Session 64 L, Health Home Initiatives. Moderator: Jennifer L. Gerstorff, FSA, MAAA. Presenters: Steve Cline, DDS, MPH Mike Randol, MBA

Transcription

1 Session 64 L, Health Home Initiatives Moderator: Jennifer L. Gerstorff, FSA, MAAA Presenters: Steve Cline, DDS, MPH Mike Randol, MBA

2 2015 SOA Health Meeting 064L: Health Home Initiatives in Medicaid Moderator: Jenny Gerstorff, FSA, MAAA Presenters: Mike Randol, Director of KDHE, Division of Health Care Finance J. Steven Cline, DDS, MPH

3 SOCIETY OF ACTUARIES Antitrust Notice for Meetings Active participation in the Society of Actuaries is an important aspect of membership. However, any Society activity that arguably could be perceived as a restraint of trade exposes the SOA and its members to antitrust risk. Accordingly, meeting participants should refrain from any discussion which may provide the basis for an inference that they agreed to take any action relating to prices, services, production, allocation of markets or any other matter having a market effect. These discussions should be avoided both at official SOA meetings and informal gatherings and activities. In addition, meeting participants should be sensitive to other matters that may raise particular antitrust concern: membership restrictions, codes of ethics or other forms of self-regulation, product standardization or certification. The following are guidelines that should be followed at all SOA meetings, informal gatherings and activities: DON T discuss your own, your firm s, or others prices or fees for service, or anything that might affect prices or fees, such as costs, discounts, terms of sale, or profit margins. DON T stay at a meeting where any such price talk occurs. DON T make public announcements or statements about your own or your firm s prices or fees, or those of competitors, at any SOA meeting or activity. DON T talk about what other entities or their members or employees plan to do in particular geographic or product markets or with particular customers. DON T speak or act on behalf of the SOA or any of its committees unless specifically authorized to do so. DO alert SOA staff or legal counsel about any concerns regarding proposed statements to be made by the association on behalf of a committee or section. DO consult with your own legal counsel or the SOA before raising any matter or making any statement that you think may involve competitively sensitive information. DO be alert to improper activities, and don t participate if you think something is improper. If you have specific questions, seek guidance from your own legal counsel or from the SOA s Executive Director or legal counsel. 2

4 Health Homes in Kansas Mike Randol, Director KDHE, Division of Health Care Finance

5 INTRODUCTION Health Homes are an option which states can choose to provide within their Medicaid programs Authorized in ACA, Section 2703 Intended for people with certain chronic conditions Health Homes can include what has been called a medical home Health Homes do not replace any existing KanCare services.

6 WHY HEALTH HOMES? Enhanced Match States receive a 90% enhanced Federal Medical Assistance Percentage for first eight quarters the program is effective Need in the Population Kansas selected our target population in part, based upon who the data showed to be the most costly to serve while at the same time continuing to display poor health outcomes

7 ELIGIBILITY FOR HEALTH HOMES Must be eligible for Medicaid, and have at least: Two chronic conditions; One chronic condition and is at risk for another chronic condition; or One serious and persistent mental illness

8 FEDERAL CHRONIC CONDITIONS Must be Medicaid eligible not in unmet spend down Mental health conditions Substance use disorder Asthma Diabetes Heart disease Being overweight, as evidenced by a body mass index over 25. Section 1945(h)(2) of the ACA authorizes the Secretary to expand the list of chronic conditions

9 TARGET POPULATIONS IN KANSAS Target population is people with serious mental illness (SMI): Schizophrenia Personality disorders Bipolar and major depression Obsessive-compulsive disorder Post-traumatic stress disorder Psychosis not otherwise specified Delusional disorders SPA approved July Services began August All Health Home members must be in KanCare

10 SIX CORE SERVICES Comprehensive care management Care coordination and health promotion Comprehensive transitional care, including appropriate follow-up, from inpatient to other settings Individual and family support (including authorized representative) Referral to community and social support services, if relevant Use of Health Information Technology (HIT) to link services

11 OTHER STATES To receive federal funding for Health Homes, states must amend their State Medicaid Plans (SPA) 16 states currently have approved Health Homes SPAs 3 states operate them using two State Plan amendments. Remaining states have a single SPA

12 KANCARE HEALTH HOME MODEL ACA allows for three distinct models. In Kansas we chose the team of health professionals model option. A partnership between the managed care organization (MCO) and another entity (Health Home Partner HHP) that is appropriate for the consumer. Model offers flexibility for providing Health Home services within a capitated, fully risked-based managed care delivery system.

