medicaid health homes webinar #2 · medicaid health homes webinar #2 tim mcneill, rn, mph. health...
TRANSCRIPT
Medicaid Health HomesWebinar #2
Tim McNeill, RN, MPH
Health Homes in the ACA
Who can be a Health Home provider
Health Home services and hospitals
Conclusion
1
2
3
4 Collaboration Models
What is a Health Home?
3
• A Health Home is a optional Medicaid benefit created
by Section 2703 of the Affordable Care Act
• Person-Centered care coordination model that
integrates primary, acute, behavioral health and LTSS
to treat the whole person
• Health Home is not a physical home
• It is also not synonymous with a Patient-Centered
Medical Home (PCMH)
Are Health Homes and Medical
Homes the same
4
• Health Homes provide care coordination for a target population
• Health Homes do not provide medical management or medical
interventions for the population
• Disease self-management is a key component of Health Home
services
• Medical Homes focus on the implementation of medical
interventions to address the health needs of the population
• Health Homes will provide support for the consumer to comply
with the medical interventions prescribed by the Medical Home
– Transportation
– CDSME
– Social Supports
Do all States Offer Health
Homes?
5
• Health Homes is an optional Medicaid benefit.
• States that wish to participate must submit a State Plan
Amendment (SPA) to establish the Health Homes
benefit in their State
• There ae Twenty (20) approved State Plan
Amendments for Health Homes
• Additional States are in the process of submitting their
SPA to establish Health Homes
– California Assembly Bill 361, authorized California to
submit a Section 2703 application
States with an approved Health
Home amendment
6
Alabama Idaho
Iowa Kansas
Maryland Maine
Michigan Missouri
New Jersey New York
North Carolina Ohio
Oklahoma Rhode Island
South Dakota Vermont
Washington West Virginia
Wisconsin District of Columbia
Matrix of Approved SPAs
7
• The following link will provide a summary matrix of each of
the currently approved State Plan Amendments for Health
Homes.
– https://www.medicaid.gov/state-resource-center/medicaid-state-
technical-assistance/health-homes-technical-
assistance/downloads/hh-spa-at-a-glance-3-19-14.pdf
• The categories in the Matrix are as follows:
– State
– Target Population
– HH Providers
– Enrollment (Opt-In vs Opt-Out)
– Payment
– Geographic area (defined region vs Statewide)
How is the Health Home benefit
paid for
8
• States have great flexibility in how they set up the
reimbursement model for health homes.
• Most of the States and the District of Columbia have
set up Per Member Per Month (PMPM)
reimbursement models
• States receive a 90% enhanced Federal Medical
Assistance Percentage (FMAP) for the first eight
quarters (2 years)
What are Health Home Services
9
• Comprehensive Care Management
• Care Coordination
• Health Promotion
• Care Transitions
• Patient and Family Support
• Referral to community & social support services
Who is eligible for a Health
Home
10
• States have great flexibility in defining the target
population to participate in the Health Home benefit
• A beneficiary must have Medicaid to be eligible to
participate
• General requirements include one or more of the
following criteria:
– Beneficiaries that have two (2) or more chronic conditions
– Beneficiaries with one (1) chronic condition and is at-risk
for second chronic condition
– Have one serious and persistent mental health condition
Are Duals Included
11
• States can not exclude people with both Medicaid and
Medicare from Health Home Services
• If a Dual Eligible, meets the clinical criteria set by the
State, then they are eligible to receive the Health
Home benefit.
• Alignment of financial incentives
– Health Home Services for Duals with chronic depression
• Duals with 2 or more chronic conditions
• Duals in an ACO
• Duals in Bundled Payment
Evaluation Measures
12
Measure
Adult Body Mass Index (BMI) Assessment
Screening for Clinical Depression and Follow-up Plan
Plan All-Cause Readmission Rate
Follow-up After Hospitalization for Mental Illness
Controlling High Blood Pressure
Evaluation Measures (cont.)
