The Affordable Care Act and Coordinated Care in IL. IL Partners April 2012 Karen Batia, PhD.

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1 The Affordable Care Act and Coordinated Care in IL IL Partners April 2012 Karen Batia, PhD.

2 Affordable Care Act Passed in March of 2010 Requires people to have insurance individual mandate Can t be denied coverage due to pre-existing conditions Young adults can stay on their parents insurance until 26 Must cover certain prevention-related services No lifetime limits on coverage

3 Affordable Care Act Medicaid is expanded to everyone at or under 138% of the Federal Poverty Line in ,000 newly eligible in Illinois (2014) 2,322,500 in Medicaid (FY 2008) Health Home Option New opportunity to pay for coordinated care A combination of medical home models, e.g. Patient Centered Medical Home (PCMH), Disease Management (DM), Primary Care Case Management (PCCM) and case management/social services models Care coordination fees are matched at 90% FFP for 8 quarters. Target population must have 2 chronic conditions (diabetes, cardiovascular disease, obesity as example) or only severe mental illness Must be eligible for Medicaid Prevention expansion incentive in 2013

4 Planning for 2014 CMS is providing new tools to manage care for people with chronic conditions, e.g. Health Home Option. States can still use current care coordination methods, e.g. capitated managed care; Patient Centered Medical Homes; and Disease Management. CMS is encouraging the development of Accountable Care Organizations (ACOs) to achieve the Three Aims: Improved population outcomes Improved individual health Reduced cost

5 Heartland Alliance Organization Overview

6 HHO serves: At most 15,000 people in the greater Chicago area People experiencing homelessness, HIV/AIDS, and multiple illnesses 26% of people served currently receive Medicaid Almost all of Heartland s participants will be eligible for Medicaid in 2014 On average, HHO s participants have three physical health issues and often a mental health and substance use issue

7 HHO Provides: Primary Care Services Oral Health Services Mental Health and Psychiatric Services Substance Use Treatment Continuum of Supportive Housing Onsite Chiropractic Care HIV Prevention Services and Specialty Care Grocery and Nutrition Centers Referral to Specialty Care Cross-Cultural Interpreting and Translation Services Health Promotion and Wellness Services Street Outreach, Linkage to Housing and offers services

8 For People Experiencing Homelessness ~ Upwards of 70% have no insurance Due to limited resources and lack of insurance health care typically is sought only in emergencies (22% of people located in 100,000 homes campaign reported emergency room use 3 or more times in last year) Life expectancy is 20 years less than the average American; those with SMI 25 years less More likely to have multiple, uncontrolled chronic medical conditions particularly problematic when medication is needed

9 State of IL Context Implementation of Medicaid reform law Requires 50% Medicaid recipients in risk-based Care Coordination by 2015 State issued Coordinated Care Key Policy Issues paper June 2011; received 76 responses ACA offers CMS initiatives Health Home Option Financial Incentives to Integrate Duals (Medicare + Medicaid)

10 The IL Innovations Project State of IL Goal ~ A redesigned health care delivery system that is more patient-centered, with a focus on improved health outcomes, enhanced patient access, and patient safety To Achieve This Goal, the State Must: Engage community partners in promoting coordinated, quality care, across all provider and community settings Offer new funding incentives and flexibility Measure delivery system effectiveness and efficiency Promote risk-based funding arrangements Break down silos in programs and funding Think outside the box on prevention and health education Julie Hamos, HFS October 2011

11 The Innovations Project is Designed to Achieve the State s Goal by: Testing community interest and capacity to provide alternative models of delivering care (i.e. not through traditional HMOs) Aligning with Accountable Care Act CMS initiatives Incorporating feedback from the Coordinated Care Key Policy Issues responses Building on interagency collaborations

12 What is Care Coordination? Integrated delivery systems where recipients receive care from providers under contract responsible for providing or arranging the majority of care, including primary care, diagnostic and treatment services, behavioral health services, in-patient and outpatient hospital services, dental services, and rehabilitation and long-term care services Must include risk-based payment based on health outcomes, use of evidence-based practices and use of electronic medical records

13 Care Coordination for the Innovations Project is Facilitating the delivery of appropriate health care and other services, and care transitions among providers and community agencies, such as: Among hospitals, primary care and specialists Among hospitals, behavioral health/substance abuse providers and primary care Among primary care and dental providers

14 What is a Care Coordination Entity? A CCE is a collaboration of providers that develop and implement a Care Coordination model that meets the state s guidelines CCE project collaborators must include participation from hospitals, Primary Care Providers, and mental health and substance abuse providers To become a CCE, a group of providers may create a new corporate entity or may contract with the state through a lead provider A CCE may subcontract with an existing health plan for back office functions

15 Priority Populations State is particularly interested in proposals that include individuals with mental illness and/or substance use disorders Section 2703 of Health Home Demonstration Option targets populations for certain care coordination: Individuals with at least two chronic conditions; or One chronic condition and at-risk for another; or One serious or persistent mental health condition Chronic conditions include a mental health illness, substance use disorder, asthma, diabetes, heart disease, and being overweight ; other chronic conditions such as HIV/AIDS will be considered. Seniors and adults with disabilities (including in long-term care, with serious mental illness) Individuals with Medicare (including duals, LTC) Children in the families of enrolled adults

16 What You Need to Know All healthcare providers are being asked to work in new and different ways Hospitals will not be paid for readmissions within 30 days for certain diagnostic issues or illnesses Providers, regardless of setting or type of practice, must be accountable for health outcomes in collaboration with colleagues Reimbursement will be determined by health outcomes which will be dependent on teams of healthcare providers and how well they work together in terms of communication, agreement to plan and ability to engage, educate and motivate participants among many other factors

17 How can providers ensure the future will serve the people we care about? Leverage federal and state dollars (i.e. planning dollars, medical home, funding streams) Braid funding sources Build service and advocacy partnerships Advocate and work towards service and systems integration Demonstrate cost savings and quality health outcomes

18 Resources Coordinating Primary Care and Behavioral Health Services Among People Who Are Homeless, SAMHSA-HRSA Center for Integrated Health Solutions (Sep, 2011) Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms: White Paper, AHRQ (June, 2011) The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care, AHRQ (Dec, 2010)

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