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1.  Costs of Chronic Conditions  Overview of Chronic Health Homes  State Plan Amendment Example: Missouri 2.

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Presentation on theme: "1.  Costs of Chronic Conditions  Overview of Chronic Health Homes  State Plan Amendment Example: Missouri 2."— Presentation transcript:

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2  Costs of Chronic Conditions  Overview of Chronic Health Homes  State Plan Amendment Example: Missouri 2

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4  More than 40% of the U.S. Population has one or more chronic conditions.  39% of the U.S. working - age population in 2007 had at least one chronic condition.  By 2020, the number of people with multiple chronic conditions is expected to increase to 81 million, up from 57 million in Source: Brody, Jane E. “Tackling care as chronic ailments pile up,” The New York Times, February 21, 2011; Cassil, Alwyn. “Innovations in preventing and managing chronic conditions: What’s working in the real world?” Center for Studying Health System Change, June

5 Sixteen percent of spending is for 50 percent of the population that has no chronic conditions. Eighteen percent of spending is for the 22 percent of the population that has only one chronic condition. Seventeen percent of spending is for the 12 percent of the population that has two chronic conditions. Sixteen percent of spending is for the 7 percent of the population that has 3 chronic conditions. Twelve percent of spending is for the 4 percent of the population that has 4 chronic conditions. Twenty-one percent of spending is for the 5 percent of the population that has 5 or more chronic conditions. Percentage of Health Care Total Spending by Number of Chronic Conditions Source: Medical Expenditure Panel Survey

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7  The Affordable Care Act was passed by Congress and signed into law by the President in March  Section 2703 of the Act adds section 1945 to the Social Security Act to allow states to amend their Medicaid state plans to provide Health Homes for enrollees with chronic conditions. 7

8  Chronic Health Homes is a new Medicaid State Plan Option that provides a comprehensive system of care coordination for Medicaid individuals with chronic conditions. ◦ Health Home providers will coordinate all primary, acute, behavioral health and long term services and supports to treat the “whole-person.” ◦ The integration of primary care and behavioral health services is critical to achievement of enhanced outcomes.  CMS encourages states to coordinate with existing medical home projects. ◦ States should compare current programs to the ACA health homes definition. 8

9  Medicaid eligible individual having: ◦ At least 2 chronic conditions, ◦ 1 chronic condition and be at risk of developing another, or ◦ At least 1 serious and persistent mental health condition. 9

10  The chronic conditions include: 1. mental health condition, 2.substance abuse disorder, 3.asthma, 4.diabetes, 5.heart disease, or 6.being overweight (as evidenced by a BMI of > 25). *States may add additional chronic conditions with approval from CMS. 10

11  States may further limit eligibility criteria, e.g., based on diagnosis or risk of institutionalization.  States must offer services to all enrollees who meet the eligibility criteria.  States may not exclude individuals dually eligible for Medicare.  States can limit the geographic area where the program is offered to places where the need is greatest, or where providers are available. 11

12  The following health home services are to be provided in a comprehensive, timely, and high quality fashion: 1.Comprehensive Care Management; 2.Care coordination; 3.Health promotion; 4.Comprehensive transitional care from inpatient to other settings; 5.Individual and family support; 6.Referral to community and social support services; and 7.The use of health information technology to link services. *States will receive a 90% federal match for these specific services. 12

13 CMS specific provider types include: 1.Designated providers, such as physicians, clinical practices, rural health clinics, community health centers, home health agencies, or any other entity/provider; 2.A team of health care professionals, including physicians, nurse care coordinator, nutritionist, social worker, behavioral health professional; which links to a designated provider; or 3.A health team, defined as an interdisciplinary, inter-professional team; including medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, physician’s assistants, etc. Providers are expected to address functions including but not limited to: 1.Providing quality-driven, cost-effective, culturally appropriate, and person- and family-centered health home services; 2.Coordinating and providing access to high-quality health care services informed by evidence-based guidelines; 3.Coordinating and providing access to mental health and substance abuse services; and 4.Coordinating and providing access to long-term care supports and services. 13

14  The provision offers States additional Federal support to enhance the integration and coordination of primary, acute, behavioral health, and long-term care services and supports for Medicaid enrollees with chronic conditions.  To aid in planning activities aimed at developing and submitting a State Plan Amendment (SPA), the legislation originally included funding for state grants of up to $500,000, but this was not funded. Any planning funds would be matched at a State’s regular FMAP. 14

15  A State could receive for the first 8 quarters 90% FMAP for health home services provided to individuals with chronic conditions, and a separate 8 quarters of enhanced FMAP for health home services provided to another population implemented at a later date.  Additional periods of enhanced FMAP would be for new individuals served through either a geographic expansion of an existing health home program, or implementation of a completely separate health home program designed for individuals with different chronic conditions. 15

16  States have significant flexibility in how they can reimburse health homes for these services.  CMS will allow capitated, fee for service, or other models approved by CMS. 16

