Transcript Slide 1
Medicaid Medical Home and Care
Management Initiatives
STAKEHOLDER FORUM
September 28, 2011
Presented on behalf of the Nevada
Division of Health Care Financing and Policy
(DHCFP)
Topics for today’s conversation
Background
Medicaid Health Home Option
Recognized Medical Homes
Care Management Organization
Proposed Future Reforms
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BACKGROUND
Background
DHCFP operated a Primary Care Case Management Program (PCCM) model
in the 1980s and 1990s. The program ended in 1997.
DHCFP contracted with a vendor to operate a Disease Management (DM)
program for high cost populations in fee-for-service Medicaid in 2008. The
program ended in 2010.
DHCFP has been exploring options to serve high-cost populations, particularly
those with complex medical and social needs complicated by chronic diseases
and multiple co-morbidities, including a high rate of behavioral health
diagnoses.
Options researched and considered include:
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Patient Centered Medical Home
Administrative Services Organization
Networks and/or Accountable Care Organizations
Background (continued)
A medical home is an enhanced model of primary care in which a team of
health professionals attend to the multifaceted needs of patients and provide
comprehensive and coordinated patient-centered care.
DHCFP conducted a Request for Information (RFI) process regarding a Medical
Home Collaborative in early 2010.
The proposed Nevada Medical Homes Collaborative was designed around a
framework to place individuals into one of three levels of care based on their
current health status:
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Level I – Healthy with minimal medical needs or expenses
Level II – Chronic diagnose(s) that are relatively managed but are at moderate risk for future
hospitalizations and could benefit from some education and preventative services.
Level III – Chronic diagnoses, multiple co-morbidities, behavioral health issues, high hospital
and emergency room utilization, complex medical and social needs and in need of
comprehensive case management
Background (continued)
DHCFP engaged PCG in late 2010 to help Nevada organize its options on how
to most effectively and efficiently provide care for its most chronically ill clients.
PCG concluded that while some opportunities appear to exist with certain
providers, there is limited statewide readiness and unclear support from the
provider community at large.
PCG recommended DHCFP take a dual-pronged “hybrid” approach:
Implement health homes on a pilot basis.
Procure a Care Management Organization to realize savings while a health home program is
established.
A decision unit in the FY12 – FY13 Biennial Budget adds $4.6M in state funds
for cost savings from care management of the Medicaid aged, blind, and
disabled population.
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Based on an estimate of cost savings done as part of the PCG assessment
MEDICAID HEALTH HOME OPTION
Medicaid Health Home Overview
Section 2703 of the Patient Protection and Affordable Care Act (PPACA) adds
section 1945 to the Social Security Act to allow States to elect a “Medicaid
Health Home” option under the Medicaid State plan.
The minimum criteria for eligible individuals include Medicaid clients with:
Two or more chronic conditions,
One condition and the risk of developing another, or
At least one serious and persistent mental health condition.
The chronic conditions listed in PPACA*, include:
A mental health condition,
A substance abuse disorder,
Asthma,
Diabetes,
Heart disease, and
Obesity (a Body Mass Index > 25).
*States may add other chronic conditions with Federal approval from CMS.
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Medicaid Health Home Services
The provision offers States additional Federal support to enhance the
integration and coordination of primary, acute, behavioral health, and long-term
care services and supports for Medicaid enrollees with chronic conditions.
The health home services are defined in PPACA, and include:
Comprehensive care management;
Care coordination and health promotion;
Comprehensive transitional care from inpatient to other settings;
Individual and family support;
Referral to community and social support services; and,
Use of health information technology, as feasible and appropriate.
Increased federal matching percentage for health home services.
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90 percent for the first eight fiscal quarters that a State plan amendment is in effect.
90 percent match does not apply to other Medicaid services a beneficiary may receive.
Medicaid Health Home Quality Reporting
Designated providers of health home services are required to report quality
measures to the State as a condition for receiving payment.
States are required to collect utilization, expenditure, and quality data for an
interim survey and an independent evaluation.
CMS will expect States to report on the core set of quality measures Examples
of key quality metrics may included:
Preventable/ambulatory care-sensitive emergency room visits,;
Ambulatory care-sensitive condition admission;
Follow-Up After Hospitalization for Mental Illness;
Hospital readmissions within 30 days, and
Other established quality measures (e.g. HEDIS, National Quality Forum, National Quality
Measures Clearinghouse,etc.).
Some CMS core measures can be drawn from claims data, but certain
measures in the core set require data extractions from medical records.
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Medicaid Health Home Payment
The Medicaid Health Home option provides States with considerable flexibility
in designing the payment methodology.
Current Health Home from other states (not yet approved by CMS) range
dramatically in terms of per member per month (PMPM) payments. There are
multiple reasons for the variations.
DHCFP envisions medical homes would combine different reimbursement
systems that would include:
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Fee-for service for office visits;
Monthly care coordination fees, and
Performance-based reimbursement.
Review of Medicaid Health Home Option
DHCFP intended to implement a Health Home Pilot Program in January 2012,
where providers in the pilot would meet core standards based on PatientCentered Medical Home (PCMH) accreditation, certification, achievement and
recognition programs from:
National Committee for Quality Assurance (NCQA),
The Joint Commission (formerly the Joint Commission on Accreditation of
Healthcare Organizations),
URAC (formerly known as the Utilization Review Accreditation Commission), or
The Accreditation Association for Ambulatory Health Care (AAAHC).
