 Costs of Chronic Conditions  Overview of Chronic Health Homes  State Plan Amendment Example: Missouri.

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Transcript  Costs of Chronic Conditions  Overview of Chronic Health Homes  State Plan Amendment Example: Missouri.

Costs of Chronic Conditions
Overview of Chronic Health Homes
State Plan Amendment Example: Missouri
More than 40% of the U.S. Population has one or
more chronic conditions.
39% of the U.S. working - age population in 2007
had at least one chronic condition.
By 2020, the number of people with multiple chronic
conditions is expected to increase to 81 million, up
from 57 million in 2000.
Source: Brody, Jane E. “Tackling care as chronic ailments pile up,” The New York Times, February
21, 2011; Cassil, Alwyn. “Innovations in preventing and managing chronic conditions: What’s
working in the real world?” Center for Studying Health System Change, June 2010.
• Sixteen percent of spending is for 50
percent of the population that has no
chronic conditions.
Percentage of Health Care Total Spending by Number of
Chronic Conditions
• Eighteen percent of spending is for the
22 percent of the population that has
only one chronic condition.
• Seventeen percent of spending is for the
12 percent of the population that has
two chronic conditions.
• Sixteen percent of spending is for the
7 percent of the population that has 3
chronic conditions.
• Twelve percent of spending is for the
4 percent of the population that has 4
chronic conditions.
• Twenty-one percent of spending is for
the 5 percent of the population that has
5 or more chronic conditions.
Source: Medical Expenditure Panel Survey 2006
The Affordable Care Act was passed by Congress and
signed into law by the President in March 2012.
Section 2703 of the Act adds section 1945 to the
Social Security Act to allow states to amend their
Medicaid state plans to provide Health Homes for
enrollees with chronic conditions.
Chronic Health Homes is a new Medicaid State Plan Option
that provides a comprehensive system of care coordination for
Medicaid individuals with chronic conditions.
◦ Health Home providers will coordinate all primary, acute,
behavioral health and long term services and supports to treat the
◦ The integration of primary care and behavioral health services is
critical to achievement of enhanced outcomes.
CMS encourages states to coordinate with existing medical
home projects.
◦ States should compare current programs to the ACA health homes
Medicaid eligible individual having:
At least 2 chronic conditions,
1 chronic condition and be at risk of developing
another, or
At least 1 serious and persistent mental health
The chronic conditions include:
1. mental health condition,
2. substance abuse disorder,
3. asthma,
4. diabetes,
5. heart disease, or
6. being overweight (as evidenced by a BMI of > 25).
*States may add additional chronic conditions with approval from CMS.
States may further limit eligibility criteria, e.g., based on
diagnosis or risk of institutionalization.
States must offer services to all enrollees who meet the
eligibility criteria.
States may not exclude individuals dually eligible for
States can limit the geographic area where the program is
offered to places where the need is greatest, or where
providers are available.
The following health home services are to be provided in a
comprehensive, timely, and high quality fashion:
1. Comprehensive Care Management;
2. Care coordination;
3. Health promotion;
4. Comprehensive transitional care from inpatient to other
5. Individual and family support;
6. Referral to community and social support services; and
7. The use of health information technology to link services.
*States will receive a 90% federal match for these specific services.
CMS specific provider types include:
1. Designated providers, such as physicians, clinical practices, rural health
clinics, community health centers, home health agencies, or any other
2. A team of health care professionals, including physicians, nurse care
coordinator, nutritionist, social worker, behavioral health professional;
which links to a designated provider; or
A health team, defined as an interdisciplinary, inter-professional team;
including medical specialists, nurses, pharmacists, nutritionists, dieticians,
social workers, behavioral health providers, physician’s assistants, etc.
Providers are expected to address functions including but not limited to:
1. Providing quality-driven, cost-effective, culturally appropriate, and personand family-centered health home services;
2. Coordinating and providing access to high-quality health care services
informed by evidence-based guidelines;
3. Coordinating and providing access to mental health and substance abuse
services; and
4. Coordinating and providing access to long-term care supports and 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.
To aid in planning activities aimed at developing and
submitting a State Plan Amendment (SPA), the legislation
originally included funding for state grants of up to $500,000,
but this was not funded. Any planning funds would be
matched at a State’s regular FMAP.
