April 2014
Leveraging the Opportunities in the Affordable Care Act:
A Community Clinic & Health Center Patient Centered Health Home Proposal
Section 2703 of the Affordable Care Act (ACA), in combination with the Centers for Medicare and Medicaid Services’ State Innovation Model (SIM) grant, presents an unprecedented opportunity for the State of California to take a leadership role in the transformation of our State’s health system. Section 2703 provides states with eight quarters of supplemental funding to support care coordination services for Medi-Cal patients, while the SIM grants support the transformation of healthcare delivery systems. Both programs require that cost savings be achieved by the culmination of the program. Because of the short timeframe for both programs, the California Primary Care Association (CPCA) proposes that the State of California allocate a portion of the SIM grant to train providers in complex case management prior to the launch of the Section 2703 demonstration, which would in turn enable the State to achieve cost savings for the SIM through effective case management and care coordination. Thanks to the investments from the Health Resources Services Administration, foundations like The California Endowment, and CPCA’s Patient Centered Health Home Initiative, California’s community clinics and health centers (CCHCs) are primed to advance the patient centered health home delivery model. By strategically leveraging available resources, California can optimize its ability to reshape the delivery of care and work towards the goals of the Triple Aim. RECOMMENDATIONS
Achieving significant savings within eight quarters will only be feasible by using demonstration funds to enhance delivery systems experienced in successfully working with the Medi-Cal populations targeted in the Section 2703 program. California CCHCs have a long history of working with Medi-Cal populations using an integrated care model to drive down costs and keep patients healthy. California’s CCHCs are critical institutions in the healthcare safety net and provide a significant proportion of the primary care services to publicly insured and uninsured individuals, including hundreds of thousands of individuals with chronic conditions.The CCHCs in California have led the way in developing and refining ground-breaking models for care delivery to complex patients, with over 100 CCHCs already having achieved Patient Centered Medical Home (PCMH) recognition and hundreds more in the process of doing so. Thanks to their expertise in providing comprehensive care to the Medi-Cal population, CCHCs are in a unique
position to build upon their existing PCMH infrastructure to implement this much needed program in California. The Section 2703 Demonstration is specifically geared towards patients with chronic conditions. By taking
advantage of this opportunity through working with the CCHCs, the State would allow health centers to expand and improve upon the work already being done for complex patient populations. Numerous studies have shown that the additional support for care coordination services produces significant and meaningful outcomes.i The Chronic
Care Model (CCM), for example, has been widely evaluated and found to be effective not only in improving delivery of appropriate therapies and reducing hospital stays, but also in having a lasting positive effect on the practices where it was implemented.ii Another study by research teams from RAND and the University of California at Berkeley assessed 51 PCHH sites that coordinated care for over 4,000 patients suffering from diabetes, congestive heart failure (CHF), asthma, and/or depression.iii The study found that because of the PCHH model, patients with
diabetes had significant decreases to their risk of cardiovascular disease, pilot patients had 35% fewer hospital days, and patients with asthma and diabetes were more likely to be receiving appropriate therapy. A third study, which looked at the entire adult managed care Medi-Cal population and compared FQHC and non-FQHC patients, demonstrated significant cost savings for FQHC patients – the unadjusted per member per month (PMPM) total FQHC adults’ costs to the health system were 37% lower than non-FQHC adults’ total costs over a two year period.
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iv,v With their experience in using multidisciplinary health teams, patient‐centered service orientation, enhanced
access, coordinated care transitions, care plans that fit the statewide needs of the Medi‐Cal and dual eligible populations, CCHCs are clearly prepared and experienced with the infrastructure needed for a successful federal demonstration.vi
CalSIM: Training Providers for 2703 Success
The California State Health Innovation Model (CalSIM) grant offers the opportunity to greatly enhance a Section 2703 demonstration. Layering CalSIM training and technical assistance resources with 2703 supplemental payments can improve the effectiveness of the demonstration by providing safety net providers with tools, training, and learning collaboratives. CalSIM resources will be targeted at practice transformation training and workforce development. While the CalSIM must be inclusive of all providers in California, CPCA recommends that a significant portion of the CalSIM resources be used to train and prepare Medi-Cal providers to take advantage of Section 2703 resources. Based on CPCA’s experience with PCHH transformation, three program components are necessary for widespread practice change and preparation for the complex case management:
1. Shared Learning: Regional safety net learning collaboratives & a statewide all provider conference
The multi-payer nature of the CalSIM initiative offers exciting opportunities for partnership and leveraging best practices across the public and private sectors.