13
Measure
Care Transition
Initiation and Engagement of Alcohol and Other Drug
dependence Treatment
Prevention Quality Indicator for Chronic Conditions
Ambulatory Care – Emergency Dept. Visits
Inpatient Utilization
Nursing Facility Utilization
What if we have Medicaid
Managed Care
14
• If a State has implemented Medicaid Managed Care,
beneficiaries that are enrolled with a MCO are eligible to
receive the Health Home benefit
• Beneficiaries receiving LTSS are eligible for Health Home
services
• Duals in a Medicaid MLTSS plan are eligible
• Duals in a Medicaid wavier program are eligible
• Medicaid beneficiaries receiving OAA services are eligible
• Duals receiving OAA services are eligible
Will the State Have Increased
Cost for Health Homes
15
• States will receive a enhanced 90% FMAP for the first
8 quarters of implementation of Health Homes
• The evaluation measures closely monitor expenditures
for the population during the 90% FMAP period
• If evaluation measures are achieved, the State will
receive more in cost savings than the cost of the
program, when it reverts to the standard FMAP
Where are the Savings?
16
• Multiple groups are in search of creating savings under the
transforming healthcare landscape
• Two Medicaid groups have the highest expenditures:
– Dual Eligibles
– Aged, Blind, and Disabled
Reform impacting Duals
17
• Value-Based Payment Reform
– ACOs
– Bundled Payment (BPCI)
– CJR
• Medicaid Managed Care
• MLTSS
• Health Homes
• Duals Demonstrations (high opt-out rates)
• D-SNP/C-SNP/I-SNP plans
• PACE programs
Which Population has the most
chronic disease?
18
• Most chronic conditions were more prevalent for dual-eligible
beneficiaries
– 72% of dual-eligible beneficiaries had two or more conditions
– Dual eligible beneficiaries were 1.7 times as likely to have 6 or more
chronic conditions
– 1.7 times more likely to have COPD
– 1.6 times more likely to have heart failure
– 1.4 times more likely to have diabetes
• 98% of readmissions, in 2010, were for Medicare beneficiaries
with two or more chronic conditions– CMS Chronic Conditions Among Medicare Beneficiaries, Chartbook – 2012 Edition.
Available Online: https://www.cms.gov/research-statistics-data-and-systems/statistics-
trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf
What are the characteristics of
Duals?
19
• According to the CBO, in 2009, there were 9 million
dual eligibles and they cost Federal and State
governments more than $250 billion in healthcare
benefits.
• Medicaid provides health care coverage to low-income
people who meet requirements for income and assets
• All Duals qualify for full Medicare benefits, but they
differ on the Medicaid benefits they qualify for
Duals and Chronic Disease
20
• Full duals are twice as likely as non-dual Medicare
beneficiaries to have at least three chronic conditions
• Duals are nearly three times as likely to have been
diagnosed with a mental illness, including chronic
depression
– Many more have undiagnosed or untreated chronic
depression
• In 2009, total average healthcare spending:
– Nonduals - $8,300 per year
– Full Duals - $33,400 per year
LTSS for Duals
21
• Less than 0.5% of partial duals are institutionalized
• 15% of full duals are institutionalized
• Partial duals often transition to a full dual after
completing the spend down period after a SNF/nursing
home admission.
• Full duals are five times as likely to use LTSS as non-
duals
• Full duals are twice as likely to use LTSS as the non-
dual ABD population
Health Homes and Mental Health
Populations
22
• Many States have targeted their Health Homes efforts to
beneficiaries with a mental illness
– Eligibility requires a mental illness and one other chronic
physical health condition
• What are some of the diagnoses that are included in the
Health Homes Mental Health diagnostic criteria
– Chronic Depression
– Bipolar Disease
– Psychizophrenia
– Schizoaffective Disorder
Experience with populations affected
by Mental Illness?