A State could receive for the first 8 quarters 90% FMAP for health
home services provided to individuals with chronic conditions, and
a separate 8 quarters of enhanced FMAP for health home services
provided to another population implemented at a later date.
Additional periods of enhanced FMAP would be for new individuals
served through either a geographic expansion of an existing health
home program, or implementation of a completely separate health
home program designed for individuals with different chronic
States have significant flexibility in how they can
reimburse health homes for these services.
CMS will allow capitated, fee for service, or other
models approved by CMS.
◦ Designated providers of health home services are required to
report quality measures to the State as a condition for receiving
◦ States are required to collect utilization, expenditure, and
quality data for an interim survey and an independent
◦ Survey of States & Interim Report to Congress 2014
◦ Independent Evaluation & Report to Congress 2017
States must:
 Consult and coordinate with the Substance Abuse and
Mental Health Services Administration (SAMHSA);
Collect and report information; and
Participate in CMS’ evaluation and assessment by an
independent organization no later than January 1, 2017.
CMS is available to:
 Provide technical assistance to States interested in
submitting a State plan amendment;
Engage in rapid learning activities to prepare for the
release of well-informed regulations; and
Continue collaborations with Federal partners, to
ensure an evidence-based approach and consistency
in implementing and evaluating the provision.
CMS has provided states resources to aid in the formation of a
State Plan Amendment (SPA).
SPA must address how the proposed approach will assure
access to mental health and substance use prevention,
treatment, and recovery services.
SPA must describe how the state will ensure a whole-health
approach to providing care and how the state will address the
required functions of a health home.
Missouri is the first state to amend its Medicaid state plan to
implement Healthcare Homes.
Missouri will have two types of Healthcare Homes
◦ Primary Care Chronic Healthcare Home
 Federally Qualified Health Centers (FQHC)
 Rural Health Centers (RHC’s)
 Physician practices
◦ Community Mental Health Center Healthcare Home
 CMHCs and CMHC affiliates
Missouri has made significant progress in establishing a Community
Mental Health Center Healthcare Home.
Health Homes: a place where individuals can come
throughout their lifetimes to have their healthcare
needs identified and to receive the medical,
behavioral and related social services and supports
they need, coordinated in a way that recognizes all of
their needs as individuals–not just patients.
Clients eligible for a CMHC Healthcare Home must meet one of the following
three conditions (identified by patient health history):
1. A serious and persistent mental illness,
o Community Psychiatric Rehabilitation (CPR) eligible adults and
kids with Serious Emotional Disorder (SED)
2. A mental health condition and substance use disorder, or
3. A mental health condition and/or substance use disorder and one other
chronic health condition.
Chronic health conditions include:
1. Diabetes,
2. Cardiovascular disease,
3. Chronic obstructive pulmonary disease (COPD),
o asthma, chronic bronchitis, or emphysema
4. Overweight (BMI >25),
5. Tobacco use,
6. Developmental disability.
Part 1: Quarterly
start-up, training
and infrastructure
cost reimbursement
Missouri will reimburse Health Homes for start-up
costs and lost productivity due to collaboration
demands on staff not covered by other streams of
Part 2: Clinical Care
Management permember-per-month
(PMPM) payment
Missouri will pay for reimbursement of the cost of
staff primarily responsible for delivery of services
not covered by other reimbursement (Primary Care
Nurses, Physician Consultants) whose duties are not
otherwise reimbursable by MO HealthNet.
Part 3: Performance Missouri will pay practices for 50% of the value of
Incentive Payment
the reduction in total health care PMPM cost,
including infrastructure & PMPM payments described
herein, for Health Home’s attributed MO HealthNet
Missouri Chronic Care Management rate is $75 PMPM.
◦ Targeted Case Management or waiver service providers will be regularly
included in the overall healthcare team and involved in development and
performance of the person centered plan.
◦ Actual costs of the portion of health home services performed by Targeted
Case Management or waiver service providers will not be included in the
CMHC health home PMPM payment.
Maryland Mental Heath Targeted Case Management rate is $105 per visit.
Maryland MCO medical management rate is $6.31 PMPM (includes outreach,
utilization management, disease management, case management, and quality
In developing a program, Maryland must determine which services are already
covered by MCOs and TCM and which would be new under Chronic Health
Homes because services may not be duplicative.