2. Direct Support: Individualized technical assistance for CCHCs
CalSIM resources should provide resources to enable CCHC teams to directly engage with a practice coach who can deliver tailored guidance on implementation planning, change management, practice redesign, and sustainability.
3. Enhancing capacity: Training and education for CCHCs providers and staff
CalSIM resources can support training in risk stratification, intensive care management, care transition models, patient activation through motivational interviewing, and care team and clinic workflow redesign.
A distinct benefit of leveraging CalSIM and 2703 is that the cross-payer focus of the CalSIM offers opportunity for new partnerships between private and public providers who may previously have been siloed. Many organizations,
foundations, and provider associations are delving into complex care management, and these distinct initiatives can inform each other, bringing innovations from the safety net into commercial markets and spreading innovations from the commercial sector into CCHCs. In particular, the Pacific Business Group on Health’s (PBGH) impressive success through its CMMI funded Intensive Outpatient Care Program (ICOP) stands out as a model. As a CMMI demonstration, PBGH and the IOCP providers are focused on complex care management for a Medicare population. Within the safety net provider setting, West County Health Center and Santa Rosa Community Health Center have collaborated with Partnership Health Plan on a successful complex care initiative. CPCA developed the CalSIM training proposal outlined above in consultation with PBGH, and CPCA envisions PBGH, in partnership with safety net organizations, playing a prominent role as a source of expertise in the CalSIM training and technical assistance program. Leveraging CalSIM facilitated partnerships, training and technical assistance with a 2703 demonstration will produce a program that can truly advance the CalSIM vision of a healthier California and achieve the cost savings demanded by both CalSIM and 2703.
Section 2703: Focusing on Clinics and Health Centers
CPCA envisions the 2703 demonstration as a program that builds upon the existing PCHH infrastructure at the CCHCs. Participating CCHCs would be available to act as a hub for coordinating care for the Medi-Cal patients, working with local community based organizations, hospitals, and school-based health centers to link patients with resources both within and outside of the primary care setting. Keeping the criteria for participation in the pilot for health centers as flexible as possible and open to a broad population of chronically ill patients will be the key to drawing down the largest amount of federal funding within the two-year timeframe.
3 Building Blocks
Given the limited timeline for a 2703 demonstration to realize significant savings, CPCA recommends that providers meet the following minimum criteria prior to being enrolled as eligible health home providers in the 2703
demonstration. In addition to participating in the CalSIM PCMH training, participating CCHCs should have: PCMH accreditation, although the demonstration should not be prescriptive as to the type or level of
accreditation (e.g. NCQA, JCAHO, AAAHC)
An EHR system in place to coordinate care electronically, identify high-need patients, and track outcomes; data exchange capabilities should also be taken into consideration
A method for electronically communicating with hospitals regarding patient admission and discharge that includes systematic follow‐up protocols
Active participation by executive leadership and the presence of a 2703 coordinator (who may be a member of executive leadership) at each site
Designated Providers
CPCA recommends that Section 2703 demonstration sites use a team-based model of care delivery and designate an individual to assume a leadership role in care coordination for each eligible panel of patients. The types of professionals and positions within the teams should remain flexible so as to allow CCHCs to tailor care based on patient need.
Including licensed or unlicensed providers should be at the CCHCs discretion. Once the care teams, designated providers, and patients are determined, each health home team will be expected to develop a care plan with the participating patients within six months of implementation, with revisions as needed. Care plans should take into account both patient and family needs and should include coordination with necessary social services and community supports that will address the patient’s social determinants of health to the greatest degree possible.
Target Population
To maximize the opportunity for savings and quality in California, CPCA encourages the State to follow the lead of many other states and construct the definition of an eligible 2703 patient to be as inclusive as possible. Patients should be considered 2703 eligible if they have:
1. Two chronic conditions;
2. One chronic medical condition and are at risk of developing another; or 3. One chronic, serious mental illness.
Acknowledging that the goal of the 2703 funding is to demonstrate savings within a two-year timeframe, enrollment prioritization should target patients with conditions that could lead to high utilization of hospital and emergency departments. Chronic conditions should include both CMS defined chronic conditions (mental illness, substance use disorder, heart disease, diabetes, asthma), as well as other high cost populations for whom patient management can make a huge difference in overall savings (HIV, Hepatitis, chronic liver disease, chronic kidney disease, and BMI > 30). Delivery System
Research suggests that patients trust and respond better to care management that is in-person and closely coordinated at the provider level.viiviii Under the CPCA proposal, we suggest that CCHCs serve as the hub for care
coordination services, providing services, linking patients to additional services, and coordinating care both internally and externally. Recognizing the role that managed care plans will need to play in identifying patients, coordinating care management activities, and providing data on total health system utilization for patient management and evaluation, CPCA recommends that the bulk of health home payment be paid directly to the participating health centers, with a small percentage of 2703 PMPM payment given to health plans for
4 Enrollment
CPCA recommends that managed care plans work with participating 2703 sites to identify high-risk patients using claims data to generate a list of potential patients. Health home providers would then conduct a review of the data and make a determination of 2703 demonstration eligibility. Patients would be able to opt out at any time.
Payment Methodology
CPCA recommends that CCHC 2703 demonstration sites receive a per-member-per-month (PMPM) payment that is developed in collaboration with the State and administered by the managed care plans. Based on other state demonstrations, PMPM payments would likely be in the range of $50-$75 PMPM, but could vary significantly depending upon the target population.x PMPM rate development would reflect the staff and administrative
resources necessary to render health home services to the target patient population and utilizing health information technology. This rate would also account for an administrative fee of approximately 3% to the managed care plans for assisting with patient identification and providing evaluation data. While prior CPCA proposals have
recommended tiered payment based on both medical and social acuity,xi we recommend for administrative
simplicity that the PMPM instead include medical acuity and an inflation factor of approximately 15%xii for three key
psychosocial factors: 1) homelessness, 2) having a concurrent mental health and/or substance abuse diagnosis, and 3) being monolingual non-English speaking.
Based on the documented lack of risk adjustment systems that take important social determinants of health into account,xiii CPCA recommends using the 2703 demonstration to explore risk adjustment for three psychosocial factors that influence the amount of resources needed for patient care management and coordination. For instance, substantially more case coordination is necessary when managing homeless patients given the importance of ensuring patients are connected to appropriate community resources for supportive, transitional, or permanent housing.xiv Research also shows that a co-occurring mental illness for adults with one of five common chronic
physical conditions is associated with 46-70% higher hospitalization rates,xv suggesting there are more cost savings
to be achieved if hospitalizations can be reduced through intensive care management for this complex population. Identifying non-English speaking referral providers and community resources can also require higher than average time from care coordination staff.
Similar to New York’s 2703 demonstration, CPCA recommends that the PMPM payment occur in two stages – first, for outreach and second, for active management. Because many of the most complex patients are difficult to engage in care, an outreach PMPM payment would provide the necessary additional resources to find and engage challenging patients. The outreach PMPM rate would be the smaller of the two payments, and the majority of the PMPM rate would be in the form of the active management PMPM rate. Procedurally, once a provider is enrolled in the 2703 demonstration the provider would begin receiving an outreach PMPM payment in the first month after assigned member eligibility determination. This outreach PMPM payment could be continued for up to six months or until a patient is actively engaged in health home services. In the month following the first instance of
documented provision of care coordination services in the patients’ medical record and submission of a “health home engagement” claim to the health plan, health homes would begin receiving the active management PMPM payment for provision of health home services. Health homes would have to document services provided and have at least one documented contact with a patient every six months to continue to receive PMPM payments, providing the necessary documentation to allow the State to draw down 2703 Federal funding.
After the completion of the 2703 demonstration, CPCA supports transitioning the PMPM payment to a performance-based payment. We propose this payment only be sustained if total cost of care and total health system quality and utilization goals are met, thus introducing a statewide value-based purchasing strategy for care management and coordination. Pay-for-performance (P4P) models with limited but high-value outcomes associated with significant performance-based payments, such as San Diego’s Low Income Health Program
Pay-for-Performance Program,xvi have demonstrated significant quality and transformation outcomes. Such models could be
5 Evaluation: Utilization and Quality Measures
CPCA supports the measurement of hospital, emergency department, and Skilled Nursing Facilities utilization and costs. Based on other state experiences with the 2703 demonstrations, there are real evaluation challenges in assessing these metrics;xvii however, based on total cost of care and quality research, these three metrics are the
most revealing. Because the demonstration is only two years, CPCA recommends that the additional quality measurements be focused on a limited set of patient health outcomes while stratifying for social determinants of health. Careful thought should also be given to establishing a control group for evaluating the overall success of the 2703 demonstration. One potential implementation strategy that would support a strong evaluation could be implementing multiple 2703 SPAs that phase in the same demonstration in proximal geographic areas, such that similar patients in adjacent geographic areas could serve as reasonable control groups for earlier phase areas. The geographic areas that proceed in the first wave should align with provider and health plan readiness.