23
• Many Community-Based Organizations state that they have no
experience working with populations that have mental illnesses
so they could not serve a Health Home population
– Dual Eligible Beneficiaries are more than twice as likely to
have depression
– Persons with two or more chronic conditions are more likely
to have a depression co-morbidity
– Depression is the most common mental health problem
among older adults
– If you are working with Older Adults and persons with
disabilities and/or dual eligibles then you are likely also
working with persons with mental illness
Alignment of Incentives
24
• Goal: Reduce per capita costs
– Readmissions, Inpatient utilization, ER utilization
• MACRA
– Physician Participation in APMs for Medicare beneficiaries
to include Duals
• Hospital Readmissions Penalty
• ACO Shared Savings
• Bundled Payment for Care Improvement (BPCI)
• Comprehensive Joint Replacement (CJR)
• Health Homes
Operationalizing the concept
25
• District of Columbia
– Health Homes started January 1, 2016
– Population must have a Mental Illness and one or more
chronic physical health conditions
– Payment rate based on acuity
• High Acuity $481 PMPM
• Low Acuity $350 PMPM
– Must have Medicaid
– Dual Eligibles are included
Hospital Collaboration Model
26
• Hospital begins screening for depression for admitted patients
with one or more chronic diseases
• Medicaid patients that screen positive for depression are
referred for Health home enrollment
• Care transitions team completes enrollment and provides a 30-
day care transitions intervention
• Consumers are linked with all relevant evidence-based
programs:
– CDSME
– Fall prevention program
– PEARLS
DC Health Home Example
27
• George Washington University Medical Center
– Hospital is closely tracking their readmission rates
– Physicians are participating in the BPCI bundled payment
program
– Dual eligibles and consumers that face social determinants
of health are of particular concern
Goals Align
28
• Case managers are screening consumers with a physical health
condition for social determinants of health and chronic
depression or other SMI
– Focused on Duals and the Medicaid ABD Population
• Consumers hat screen positive are referred to the Health Homes
program
• A care transitions intervention is initiated
• Post transition, the consumers can be referred to community-
based evidence-based programs:
– CDSME
– Fall Prevention
– HCBS
Who is Paying for the Service
29
• Medicaid is the Payer for Health Home services
• GWU is the benefactor by partnering with the community
provider to serve Duals
• Both are incentivized to reduced readmissions, reduce inpatient
admissions, and improve health outcomes for a target
population of Duals
– GWU limits their risk for bundled payment and readmission
penalties for high-risk duals
– CBO receives an ongoing PMPM payment to provide care
coordination to the target population
– Community-Base Organization executes an agreement to expand
Health Home services to all admitted consumers that meet the
criteria.
Are Health Homes coming to my
State?
30
• States that intend to implement Health Homes must submit a
State Plan Amendment to CMS.
• The State Plan amendment is submitted by the Division of
Medicaid
• The Division of Medicaid must obtain stakeholder input
• Notice of submission of the SPA and the content must be made
available to the public
– Generally available on the State Division of Medicaid
website
– Monitor for notices of intent and make sure you attend the
planning meetings
Health Homes are in my State
31
• If you are in a State that has an approved State Plan
Amendment for Health Homes you should:
– Review the State Plan amendment from the Division of
Medicaid
– Read closely to determine the population that the State
included in the benefit
– Analyze the requirements to become an approved Health
Home provider
– Review the list of currently approved Health Home
providers
– Complete a GAP analysis to determine if you can be a
Health Home provider or partner with an existing provider
Key components of the Health Home
provider RFQ?
32
• What types of organizations can provide Health Home
Services?
• What is the application process to become a Health Home
provider?
• What are the staffing requirements to become a health home?
• What are the target populations for health home services?
• Are health homes limited to a defined geographic region in the
State?
What if I am not Eligible to be a
Health Home provider
33
• Identify an eligible population that you are currently serving
• Develop a scope of services you would expand under Health
Homes
• Define the cost to deliver the program
• Develop a pricing plan based on the market rate in comparison
to the Health Home rate
Health Home Collaboration Model
34
• Implement a service delivery model targeted to the population
you serve
• Develop a model to jointly deliver services to the target
population
• Propose a pricing/reimbursement model where costs are
allocated first.
