Home Care Coordination Benefit

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1 Overview of the Medicaid Health Home Care Coordination Benefit June 7, 2011 Alicia D. Smith, MHA Senior Consultant Health Management Associates

2 Poll Question Which of the following most closely describes you? a) Mental health/addiction h/ provider b) Mental health/addiction consumer c) Friend/Family member d) Fed/State/county government employee e) Other 2

3 Discussion Topics About HMA Medicaid dand behavioral health The business case for coordinated care Behavioral health opportunities under the ACA Overview of the Medicaid health home benefit Other benefit design considerations States proposed approaches Participant Questions 3

4 About Health Management Associates Founded in 1985 Independent national research and consulting firm specializing in complex health care program and policy matters 88 staff in 11 cities Lansing, MI Tallahassee Columbus Austin New York City Boston Washington, DC Chicago Indianapolis Sacramento Atlanta 4

5 Why Medicaid programs care about behavioral health? Nationally: Medicaid is the single largest payer for mental health services in the US. Medicaid is the nation s dominant purchaser of antipsychotic medications. By 2014, Medicaid spending is expected to increase annually by 8.3% for mental health services and by 6.2% for substance use disorder (SUD) treatment services. About 12% of Medicaid beneficiaries received mental health or SUD treatment services in 2003, accounting for almost 32% of total Medicaid expenditures. Nearly 27% of all inpatient hospital days paid for by Medicaid in 2003 were for mental health and addiction treatment. t t Beneficiaries with mental illness and SUD are more likely than other Medicaid beneficiaries to have one or more costly co occurring physical health conditions. 5

6 Example: The Ohio Medicaid Business Case for Coordinated Care The Best Practices in Schizophrenia Treatment (BEST) Center of the Northeastern Ohio Universities Colleges of Medicine i and Pharmacy (NEOUCOM) and the Health Foundation of Greater Cincinnati commissioned a study to document the business case for integrated physical and behavioral health care. Findings are available at edu/bestcenter/index php/news/4 9/58/Report shows Medicaid Beneficiaries with mentalillness also likely to have chronic physical problems 6

7 Example: The Ohio Medicaid Business Case for Coordinated Care Ohio s adult Medicaid beneficiaries with SMI: Represent about 10% of total Medicaid beneficiaries and account for 26% of total Medicaid expenditures; Have co occurring chronic physical health conditions at rates higher than adult Medicaid beneficiaries without SMI (heart disease, hypertension, diabetes, chronic respiratory conditions, dental disease); Have more than twice as many hospitalizations for certain ambulatory care sensitive conditions (asthma and diabetes) than non SMI adults; and Have two times higher rates of emergency department visits for asthma than non SMI adults. 7

8 Example: The Ohio Medicaid Business Case for Coordinated Care As a subset of the SMI population, Ohio s adult Medicaid beneficiaries with schizophrenia: Have three times more hospitalizations for uncontrolled diabetes and twice the number of hospitalizations for pneumonia and chest pains compared with non SMI adults; Have twice the number of hospital emergency department visits for hypertension and uncontrolled diabetes than non SMI adults; and Have three times higher costs forskilled nursing facility, prescription drug and home health services than non SMI adults. 8

9 Commonly cited barriers to coordinated care In 2007, HMA developed a report for RWJF on 13 initiatives designed to integrate physical and behavioral health care. Among the barriers to implementation and sustainability were: No payment for care management & consultation services Lack of incentives to share information between providers Lack of an integrated health record Limitations of fee for service payment methodologies 9

10 Behavioral Health Opportunities under the ACA Medicaid emergency psychiatry services Removal of barriers to home and communitybased services Co locating primary care and specialty ilt care in community based mental health settings Health homes for individuals with chronic conditions 10

11 How does the ACA address barriers to integrated care? Providers of health home services can be paid for care management, linkage and coordination Payments provide an incentive to collect, act on and share information Reimbursement does not have to be limited to FFS arrangements 1915(i) offers a broader continuum of services (e.g., other services requested by the state ) State plans can be developed for specific populations 11

12 Defining Health Homes Enumerated in Sec of the Social Security Act Provides states the option to cover care coordination for individuals with chronic conditions through health homes Eligible Medicaid beneficiaries have: Two or more chronic conditions, One condition and the risk of developing another, or At least one serious and persistent mental health condition 12

13 Defining Health Homes Provides 90% FMAP for eight quarters for: Comprehensive care management Care coordination Health promotion Comprehensive transitional care Individual and family support Referral to community and support services Services by designated providers, a team of health care professionals or a health team 13

14 Defining Health Homes Beneficiaries choose the provider, team of health professionals or health team States may apply for matchable planning grants up to $500K Reimbursement may be on a PMPM or alternative basis 14

15 Guidance No immediate CMS plans to issue regulations. Instead guidance is available through: SSA Sec (Sec of the ACA) November 16, 2010 Dear State Medicaid Director letter issued by CMS available at https://www.cms.gov/smdl/downloads/smd10024.pdf Medicaid SPA Pre Print available at https://www.cms.gov/smdl/downloads/smd10024b.pdf Informal feedback from CMS and SAMHSA 15

16 How are health homes different from patient centered medical homes? Serve all populations PCMHs Health Homes Enhanced Medicaid reimbursement is for individuals id with ihapproved chronic conditions Are typically y defined ed as physician led ysca primary care practices, but also mid level practitioners May include primary ycare practices, ces, community mental health centers, federally quality health centers, health home agencies, etc. In existence for multiple payers (e.g., Medicaid, commercial insurance) Currently are a Medicaid only construct 16

