1. Medicaid Medical Homes Initiatives:
Promising Practices to
Inform 2703 SPAs
The Power of Integrated Care: Implementing
Health Homes in Medicaid
February 15, 2011
Mary Takach, MPH, RN
Program Director
National Academy for State Health Policy
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2. NASHP Medical Home Projects
v The Commonwealth Fund: Advancing Medical Homes in Medicaid
n Round I 2007-2009 (CO, ID, LA, MN, NH, OK, OR, WA)
n Round II 2009-2010 (AL, IA, KS, MD, MT, NE, TX, VA)
n Round III 2011-2012 (RFA released 1/2011)
v Office of the Assistant Secretary for Planning & Evaluation in the
US Department HHS
n With RTI, evaluation design for Medicaid State Plan Option for
Chronically Ill Health Homes (Section 2703 Affordable Care Act)
v Federal HRSA Bureau of Primary Health Care
n Informing state policymaking as it affects health centers through a
National Cooperative Agreement
v Federal HRSA Maternal Child Health Bureau
n Coordinating medical home policies between State Title V & Medicaid
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3. Since 2006, most states have new Medicaid
or CHIP medical home initiatives
WA
ME
MT ND
OR VT
ID MN
NH MA
WI
SD MI NY
WY
RI
PA CT
IA
NV NE NJ
UT IN OH
IL DE
CA CO WV MD
VA DC
KS MO KY
NC
TN
AZ OK
AR SC
NM
AL GA
MS
TX LA
AK FL
HI
States with at least one effort that met criteria for analysis
SOURCE: NASHP analysis
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4. Medicaid medical homes:
wide variation
n Several target chronic, complex populations
n Several participate in >1 initiative
n Several use state plan amendments or
Medicaid waivers: MN & NE recent SPAs
n Recognition standards vary
p NCQA, modified NCQA, state-grown
n Payment is mainly fee for service plus monthly
care coordination fee, often adjusted
p Added payment for networks, teams, start-up
costs, performance
p Plans participate like other payers
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5. Enrolling populations
Minnesota Health Section 2703 Health
Care Homes Homes
v Provider-determined tier v Two or more chronic
assignment conditions; one condition and
v Five tiers based on the the risk of developing
number of conditions – another; or at least one
groups that are chronic, serious and persistent
severe, and requiring a care mental health condition.
team for optimal management v Examples include:
v Two supplemental complexity § Mental health conditions
factors added § Substance abuse disorders
n Non-English as primary § Asthma
language § Diabetes
n Significant mental illness
§ Heart disease
§ Obesity
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6. Enrolling populations (cont.)
North Carolina Section 2703
v General Medicaid v No statutory flexibility
population to exclude dual
v Aged Blind & Disabled eligibles from health
population homes services.
v Dual eligibles:
Medicare 646
demonstration
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7. Provider infrastructure
Vermont Advanced
Primary Care Practices Section 2703
v Recognized providers form v Three distinct types of
internal teams, and providers from which a
v Community Health Teams: beneficiary may receive
services:
5-member multidisciplinary
teams support providers 1. Designated providers
n Support patients and families (physician, clinic, etc.)
n Support practices 2. A team of health care
Coordinate care & services
n
professionals linked to a
n Referrals and transitions
n Case management
designated provider
n Self-management (virtual, based at practice,
n Counseling or other sites)
Population management
n
3. Health team (section 3502
of ACA)
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8. Provider standards
Maine PCMH
NCQA + 10 Expectations
Section 2703
v Demonstrated leadership v Culturally effective, patient centered care
v Team-based approach to care v Evidence-based clinical guidelines
v Preventive & health promotion services
v Population risk stratification and
management v Mental health & substance abuse services
v Care management, care coordination, &
v Practice-integrated care transitional care
management
v Chronic disease management, including
v Enhanced access to care self- management
v Behavioral-physical health v Individual and family supports
integration v Long-term care supports & services
v Inclusion of patients & families v Person-centered care plan
v Connection to community v HIT to link services, facilitate
communication, provide practice feedback
v Commitment to reducing waste v Continuous quality improvement program
and increasing efficiency
v Integration of HIT
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9. Provider standards (long-term care)
Oregon Primary Care
Section 2703
Home
v Referral and Specialty v Coordinate and provide access
to comprehensive care
Care Coordination management, care
n PCH either: coordination, and transitional
1. Manages hospital and care across settings.
nursing facility care; or v Transitional care includes
appropriate follow-up from
2. Demonstrates active
inpatient to other setting,
involvement and including participation in
coordination of care when discharge planning and
its patients receive care in facilitating transfer from a
these specialized settings pediatric to an adult system
of health care
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10. Provider standards: behavioral health
Pennsylvania Chronic
Care Initiative Section 2703
NCQA PLUS
v Periodic screenings on all v Access to a wide range of
patients with chronic physical health, mental
conditions using an health and substance use
evidence-based screening prevention, treatment, and
tool, such as the PHQ9 recovery services.
v Practices will provide or v Examples:
arrange for appropriate n Alcohol/drug screening
evidence-based behavioral n Identifying available
therapy to achieve optimal mental health and
treatment outcomes. substance abuse services
n Discharge/Care planning
n Continuity of Care services
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11. Payment Methodologies
Minnesota Health Section 2703
Care Homes
v Medicaid fee-for-service: v Payment methodology must be
$10.14-$79.05 PMPM included in SPA.
p Considerable flexibility in the
payment, varying on
design.
patient complexity and
p Expressly permits states to
other factors structure a tiered payment
v Multi-payer. State methodology that accounts for the
regulated payers and severity of each individual’s
chronic conditions and the
Medicare to adopt payment “capabilities” of the health home.
method “consistent” with v ACA permits States to propose
Medicaid fee-for-service alternative models of payment
method. that are not limited to per
member per month payments for
CMS approval.
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12. Payment methodologies-state payments to
external practice supports
Community Care of Vermont Community
North Carolina Health Teams
v General Medicaid v Insurers currently share the
n $3 per member per costs of CHTs equally.
v This support allows the services
month
of a CHT to be offered free of
v Aged, Blind, & Disabled charge to patients and
practices, with no co-pay or
population prior authorization.
n $13.72 per member per v Insurers provide a total of
month $350,000 per CHT annually.
v Dual-Eligibles n CHTs serve a general
population of 20,000. Shares
n Payment only if there are paid to a single existing
shared savings after administrative entity in each
meeting certain Hospital Service Area.
thresholds
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13. Monitoring requirements
Maryland Multi-stakeholder
Medical Home Pilot Section 2703
v Adopted 23 adult and pediatric v Outcomes:
quality measures, including n Individual-level clinical outcomes
seven CMS EHR Meaningful Use n Experience of care outcomes
Core or Alternate Core n Quality of care outcomes.
measures. Outcomes of interest v Avoidable hospital Readmissions
include: v Cost savings from improved
n Decreased acute care utilization coordination of care and chronic
n Increased preventive care
disease management
utilization v HIT use to improve service delivery
n Increased patient and provider
and coordination across the care
satisfaction continuum
v Emergency room visits
v Skilled nursing facility admissions.
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14. State challenges & opportunities
v Dual eligibles
v New boundaries: behavioral health
care and long-term care integration
v Time interval to see outcomes
v Financial
v Retrofitting existing programs
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15. For More Information on State Medical
Home Initiatives:
v Please visit:
www.nashp.org
v Contact:
mtakach@nashp.org
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