SUCCESS: SAVINGS AND QUALITY
With a Section 2703 Health Home demonstration, California has a remarkable opportunity to pilot care coordination efforts and to generate total cost of care savings from better coordination of care services at no cost to and no risk for DHCS. State general fund savings would likely be generated in the first two years by leveraging enhanced federal match for some care management services that are currently built into managed care capitation rates.xviii By designing the
payment methodology to transition to a performance-based payment after the first eight calendar quarters of enhanced federal match, DHCS would be protected from any ongoing costs associated with the 2703 demonstration. CPCA is poised to work with DHCS and the managed care plans to ensure that the first group of health homes is well prepared to implement evidence-based care management, care coordination, and care transition strategies through rigorous training and tools provided through SIM resources. Additionally, the savings achieved through this innovative program could be used to fund a permanent health home benefit that would allow the State of California to continue to achieve significant returns on the initial investment for decades to come. The experiences and lessons learned from the vanguard group of California health centers will be translated into resources to benefit both the State and the nation, as California once again assumes the role as a leader in ACA implementation and health system transformation.
iMoses K, Ensslin B, Seizing the Opportunity: Early Medicaid Health Home Lessons. Centerfor Health Care Strategies, Inc. March 2014. iiImproving Chronic Illness Care. “The Chronic Care Model.” [website]. Accessed July 29, 2013. Available at
http://www.improvingchroniccare.org/index.php?p=The_RAND_Evaluation&s=32
iii JSI. (n.d.). “California Primary Care Association Position Paper Regarding a State Option to Provide Chronic Care Health Ho me in California.” [unpublished] iv Partnership HealthPlan of California. (January 2013) “Value of Community Health Centers Study.” CPCA. Available at http:// www.cpca.org/cpca/assets/File/Data-Reports/2013-03-18ValueofCHCStudy.pdf
vMoore, A. et. al. “Patient Centered Health Home Innovation Grant – Phase I” and “Patient Centered Health Home Innovation Grant – Phase II” [ppt]
vi JSI. (n.d.). “California Primary Care Association Position Paper Regarding a State Option to Provide Chronic Care Health Ho me in California.” [unpublished] vii Brown and Mann, Best Bets for Reducing Medicare Costs for Dual Eligible Beneficiaries. Kaiser Family Foundation, October 2012
viii Hamblin and Somers, Introduction to Medicaid Care Management Best Practices. Center for Healthcare Strategies, D ecember 2011. ix NYS Health Home Program, New York State Department of Health NASHP Presentation, June 2012
x Assessment of Potential Health Home State Plan Options for California Presented to California Department of Health Care Services, Health Management Associates. February 3, 2012.
xi CPCA Patient-Centered Health Home Work Group Recommendations to Date April 15, 2013
xii Adapted from the Minnesota Health Home program detailed in Minnesota Department of Human Services and Department of Health. H ealth Care Homes Payment Methodology. January 2010 [Online]. Available at http://www.health.state.mn.us/healthreform/homes/payment/PaymentMethodology_ March2010.pdf.
xiii Long A, Phillips K, Hoyer D. Payment Models to Support Patient-Centered Medical Home Transformation: Addressing Social, Behavioral, and Environmental Factors. 1st ed. Phillips K, ed. Seattle, WA: Qualis Health; August 2011
xiv Bodenheimer T, Strategies to Reduce Costs and Improve Care for High-Utilizing Medicaid Patients: Reflections on Pioneering Programs. Center for Heatlh Care Strategies. October 2013.
xv Boyd C, Leff B, Weiss C, Wolff J, Hamblin A, Martin L. Clarifying Multimorbidity Patterns to Improve Targeting and Delivery o f Clinical Services for Medicaid Populations. Center for Health Care Strategies, Inc. December 2010.
xvi County of San Diego Health and Human Services Agency, P4P Value-Based Payment Model. Presentation. Available by request.
xvii Spillman B, Ormond B, and Richardson E, Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Final Annual Report - Base Year, Urban Institute, December 2012 [Online] Available at http://aspe.hhs.gov/daltcp/reports/2012/HHOption.shtml#overview
xviii Health Homes (Section 2703) Frequently Asked Questions [Online] Available at: http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/Health-Homes-FAQ-5-3-12_2.pdf