17 How are health homes different from patient centered medical homes? PCMHs Focused on the delivery of traditional medical care (referral and lab lbtracking, guideline adherence, electronic prescribing, provider patient communication) cat o Health Homes Strong focus on behavioral health (including substance abuse treatment), social support, other services (nutrition, home health, coordinating activities) Use of IT for traditional care delivery Use of IT for coordination across continuum of care, including in home solutions (in actual patient home, e.g. wireless monitoring) 17

18 Why are states considering CMHCs to serve as health homes? Individuals with behavioral health conditions either under or over use primary care services or are frequently treated in hospital emergency departments Many individuals consider the CMHC as their health home Many CMHCs have historically provided the six health home services 18

19 CMS Expectations of Health Home Services Services provide value for State Medicaid programs Reduce hospital and nursing facility admissions and lower hospital emergency department use Support CMS three areas for improvements (experience of care, health status, reduce costs) Person centered care that improves outcomes Whole person service orientation Client choice 19

20 Considerations for states planning to submit a health home SPA Is the motivation transformation or match grab? On what care management model will health home services be based? On what scale will the implementation occur (i.e., statewide, regional)? What chronic conditions will be addressed? 20

21 Considerations for states planning to submit a health home SPA Which providers should serve as health homes? What measures will be used to track processes and outcomes? What will be the role of managed care organizations? How will illhit be utilized? How will health homes demonstrate the provision of whole person care? How will services be paid? 21

22 Key Implementation Factors Can you do what you say will you will do? Will the approach result in reduced ED use and hospital readmissions? Improved health status? What changes will be necessary in your system? Learning collaboratives or other training on care management Changes in team members and roles Provider contract or certification amendments Formalizing relationships between providers Requiring the use of HIT (e.g., registries, EHRs) 22

23 Developing the SPA SAMHSA consultation Single state Medicaid agency as lead (or hall pass to SMHA) Overview of health home model Areas of consultation Available dates for teleconference Suggested draft SPA documents to CMS Cover letter SPA template Client process narrative Graphic depiction of model from the client s perspective 23

24 Key SPA Sections Geographic area Population criteria Provider infrastructure Service descriptions / HIT Provider standards Assurances Hospital referrals SAMHSA coordination Report evaluation results Monitoring Tracking avoidable aodabe hospitalizations Cost savings Proposal for using HIT Quality measures Clinical outcomes Experience of care Quality of care Evaluations 24

25 States Should Spend Time Addressing Use of HIT Identify sources and uses of existing data (e.g., claims and MCO encounter data) Leverage EHR use Explore connections with statewide HIE initiatives Identify options for HIE between behavioral health and primary care providers (e.g., National TA Center) Quality Measures Clinical outcomes relate to changes in health status Experience of care measures should derive from client surveys Quality of care measures relate to processes of care CMS will assist states in mapping measures to service definitions 25

26 Likely feedback from SAMHSA and CMS From SAMHSA Use of a chronic care model Provider qualifications Health team members Engaging primary care Addressing SUD Capacity for new service users Use of HIT Interim outcome measures Need help (e.g., screening tools, integration models)? From CMS Choice and opt out No age restrictions No exclusion of duals Provider and client notification Leveraging existing services (e.g., TCM, HCBS waiver) Non duplication of payment Mapping quality measures to services Need help (e.g., quality measures, reimbursement)? 26

27 Measures Leverage data already being collected (e.g., NOMS) Claims based ddata for clinical i l outcomes measures Survey data for experience of care Care management and registry data for quality outcomes (suggest limiting record reviews) CMS is aligning i measures across the ACA CMS will provide guidance on a core set of measures states tt can use for health lthhomes 27

28 Reimbursement Methods Case rate PMPM Base rate Tiered by severity Performance incentive Other Considerations Start up costs Training Health team composition Sustainability 28

29 Cost Savings Most savings accrue to physical health Consider how savings can be applied to sustaining health home services Costs may increase for a period before savings estimates achieved Consider a longer tail (e.g., savings or slower rate of increase over 5 years) 29

30 Some Proposed Approaches Missouri State Designated Provider Population Criteria Rhode Island North Carolina Community mental health centers Primary care practices (FQHC, RHC, public hospital clinics) Community mental health organizations Patient centered medical home (initial i i focus) SPMI Mental health + SUD + Asthma, CVD, diabetes, DD, BMI > 25, other high risk SPMI A number of conditions (e.g., CVD, asthma, etc.) 30

31 Benefit Design Considerations What other services should be leveraged to enhance the effectiveness of health home services? 1915(i) home and community based State plan services Enhanced continuum of care (preventive to acute) Pay for a basic package of behavioral health services in primary care settings (e.g., SBIRT) Pay for a basic package of primary care in behavioral health (e.g., diabetes screening) 31

32 Parting thoughts Leadership and buy in is paramount for planning and SPA development Start with iha model dland develop the SPA; not the other way around Ask CMS early and often about confounding ndin issues (i.e., how demonstrate cost savings for duals; narrowing down measures) Start planning and forecasting early! The process takes 3 times longer than time estimates. 32

33 SMHA and Provider Perspective & Participant Questions and Answers 33

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