NASHP Learning the ABCs of

APCs and Medical HomesOctober 5, 2010

Foster Gesten, MDNew York State Department of Health

fcg01@health.state.ny.us

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Outline

• NY Background • What are we trying to fix?

– Why didn’t managed care fix it?

• Medical Home Standards and Payments– Wide vs Deep– Going it alone and/or playing in the sandbox

• Trust and anti-trust

• Challenges and Opportunities

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Background: Medicaid

• 5 million members - $47 billion• Most in managed care plans (1115 waiver since 1997)

but complex and expensive populations remain in FFS– 20 health plans– Carve outs (pharmacy, SA, MH for some)

• SCHIP (Child Health Plus) separate program but delivered through health plans

• Medicaid and public and private plans regulated through same organization in state health department

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Enrollment

Enrollment as of December 31st of each yearSource: DOH/OHIP Recipient Summary Fact, Child Health Plus and EPIC4

What are we trying to fix?

• Rightsizing balance of inpatient and outpatient care expenditures

• Excess of preventable admissions (and readmissions)• Years of quality reporting…good, getting better, but

good enough?• Institutional care settings• Primary care standards and the chronic care model –

time to raise the bar• Disparities

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Inpatient Spending Per Enrollee Significantly Exceeds National Averages;

Spending on Ambulatory Care Has Lagged

0

200

400

600

800

1000

1200

Inpatient Physician Dental Outpatient Hospital Lab/Xray

Ave C

ost

per

Eli

gib

le

NY USSource: CMS, 2008 Statistical SupplementTable 13.26

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Despite High Spending, NY Performs Average (or Poorly) on Some Key Quality

Indicators2009 Commonwealth State Scorecard on Health System PerformanceCare Measure National Ranking

Overall 21

Equity 11

Prevention and Treatment 22

Avoidable Hospital Use 50

2009 AHRQ State SnapshotsClinical Area State

Rating Trend

Diabetes Weak Same

Heart Disease Average Slightly Better

Maternal and Child Health Average Getting Worse

Respiratory Disease Weak Getting Worse

77

New YorkFocus on Payer

How Does the Quality of Care for Medicaid Compare to the US?

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New York Medicaid Managed Care vs National Effectiveness of Care Measures NYS Medicaid 2008 National Medicaid 2008 Result

Monitoring Persistent Medications 86.6 82.6

Appropriate Testing - Pharyngitis 80.5 61.4

Breast Cancer Screening 66.8 50.8

Cervical Cancer Screening 73.4 66.0

Childhood Immunization Status 77.4 73.7

Cholesterol Management – LDL-C <100 46.8 40.1

Comprehensive Diabetes Care – Eye Exams

62.0 58.8

Comprehensive Diabetes Care – Good HbA1c Testing

37.9 32.9

Controlling High Blood Pressure 65.0 55.8

Follow-Up After Hospitalization for Mental Illness – 30 days

78.4 61.7

Care for Children w/ ADHD Med. – Continuation

60.7 39.5

Lead Screening 86.4 66.7

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The Executive Budget of 2009-10: Medicaid

• Enabling legislation: Authorized the Department to implement a Statewide initiative to incentivize the development of PCMHs to improve health outcomes through better coordination and integration of patient care– No savings assumed – primary care ‘investments’ from savings

achieved in (overdue) inpatient payment reductions– ~ $66 million growing to $140 million in year 3

• Medical home standards are the National Committee for Quality Assurance’s (NCQA) Physician Practice Connections® -Patient Centered Medical Home™ (PPC®-PCMH™) Recognition Program

• Program implementation- July 1, 2010; Hospital OPD participation still pending CMS approval

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Medicaid Reimbursement For PPC®-PCMH™

• Medicaid providers receive a payment commensurate with their level of NCQA PCMH designation (Level I- $2 pmpm, II - $4pmpm, or III- $6pmpm)– ‘Enhanced’ payment of qualifying claims (primary care E&M

code) for FFS– PMPM from health plans for MMC

• State adds to premium and directs payments to recognized providers for common amounts

• Level I incentive ends 2013• Evaluation• P4P?

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Regional Multi-payer Demonstration• Enabling 2009 legislation (including anti-trust) and

budget (Medicaid)– $3-4 million

• Rural upstate NY• 35 practices (including multi-site FQHC), 5 hospitals,

over 130 providers– Around 100k patients

• 8 payers, including Medicaid and State Employee Plan• NCQA level 2 or 3 in first year….‘plus’• $7pmpm• Medicare application/invitation (MAPCP)

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Challenges/Opportunities• Multi-payer most promising, and most difficult• Alignment with HITEC• ACA

– More business, more imperative– ‘health homes’?

• Beyond the home to the ‘hood’• Journey, not destination• Sustainability

– Interest– Resources– Primary care pipeline

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