Overview of the Medicaid Health Overview of the Medicaid Health Home Care Coordination Benefit
June 7 2011 June 7, 2011
Alicia D. Smith, MHA Senior Consultant
Health Management Associates asmith@healthmanagement.com
Poll Question
Which of the following most closely describes you?
) l h l h/ dd d
a) Mental health/addiction provider b) Mental health/addiction consumer c) Friend/Family member
d) Fed/State/county government employee
e) Other
Discussion Topics
About HMA
d d d
Overview of the
Medicaid health home
Medicaid and
behavioral health
Th b i f
Medicaid health home benefit
Other benefit design
The business case for coordinated care
Behavioral health
Other benefit design considerations
States’ proposed
Behavioral health opportunities under the ACA
States proposed approaches
Participant Questions
the ACA Participant Questions
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 Washington, DC
Tallahassee Chicago
Columbus Indianapolis
Austin Sacramento
New York City Atlanta
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
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 t l h lth d ddi ti t t t
mental health and addiction treatment.
Beneficiaries with mental illness and SUD are more likely than other Medicaid beneficiaries to have one or more costly co‐occurring physical health
conditions.
Example: The Ohio Medicaid Business Case for Coordinated Care
The Best Practices in Schizophrenia Treatment (BEST) Center of the Northeastern Ohio Universities Colleges of
M di i d Ph (NEOUCOM) d h H l h
Medicine 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
http://www neoucom edu/bestcenter/index php/news/4 http://www.neoucom.edu/bestcenter/index.php/news/4 9/58/Report‐shows‐Medicaid‐Beneficiaries‐with‐mental‐
illness‐also‐likely‐to‐have‐chronic‐physical‐problems
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;
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 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 ambulatory care sensitive conditions (asthma and diabetes) than non‐
SMI adults; and
Have two times higher rates of emergency department visits for
Example: The Ohio Medicaid Business Case for Coordinated Care
As a subset of the SMI population, Ohio’s adult Medicaid beneficiaries with schizophrenia:p
Have three times more hospitalizations for uncontrolled diabetes and twice the number of hospitalizations for pneumonia and chest pains compared with non‐SMI adults; p ;
Have twice the number of hospital emergency department visits for hypertension and uncontrolled diabetes than non‐SMI adults; and
Have three times higher costs for skilled nursing facility prescriptionHave three times higher costs for skilled nursing facility, prescription drug and home health services than non‐SMI adults.
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
No payment for care management & consultation services
Lack of incentives to share information between providers
Lack of an integrated health recordLack of an integrated health record
Limitations of fee‐for‐service payment methodologies
Behavioral Health Opportunities under the ACA
Medicaid emergency psychiatry services
l f b h d
Removal of barriers to home and community‐
based services
C l ti i d i lt i
Co‐locating primary care and specialty care in community‐based mental health settings
Health homes for individuals with chronic
Health homes for individuals with chronic
conditions
How does the ACA address barriers to integrated care? g
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 arrangementsReimbursement 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”)
( g q y )
State plans can be developed for specific
populations
Defining Health Homes
Enumerated in Sec. 1945 of the Social Security Act
Provides states the option to cover care coordination for individuals with chronic conditions through health homes
conditions through health homes
Eligible Medicaid beneficiaries have:
• Two or more chronic conditions
• Two or more chronic conditions,
• One condition and the risk of developing another, or
• At least one serious and persistent mental health condition
Defining Health Homes
Provides 90% FMAP for eight quarters for:
• Comprehensive care management
• Care coordination
• Health promotion
• Comprehensive transitional care
• 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
Defining Health Homes
Beneficiaries choose the provider, team of health professionals or health team
professionals or health team
States may apply for matchable planning grants up to $500K
up to $500K
Reimbursement may be on a PMPM or alternative basis
alternative basis
Guidance
No immediate CMS plans to issue regulations.