13 KANCARE HEALTH HOME MODEL Flexibility critical since Kansas is a largely rural state and familiar community providers are important Health Home recipients likely have experience with, and preferences for, different types of HHPs depending upon where they live and what Medicaid population they belong to

14 PARTNERING TO PROVIDE SERVICES Some Health Home services provided by the MCOs and some by the HHP Some services may be jointly provided by the two Division of services, as well as payment between the MCO and the HHP, will be spelled out in contract between the MCO and HHP

15 SERVICE STRUCTURE Individual and Family Supports Comprehensive care management Referral to community and social supports Health Promotion MCO Member with designated condition HH Partner (HHP) Care Coordination Comprehensive transitional care

16 HEALTH HOMES PROJECT STRUCTURE Interagency team of KDHE and KDADS staff Technical assistance partner Center for Health Care Strategies (CHCS) Project team of state staff, university and actuary partners, with MCO representatives Health Homes Focus Group 70+ stakeholders who provide advice and input

17 IMPLEMENTATION Unlike some states, Kansas did not have a robust PCMH history or an existing culture or framework for Health Homes-type service provision. Stakeholder buy-in and engagement was developed over a two-year period. This was a lesson learned that we found when researching other states experience. Very important! Focus Group Multiple stakeholder, provider and consumer tours and meetings.

18 ENROLLMENT Passive enrollment with opt out feature Enrollee will receive a letter and have some period to choose to opt out Will have a choice of health home provider, but will be required to remain in the health home for some period of time Can change for good cause reasons Grievance and appeal rights

19 Health Homes Today 33,914 KanCare members are eligible for the SMI Health Home (as of April 1) 28,087 members are enrolled in Health Homes (as of April 1) 5,827 people have opted out of Health Homes enrollment, for an opt out rate of 17% There are approximately 80 contracted Health Home Partners across the state

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21 Health Homes Initiatives Society of Actuaries Health Meeting-Session 64L June 15-17, 2015 Atlanta, GA ROI for Health Homes at CCNC right Patient. right Time. right Setting. right Intervention. right Care Team. J. Steven Cline, DDS, MPH Vice President for Strategic Partnerships

22 Presentation Objectives 1) Provide an overview of CCNC to include: Mission and Goals History and Evolution of the organization Clinical Operations 2) Communicate the value of Health Homes as it relates to achieving organizational goals. 21

23 Mission Statement To improve the health and quality of life of all North Carolinians by building and supporting better community-based health care delivery systems. 22

24 Goals Improve the care of the enrolled population while controlling costs Provide a medical home for patients, emphasizing primary care Build community networks capable of managing recipient care Strengthen local systems that improve management of chronic illness in both rural and urban settings 23

25 Lessons Learned We rarely talk about cost. We talk about waste, quality, and safety, and we find our costs go down. Patrick Hagan, former COO, Seattle Children s Hospital

26 Timeline: From a Pilot to Carolina Access to Now 1985 Single County Medical Home Pilot (Wilson Co.) 1989 Expanded to 12 Counties 1992 Carolina Access spreads statewide WHAT NOW? 25

27 to Access II & III 1997 Federal funding approved for Carolina Access II & III County pilot of the first Networks Asthma Initiative 2001 Building on success of Asthma launched Diabetes Initiative 2003 State-wide Expansion And various disease pilots began 26

