a plan with their application for achieving
compliance with the final health home HIT requirements within 18 months of program
implementation
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NY will be using quality measures that fall into the following categories:
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Measures collected from claims and encounters
Measures currently collected by managed care plans
Measures per NQF and/or meaningful use measures
New measures that meet federal reporting requirements
Referral to community and social support services
 Provider will identify and coordinate community and social supports
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Use of health information technology (HIT) when feasible
 Health home providers will be encouraged to utilize RHIOs or a qualified entity to access
patient data and to develop partnerships that maximize the use of HIT across providers.
Health home provider applicants must submit a plan with their application for achieving
compliance with the final health home HIT requirements within 18 months of program
implementation
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976,000+ high cost/high need
Medicaid enrollees
(1) Chronic conditions
at risk for a 2nd
chronic condition
(2) Chronic
conditions
(1) Serious &
Persistent Mental
Health Condition
*Medically and Behaviorally
Complex
Yes
Patient Meets
Health Home
Criteria
Non-Compliant with Treatment
Health Literacy Issues
ADL Status
Inability to Navigate Health Care
System
Social Barriers to Care
Assigned a
Health Home
Homelessness
Temporary Housing
Patient
Assessment*
Level I Health Home
Services –
Moderate Need
Level II Health Home
Services – Multiple
Complex Needs
Lack of Family or Support
System Food , Income
Need assistance applying for
Entitlement Programs
Level III Health Home
Services –
Intensive Complex Needs
Periodic Reassessment *
for continuation of Health Home Services
Health Home Services
Not Required
Primary Care
Practitioner
Manages
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Contract with HHs
Medicaid Agency
MCO/
BHO
HH
HH
Recipient
Recipient
Recipient
Recipient
MCO/
BHO
PCMH
CMHC
Other
Recipient
Recipient
Recipient
Recipient
MCO plus provider = HH
Recipient
MCO/BHO/ACO is HH
Recipient
Recipient
Recipient
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The State will use a combination of the following to assign Medicaid enrollees
to Health Homes:
◦ clinical risk groups (CRG),
◦ an algorithm that predicts hospitalizations, and
◦ behavioral health indicators
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Medicaid enrollees will be assigned to a health home, to the extent possible,
based on existing relationships with ambulatory, medical and behavioral health
care providers or health care system relationships, geography, and/or
qualifying condition.
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Initial assignments will be for members who qualify for Health Home services
but currently do not have a meaningful primary care or case management
connection.
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Patients will not be moved from their current TCM/COBRA, CIDP, MATS
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The State will also include any supportive housing services an individual may
have in keeping those connections in health home assignments.
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Once assigned, enrollees will be given the option to choose another provider
when available, or opt out of health home enrollment.
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The State will provide health home providers a roster of assigned enrollees
and current demographic service access information to facilitate outreach and
engagement.
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With the exception of TCMs, where special arrangements may be made,
Medicaid members enrolled with plans will be assigned into Health Homes by
the plan utilizing loyalty and attribution data provided by the state.
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165 LOIs received
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Many comprehensive well thought through networks
Some concerns about specific network adequacy issues
Some LOIs have more comprehensive networks than others
Some overlapping regions and partners
Some smaller less robust entities that should merge
DOH is working with OMH, OASAS and NYCDOHMH to
assess network adequacy and suggest additional
network partners and any appropriate mergers
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Phasing in Health Home Implementation:
 Phase I -13 counties
◦ Applications due November 1
◦ Implementation January, 2012
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Phase II – Counties TBD
◦ Target Implementation April, 2012
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Phase III-Counties TBD
◦ Target Implementation June, 2012
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Bronx
Brooklyn
Nassau
Monroe
Warren
Washington
Essex
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Hamilton
Saratoga
Clinton
Franklin
St. Lawrence
Schenectady
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Finalizing roles of responsibilities for managed care plans
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Targeted Care Management transition
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Timing and counties in phases II and III
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Network adequacy review and feedback
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Final CMS SPA roles (outreach and engagement; quality
measures)
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Rate adequacy feedback (HIV upweights, etc.)
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Housing is one of the key determinants in identifying a
member’s need for care coordination
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Opportunity for the medical community and supportive
housing community to work more collaboratively.
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Some Medicaid members in supportive housing will be
eligible for Health Home services.
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Similar to members in TCM, supportive housing is providing
effective and comprehensive care coordination services.
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More formal arrangements between supportive housing providers
and direct service providers to assure care coordination is tethered
to direct care services.
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Both the supportive housing community and the medical (both
physical and behavioral health) community can work towards
identifying additional resources for housing and increase housing
opportunities
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Members in supportive housing eligible for Health Home services
can be assigned to Health Homes that include their supportive
housing as a partner.
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Improved patient health outcomes
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Reduce inappropriate ED visits
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Reduce avoidable hospital admissions and readmissions
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Achieve a ROI and ultimate cost savings
Increasing the number of publicly insured members will only be
possible if we create a sustainable system
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Speed at which the program is getting launched
◦ Addressing some of that with the phased implementation
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Lack of housing slots
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Effectuating change at the site of service delivery
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Bringing care coordination closer to service delivery
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NYS Health Home Web site (links to many relevant
materials):
http://nyhealth.gov/health_care/medicaid/program/medicaid
_health_homes/index.htm.
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Questions and/or comments regarding New York's
implementation of health homes can be directed to
[email protected]
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