Transcript Iowa’s Medicaid Program

Iowa’s
Section 2703 Health Home
Development
October 04, 2011
Presentation to:
State Health Policy Conference
Show Me…New Directions in State Health Policy
Westin Crown Center
Kansas City, Missouri
24th Annual
Iowa Department of
Human Services
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Presentation Overview
1. Iowa Health Home Program
2. Other Iowa Medical Home Pilots
3. Lessons Learned
Department of Human Services
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ACA Section 2703 Health Homes
High level Concept:
• Following the 7 principles of a Patient Centered
Medical Home (PCMH) with added flexibility
around the location which care coordination is
provided.
• Focusing on Members with Chronic Conditions
• Starting mid 2012
• Iowa is predominantly a FFS environment with a
mental health managed care carve out
Department of Human Services
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ACA Section 2703 Health Homes
– Limited to practices with at least one of the
following provider types:
• MD/DO
• ARNP
– May include, not limited to entities enrolled as:
•
•
•
•
Physician Clinic
Community Mental Health Centers
Federally Qualified Health Centers
Rural Health Centers
Department of Human Services
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ACA Section 2703 Health Homes
• Certification/Recognition:
• Health Homes will have to meet PCMH standards specified
in IDPH rules. Those rules require NCQA or other national
accreditation.
• Practices may enroll as a health home by:
– Signing an agreement delineating responsibilities of a health
home,
– Completing a TransforMed self-assessment (if not already PCMH
recognized),
– Achieve PCMH recognition within first year of operation.
(providers that have submitted application with first 12 months
and are pending a decision will have an extension)
Department of Human Services
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ACA Section 2703 Health Homes
Payment Methodology
• Fee-For-Service payments (standard)
• Per-member-per-month (PMPM) care
coordination health home payment:
– Targeted only for persons with defined chronic
disease
– PMPM Tiered payment Levels 1 to 4
– Depending on the acuity/risk of the enrollee the
PMPM increases by the tier assignment
Department of Human Services
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ACA Section 2703 Health Homes
Payment Methodology
• Performance payment tied to achievement of
quality/performance benchmarks:
– Annually, starting in year two correlating with
state fiscal year
– Measures align with, meaningful use, national
quality programs, and other payer initiatives
– Providers will track progress of measures through
a tool provided by the State Health Information
Network (HIN)
Department of Human Services
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ACA Section 2703 Health Homes
Eligible Individuals
• Diagnosed with at least one serious and persistent mental
health condition, or;
• Has at least two chronic conditions or ;
• Has one chronic condition and is at risk for a second chronic
condition from the following list of categories:
–
–
–
–
–
–
–
Mental Health Condition
Substance Use Disorder
Asthma
Diabetes
Heart Disease
Obesity (overweight, as evidenced by a BMI over 25)
Hypertension
• Individual opts-in to the program through the engagement of
the provider
Department of Human Services
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Serious and Persistent Mental
Health Condition
• Defined by Iowa as a population with Serious
Mental Illness (SMI) or Serious Emotional
Disturbance (SED)
• The ACA language has emphasis on this group
and so Iowa is working to establish an
Integrated Health Home to provide whole
person, care coordinated services for those
with SMI or SED
Department of Human Services
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Integrated Health Home (IHH)
• An IHH ensures quality management of both
physical and behavioral health care needs
through a partnership of behavioral and
physical health care providers, coordination of
a broad set of services and supports, and
measurable improvement in health outcomes.
• Magellan Health Services is both managing
and providing program level support to IHHs
established in Iowa.
Department of Human Services
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Why Integrate Behavioral Health
and Physical Health Care?
• People with serious mental illness often have
chronic physical health conditions.
• Many people with serious mental illness often
do not receive the preventive or physical health
care services they need.
• Integrating services to treat both can provide
the best outcomes for individuals being served.
• Health care reform encourages integrated care.
Department of Human Services
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IHH – Key Elements
• Co-location of medical services with
behavioral health providers
• Comprehensive care coordination and health
promotion
• Member engagement, peer support and
family support
• Referral to community resources and social
support
Department of Human Services
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Iowa Care Program - History
• IowaCare program operates under an 1115
Waiver and provides a limited set of benefits
to members otherwise uninsured.
• Program started in 2005 with only two
providers in the network.
• Members had to travel great distances to
receive medical care and typically wait months
before being seen by a specialist.
Department of Human Services
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Iowa Care Medical Home Program
• On October 1, 2010, the IowaCare network
expanded to include 2 FQHCs and the
implementation of a Medical Home model for
IowaCare members.
• Upon completion of the expansion in 2012, 6
FQHCs and 2 participating hospitals will
provide medical home services for over
50,000 IowaCare members.
Department of Human Services
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IowaCare Population in 2014
• It is expected that in 2014, most of the IowaCare
population will be full Medicaid Eligible.
• The primary care services this population is
receiving now through the IowaCare Medical
Home program is managing the population before
they enter into full Medicaid Benefits.
• The same IowaCare Medical Home providers will
likely be Health Home providers for the Medicaid
Population.
Department of Human Services
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IowaCare Medical Home Progress
Report
Overall, the IowaCare medical homes are managing patients with
diabetes better than the general Medicaid population. As of
June 30th, 2011:
• 2,580 Patients with Diabetes have been seen in an IowaCare
Medical Home
• 82% of medical home members seeking care have had an A1c
in the last twelve months
• Overall Medicaid population with diabetes is reported that
44% of have had an A1c in the last 12 months
Department of Human Services
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IowaCare Progress Report
• Access has increased for IowaCare
patients in a medical home
• In the first 6 months
– 18,717 same day visits for emergent care
needs through a primary care office
– 49,137 patient encounters occurred at a
primary care office
– Average .91 encounters per member
Department of Human Services
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IowaCare Progress Report
• Non-emergent care wait times vary from medical home
to medical home, using the standard measurement of
the 3rd next available appointment, wait times varies from
1 week to 11 weeks.
• Referral tracking continues to be a problem within the
Medical Home network. Access to referral data has
been challenging.
– Interpretations of HIPPA regulations
– The lack of stable or well established HIT connections between
the medical homes and participating hospitals hinders
communication for referrals, discharges and transfers of care
data
Department of Human Services
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IowaCare - Other Lessons
• More work needs to be done to ready a practice for
an assigned mass of members needing care all on the
same day
• Attention is needed to understand the higher
medical needs of this population before rolling out to
other practices
• Referral protocols and communication lines should
be pre-established and understood
Department of Human Services
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