28 Access II & III to CCNC 2004 NC General Assembly passes legislation to extend program into ABD population Chronic Care Pilot CHF, HTN, COPD, Behavioral Health 2008 Statewide in all 100 Counties Chronic Care 27

29 CCNC Practices Practices: 1,800 Primary care practices 380 OB Practices Practice Type: Independent: 1053 Hospital Owned: 597 Population Served: Independent: 67% of enrollees Hospital owned: 33% of enrollees 28

30 Inside the PCP World Greater care complexity Patients are older and sicker Behavioral Health Disorders Multiple Providers Patients see multiple specialists without effective communication to medical home Patients have multiple prescribers Poor care coordination Fragmented Care Admitted and discharged from hospital without communication to medical home Need effective and timely communication with hospitalists / discharge planners Need to ensure follow-up with PCP and/or specialist & medication reconciliation Information systems do not talk with each other

31 Chronic Disease Prevalence 3 or More Major Co-morbidities 43% 45% Hypertension 24% Diabetes 14% Asthma 14% COPD 13% Ischemic Vascular Disease 12% Neurological Disorders 6% Chronic Kidney Disease 3% Heart Failure 41% Mental Health conditions

32 ED and Inpatient Utilization of ABD Population (over 6 month period) At Least 1 ED Visit At Least 1 Hospitalization 41% 17%

33 CCNC Clinical Initiatives Core Initiatives Chronic Disease Behavioral Health Pediatrics Pregnancy Medical Home QI and Practice Support Transitional Care ED Super Utilizers Complex Care Management Pharmacy Home Medication Management Med Reconciliation Formulary adherence Diabetes Ischemic Vascular Disease Hypertension Asthma/ COPD CHF Depression Chronic Pain Palliative Care Supporting Integration Coordinate care with LME-MCOs Co location BH Provider Network Supporting Primary Care Depression SBIRT Chronic Pain Initiative Asthma Obesity ADHD Antipsychotic Reduction Sickle Cell Foster Child Medical Home Oral Health Pediatric EHR Peds Accountable Care Preterm Birth Prevention Clinical Pathways 17-P Elective Delivery < 39 weeks Primary C- section Risk Screening Postpartum care LARC Pregnancy care management PCMH Accreditation Meaningful Use Quality Data Reporting Chronic disease initiatives Care Gaps Outreach Toolkits Care management 32

34 Clinical Programs Structure Health Informatics Pregnancy Pediatrics Adult Health Chronic Disease Palliative Care Pharmacy Behavioral Health Care Management & Practice Support

35 Key Principles of all Networks Clinical partnership Strong Primary care is foundational to a high performing healthcare system Physician leadership is critical. If expected to improve care - physicians must have ownership of the improvement process Ensure patients receive optimal care and avoid unnecessary utilization Local relationships, local resources, local solutions Improve the quality of care provided and cost will come down

36 Clinical Director Network Director Support Staff OB Physician OB Nurse Coordinator Palliative Care All 14 Network Offices Include Care Managers (Interdisciplinary Care Team) Pharmacy Team Psychiatrist and BH Coordinators

37 CCNC Informatics Center 36

38 1.5 M Recipients all need CM? System Resources Population Needs

39 PCP/ Specialist RIGHT PATIENT RIGHT INTERVENTION Patient Engagement and Activation Condition Self Management Care Coordination with PCP, specialists Medication Therapy Management RIGHT CARE TEAM MEMBER Nurse Case Manager Social Worker Pharmacist Behavioral Health RIGHT SETTING Pharmacy Home Behavioral Hlth Hospital Telephone RIGHT TIMING / PRIORITY

40 Identifying the Right Patients Targeted Approach to population management Analytics team identifies most impactable patient population CCNC Priority Population Methodology: Care Triage Readmission Risk Above expected hospital costs -> PPL ED super utilizers Dual Eligible Priority Behavioral Health Priority Population stratified by clinical risk groups and then by disease severity/control Interventions evaluated based on Number Needed to Treat