Have a substantial percentage of its patients enrolled in Medicaid;
Have strong, engaged leadership personally committed to and capable of leading
the practice through the transformation process and sustaining transformed
practice processes as demonstrated by through the application process and
agreement to participate in learning activities.
Meet state requirements for patient empanelment (i.e., each patient receiving
CMHC health home services must be assigned to a physician);
Meet the state’s minimum access requirements as follows: Prior to
implementation of health home service coverage, provide assurance of enhanced
patient access to the health team, including the development of alternatives to
face-to-face visits, such as telephone or email, 24 hours per day 7 days per week;
Actively use MO HealthNet’s comprehensive electronic health record (EHR) to
conduct care coordination and prescription monitoring for Medicaid participants;
Utilize an interoperable patient registry to input annual metabolic screening
results, track and measure care of individuals, automate care reminders, and
produce exception reports for care planning;
Routinely use a behavioral pharmacy management system to determine
problematic prescribing patterns;
Conduct wellness interventions as indicated based on clients’ level of risk;
Complete status reports to document clients’ housing, legal, employment status
education, custody etc.;
Agree to convene regular, ongoing and documented internal Health Home team
meetings to plan and implement goals and objectives of practice transformation;
Agree to participate in CMS and state-required evaluation activities;
Agree to develop required reports describing CMHC Health Home activities,
efforts and progress in implementing Health Home services;
Maintain compliance with all of the terms and conditions as a CMHC Health
Home provider or face termination as a provider of CMHC Health Home
services; and
Present a proposed Health Home delivery model that the state determines to
have a reasonable likelihood of being cost-effective.
Within 3 months of Health Home service implementation, have developed a contract or
MOU with regional hospital(s) or system(s) to ensure a formalized structure for
transitional care planning, to include communication of inpatient admissions of Health
Home participants, as well as maintain a mutual awareness and collaboration to identify
individuals seeking ED services that might benefit from connection with a Health Home
site, and in addition motivate hospital staff to notify the CMHC Primary Care Nurse
Manager or staff of such opportunities. The state will assist in obtaining hospital/Health
Home MOU if needed;
Develop quality improvement plans to address gaps and opportunities for improvement
identified during and after the application process;
Demonstrate continuing development of fundamental medical home functionality at 6
months and 12 months through an assessment process to be applied by the state; Demonstrate significant improvement on clinical indicators specified by and reported to
the state;
Provide a Health Home that demonstrates overall cost effectiveness; and
Meet NCQA level 1 PCMH requirements as determined by a DMH review or submit an
application for NCQA recognition by month 18 from the date at which supplemental
payments commence OR meet equivalent recognition standards approved by the state as
such standards are developed.
Primary Care Physician Consultant – 1hour/enrollee/year
◦ Provides medical leadership.
Healthcare Home Directors – 1 FTE/500 enrollees
◦ Provide leadership in the implementation and coordination of Healthcare Home
◦ Champions practice transformation based on Healthcare Home principles; and
◦ Develops and maintains working relationships with primary and specialty care
providers, including inpatient facilities.
Nurse Care Managers – 1 FTE/250 enrollees
◦ Develop wellness and prevention initiatives, provide trainings, track required
assessments, administrative support, etc.,
Administrative Support – 1 FTE/500 enrollees
◦ Referral tracking, training, data management, reporting, care coordination.
Definition Source
Data Source
Benchmark Goal *
Gap Closing Goal *
Quality Prescribing
Psychiatric Medications% prescriptions flagged
as potentially
inconsistent with quality
Decrease by 5%
All-cause 30-day
readmission rate
NCQA’s most recently
published 50th percentile
regional rate for Medicaid
managed care
Decrease by 10%
Preventable admissions
per 1000 (i.e.,
Ambulatory CareSensitive Conditions
(ACSC) admissions)
NCQA’s most recently
published 50th percentile
regional rate for Medicaid
managed care
Decrease by 10%
ED visits per 1000
Decrease by 10%
% of hospitalized patients
who have clinical,
telephonic or face-toface follow-up interaction
with the care team within
2 days of discharge
during the measurement
Claims & monthly report
NCQA’s most recently
published 50th percentile
regional rate for Medicaid
managed care
Increase by 25%
Health homes mailbox for any questions or comments [email protected]
11/16/10 Health Homes State Medicaid Director Letter
12/23/10 CMCS Informational Bulletin on Web-Based
Submission Process for Health Home SPAs