Instead guidance is available through:
SSA Sec. 1945 (Sec. 2703 of the ACA)
November 16, 2010 Dear State Medicaid Director letter issued by CMS available at
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
How are health homes different from patient centered‐medical homes?
p
PCMHs Health Homes
Serve all populations Enhanced Medicaid reimbursement is for
i di id l i h d h i
individuals with approved chronic conditions
Are typically defined as physician‐led e typ ca y de ed as p ys c a ed May include primary care practices, primary care practices, but also mid‐level
practitioners
ay c ude p a y ca e p act 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
How are health homes different from patient centered‐medical homes?
p
PCMHs Health Homes
Focused on the delivery of traditional
d l ( f l d l b k
Strong focus on behavioral health
( l d b b )
medical care (referral and lab tracking, guideline adherence, electronic
prescribing, provider‐patient communication)
(including substance abuse treatment), social support, other services (nutrition, home health, coordinating activities) co u cat o )
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)
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
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
CMS Expectations of Health Home Services
Services provide value for State Medicaid programs
Reduce hospital and nursing facility admissions and Reduce hospital and nursing facility admissions and lower hospital emergency department use
Support CMS’ three areas for improvements pp p (experience of care, health status, reduce costs)
Person‐centered care that improves outcomes
Whole‐person service orientation
Client choice
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)?
statewide, regional)?
What chronic conditions will be addressed?
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?
H ill HIT b tili d?
How will HIT be utilized?
How will health homes demonstrate the provision of whole‐person care?p
How will services be paid?
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)
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
Key SPA Sections
• Geographic area
• Population criteria
• Monitoring
• Tracking avoidable
Population criteria
• Provider infrastructure
• Service descriptions / HIT
ac g a o dab e hospitalizations
• Cost savings
• Proposal for using HIT
• Provider standards
• Assurances
• Hospital referrals
• Quality measures
• Clinical outcomes
• Experience of care
• Hospital referrals
• SAMHSA coordination
• Report evaluation results
Experience of care
• Quality of care
• Evaluations
States Should Spend Time Addressing
Use of HIT Quality Measures
Use of HIT
• Identify sources and uses of
existing data (e.g., claims and MCO encounter data)
Quality Measures
• Clinical outcomes relate to changes in health status
E i f
encounter data)
• Leverage EHR use
• Explore connections with statewide HIE initiatives
• Experience of care measures should derive from client surveys
• Quality of care measures relate to processes of care
HIE initiatives
• Identify options for HIE between behavioral health and primary care providers (e g National TA Center)
processes of care
• CMS will assist states in mapping measures to service definitions providers (e.g., National TA Center)
Likely feedback from SAMHSA and CMS
From SAMHSA From CMS
From SAMHSA
• Use of a chronic care model
• Provider qualifications
From CMS
• Choice and opt‐out
• No age restrictions
• Health team members
• Engaging primary care
• Addressing SUD
• No exclusion of duals
• Provider and client notification
• Leveraging existing services (e.g.,
• Capacity for new service users )
• Use of HIT
• Interim outcome measures
TCM, HCBS waiver)
• Non‐duplication of payment
• Mapping quality measures to
• Need help (e.g., screening tools, i integration models)?
services
• Need help (e.g., quality measures, reimbursement)?
Measures
• Leverage data already being collected (e.g., NOMS)
Cl i b d d f li i l
• Claims‐based data for clinical outcomes measures
• Survey data for experience of care
• Care management and registry data for quality outcomes (suggest limiting record reviews)
CMS i li i h ACA
• CMS is aligning measures across the ACA
• CMS will provide guidance on a core set of
i b
Reimbursement
Methods Considerations
Methods
• Case rate
• PMPM
Considerations
• Start‐up costs
• Training PMPM
• Base rate
• Tiered by severity
P f i ti
Training
• Health team composition
• Sustainability
• Performance incentive
• Other
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
f i 5 )
of increase over 5 years)
Some Proposed Approaches
State Designated Provider Population Criteria Missouri Community mental health
centers
SPMI
Mental health + SUD +
Primary care practices (FQHC, RHC, public hospital clinics)
Asthma, CVD, diabetes, DD, BMI > 25, other high risk Rhode Island Community mental health
organizations
SPMI
North Carolina Patient‐centered medical home (i i i l f )
A number of conditions (e.g.,
CVD h )
(initial focus) CVD, asthma, etc.)
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
Pay for a basic package of primary care in behavioral health (e.g., diabetes screening)