41 Priority Patient List...identification of individuals who are incurring preventable hospital costs and are most likely to benefit from care management outreach 40

42 At the Right Time Care Management Model Targets Opportunities in Real Time Transitional Care Priority: Patients with disease profile that benefit most from transitional care Admission Discharge Transfer Feeds: ADT feeds with 56 hospitals identify patients every 8 hours that are in hospital or ED Point of Care Referrals: Physician, Hospital, ED, LME/MCO Synchronize care alerts with medical home visits E.g. diabetics with gaps in care Patients with drug therapy problems

43 In the Right Care Settings Care managers coordinate care with medical home, specialists, hospital Care managers embedded in large practices, hospitals, ERs Pharmacists embedded in hospitals, practices, and community pharmacies 42

44 Provide the Right Care CCNC Care Management Team 600 Complex Care Managers (RN, BSW, MSW) 300 OB Care Managers 300 High Risk Pediatric Care managers 60 Pharmacists Care Management Model Patient engagement through motivational interviewing Assessment, care planning, goal setting based on NCQA framework Interdisciplinary team linked by informatics platform Integration with medical home and other care settings

45 Care Management Interventions for High Risk Patients Medical home linkage Medication Management Patient-centered goal setting and care plan development Health education Self management coaching Motivational interviewing Preparation for provider visits Linkage to community resources 44

46 C. Q. I. Practices STILL need help with Quality Data Evidence-based guidelines How to function as a medical home Meet practices where they are and provide flexible menu of offerings Help physicians with their payer issues and with their most challenging patients 45

47 46

48 CCNC Quality Measures Asthma Appropriate Pharmacological Therapy Cardiovascular Smoking Status and Cessation Advice or Treatment Lipid Testing (IVD) LDL <100 (IVD) BP <140/90 Diabetes A1C Testing A1C >9% A1C <8% LDL-C <100 BP Control < 140/90 Eye Exam Lipid Screening Nephropathy Screening Adult Prevention Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening Pediatrics Annual Dental Visit (ADV) (age 2-21) EPSDT Visit (W15) - Well-child Visits in the First 15 Months of Life EPSDT Visit (W34) - Well-child Visits in the 3-6 Years of Life EPSDT Visit (AWC) - Adolescent Well-Care Visits (age 12-21) BMI (age 3-20) GOAL: CCNC will perform at or above the HEDIS mean. 47

49 Key Performance Indicators GOAL: Maintain or reduce the following rates: 1. Per Member Per Month (PMPM) Medicaid Spend 2. Inpatient Hospitalization 3. Emergency Department Utilization day Readmissions 48

50 Peer-reviewed research Transitional Care 20% reduction in readmissions for patients with multiple chronic conditions in the transitional care program Benefit persists far beyond the first 30 days For every six interventions, one hospital readmission avoided strong ROI

51 Reduction in PMPM Total Spending After Appearing on the PPL List By Above Expected Strata Change in PMPM Costs Overall, difference of $73 PMPM, or 5.7% reduction in total spending relative to control group Above Expected Strata: $6K+ $5-6K $4-5K <$4K Overall

52 Peer-reviewed research Cutting Costs for Highest Risk Recipients Significant savings for 169,667 non-elderly, disabled Medicaid recipients $184 million savings over 5 years Higher per-person savings for patients with multiple chronic conditions. VOLUME 17, NUMBER 3, JUNE 2014

53 CCNC Outperforms Commercial Managed Care on Quality of Chronic Disease Care Cholesterol Control LDL < 100 Diabetes Blood Pressure Control < 140/90 A1C Control < 8.0 >10,000 more North Carolinians with good diabetes control CCNC 2009 Nephropathy Screening CCNC 2012 Cardiovascular Disease Cholesterol Control LDL < 100 Blood Pressure Control < 140/90 Higher is better! 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% National Medicaid HMO HEDIS Mean 2011 >11,000 more North Carolinians with good BP control What does this mean in absolute numbers? 52

54 Questions?