Discussions with CMS have raised several issues (e.g. potential exclusion of
HCBS waiver clients, limitations in per member per month payment
arrangements) that make the Medicaid Health Home option not a practical
solution for Nevada.
DHCFP will implement a medical home program that incorporates features of
the Medicaid Health Home option, but seek authority from CMS that allows
greater flexibility.
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RECOGNIZED MEDICAL HOMES
Medical Home Recognition & Accreditation Programs
Several organizations have developed or in the process of developing
programs that recognize and/or accredit various health care organizations as
medical homes according to specified sets of standards.
The industry leader in developing an assessment tool has been the National
Committee for Quality Assurance (NCQA), used for the national Multi-Payer
Advanced Primary Care Practice Demonstration.
Each separate “off the shelf” medical home recognition program has its own,
unique set of standards.
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Major PCMH Recognition Programs
Content Emphasis by Scoring Emphasis
CONTENT DOMAINS
Health IT
Presence of Policies
Coordination of Care
Quality Measurement
Patient Engagement & Self Mgt.
Evidence-Based Care
Population Management
Quality Improvement
Culturally Competent Communication
Care Plan
Medical Records
Access to Care
Comprehensiveness of Care
Team-Based Care
Adheres to Current Law
Continuity of Care
Community Resources
Standard Care (non-PCMH)
NCQA
29%
5%
12%
12%
6%
4%
9%
6%
3%
4%
2%
3%
1%
2%
0%
1%
2%
0%
URAC
16%
17%
14%
8%
8%
6%
9%
2%
1%
3%
3%
0%
2%
1%
2%
0%
5%
0%
AAAHC
2%
23%
9%
11%
6%
5%
0.4%
8%
4%
0.4%
10%
1%
8%
0.4%
4%
5%
0.4%
4%
Joint
Commission
6%
13%
7%
4%
7%
2%
2%
4%
13%
4%
2%
4%
7%
11%
4%
7%
0%
2%
SOURCE: Burton, R., Devers, K. and Berenson, R (May 2011) Patient-Centered Medical Home Recognition Tools:
A Comparison of Ten Survey’s Content and Operational Details, The Urban Institute, Washington, DC.
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CARE MANAGEMENT ORGANIZATION
Care Management Organization Rationale
Nevada Medicaid’s FFS population as a whole has high utilization rates.
Particularly high in population of clients with multiple co-morbidities, is beset by numerous
chronic illnesses, and has a high prevalence of mental illness.
Little coordinated care management exists for this FFS population, which, at
least partially, may explain the high utilization of inpatient admissions and
emergency rooms.
PCG’s analysis shows that clinical interventions can achieve savings and
improve quality of care in the near-term.
PCG’s assessment is that the statewide implementation of a medical homes
model would be difficult.
A Care Management Organization (CMO) could achieve near-term
improvements and support future medical homes development.
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Care Management Organization Structures
Nevada experience, like other states, has shown that what seems to work best
in chronic care management to have the PCP’s in the center of the focal point.
Traditional primary care case management (PCCM) programs focus on
delivering basic primary and coordinating access to specialty care. A number of
States have enhanced their PCCM models to provide more intensive care
management for patients with complex needs.
Enhanced PCCM models offer a variety of added features including:
Tailored, evidence-based care management,
Additional provider payments/targeted provider incentives,
Access to health information technology, and
Increased use of performance measures.
Newer models for more holistic, integrated structures are emerging to promote
accountable care that build on medical homes, emphasize evidence-based
practice and facilitate adoption of health information technology.
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Care Management Organization Scope
DHCFP intends to contract with a Care Management Organization (CMO) in
July 2012 to allow for broader implementation of medical homes services with
providers that may need support to integrate the medical, mental health and
social needs of the recipient.
The CMO would provide an essential medical home “infrastructure” that can be
utilized by providers that do not have the resources to build a medical home
capacity. Examples of support provided by the CMO:
Identifying admissions in real-time and providing notification to the health home,
Providing information regarding best practices and continuing education, and
Linking patients to community resources (e.g., Diabetes Self-Management Training, Assertive
Community Treatment).
The CMO will also directly provide specific care management programs for
Medicaid clients without a medical home.
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PROPOSED FUTURE REFORMS
Future Reforms for Medical Homes
DHCFP will seek to expand implementation of medical homes and address
broader payment reforms, such as capitating medical home providers for
medical services, than permitted under the Medicaid Health Home option.
DHCFP will seek an 1115 Research and Demonstration Waiver (1115 Waiver)
which is required to obtain the flexibility to institute cost-effective payment
arrangements with the new medical homes.
Payment reforms, including shared savings arrangements, would be addressed
in the 1115 Waiver submitted to CMS. These cost savings will be tied to
tangible utilizations metrics (e.g., hospitalizations rates for ambulatory care
sensitive conditions, avoidable readmissions, utilization of emergency room for
non-emergent conditions, etc.).
The 1115 Waiver will also seek authority to mandate clients enroll with the Care
Management Organization and/or medical homes for the provision of
evidenced-based, cost-effective delivery of medical services.
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