17  Providers ◦ Designated providers of health home services are required to report quality measures to the State as a condition for receiving payment.  States ◦ States are required to collect utilization, expenditure, and quality data for an interim survey and an independent evaluation.  Congress ◦ Survey of States & Interim Report to Congress 2014 ◦ Independent Evaluation & Report to Congress

18 States must:  Consult and coordinate with the Substance Abuse and Mental Health Services Administration (SAMHSA);  Collect and report information; and  Participate in CMS’ evaluation and assessment by an independent organization no later than January 1,

19 CMS is available to:  Provide technical assistance to States interested in submitting a State plan amendment;  Engage in rapid learning activities to prepare for the release of well-informed regulations; and  Continue collaborations with Federal partners, to ensure an evidence-based approach and consistency in implementing and evaluating the provision. 19

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21  CMS has provided states resources to aid in the formation of a State Plan Amendment (SPA).  SPA must address how the proposed approach will assure access to mental health and substance use prevention, treatment, and recovery services.  SPA must describe how the state will ensure a whole-health approach to providing care and how the state will address the required functions of a health home. 21

22  Missouri is the first state to amend its Medicaid state plan to implement Healthcare Homes.  Missouri will have two types of Healthcare Homes ◦ Primary Care Chronic Healthcare Home  Federally Qualified Health Centers (FQHC)  Rural Health Centers (RHC’s)  Physician practices ◦ Community Mental Health Center Healthcare Home  CMHCs and CMHC affiliates  Missouri has made significant progress in establishing a Community Mental Health Center Healthcare Home. 22

23  Health Homes: a place where individuals can come throughout their lifetimes to have their healthcare needs identified and to receive the medical, behavioral and related social services and supports they need, coordinated in a way that recognizes all of their needs as individuals–not just patients. 23

24 Clients eligible for a CMHC Healthcare Home must meet one of the following three conditions (identified by patient health history): 1.A serious and persistent mental illness, o Community Psychiatric Rehabilitation (CPR) eligible adults and kids with Serious Emotional Disorder (SED) 2.A mental health condition and substance use disorder, or 3.A mental health condition and/or substance use disorder and one other chronic health condition. Chronic health conditions include: 1.Diabetes, 2.Cardiovascular disease, 3.Chronic obstructive pulmonary disease (COPD), o asthma, chronic bronchitis, or emphysema 4.Overweight (BMI >25), 5.Tobacco use, 6.Developmental disability. 24

25 Part 1: Quarterly start-up, training and infrastructure cost reimbursement Missouri will reimburse Health Homes for start-up costs and lost productivity due to collaboration demands on staff not covered by other streams of payment. Part 2: Clinical Care Management per- member-per-month (PMPM) payment Missouri will pay for reimbursement of the cost of staff primarily responsible for delivery of services not covered by other reimbursement (Primary Care Nurses, Physician Consultants) whose duties are not otherwise reimbursable by MO HealthNet. Part 3: Performance Incentive Payment Missouri will pay practices for 50% of the value of the reduction in total health care PMPM cost, including infrastructure & PMPM payments described herein, for Health Home’s attributed MO HealthNet patients. 25

26  Missouri Chronic Care Management rate is $75 PMPM. ◦ Targeted Case Management or waiver service providers will be regularly included in the overall healthcare team and involved in development and performance of the person centered plan. ◦ Actual costs of the portion of health home services performed by Targeted Case Management or waiver service providers will not be included in the CMHC health home PMPM payment.  Maryland Mental Heath Targeted Case Management rate is $105 per visit.  Maryland MCO medical management rate is $6.31 PMPM (includes outreach, utilization management, disease management, case management, and quality management).  In developing a program, Maryland must determine which services are already covered by MCOs and TCM and which would be new under Chronic Health Homes because services may not be duplicative. 26

27 1. Have a substantial percentage of its patients enrolled in Medicaid; 2. Have strong, engaged leadership personally committed to and capable of leading the practice through the transformation process and sustaining transformed practice processes as demonstrated by through the application process and agreement to participate in learning activities. 3. Meet state requirements for patient empanelment (i.e., each patient receiving CMHC health home services must be assigned to a physician); 4. Meet the state’s minimum access requirements as follows: Prior to implementation of health home service coverage, provide assurance of enhanced patient access to the health team, including the development of alternatives to face-to-face visits, such as telephone or , 24 hours per day 7 days per week; 5. Actively use MO HealthNet’s comprehensive electronic health record (EHR) to conduct care coordination and prescription monitoring for Medicaid participants; 6. Utilize an interoperable patient registry to input annual metabolic screening results, track and measure care of individuals, automate care reminders, and produce exception reports for care planning; 27

28 7. Routinely use a behavioral pharmacy management system to determine problematic prescribing patterns; 8. Conduct wellness interventions as indicated based on clients’ level of risk; 9. Complete status reports to document clients’ housing, legal, employment status education, custody etc.; 10. Agree to convene regular, ongoing and documented internal Health Home team meetings to plan and implement goals and objectives of practice transformation; 11. Agree to participate in CMS and state-required evaluation activities; 12. Agree to develop required reports describing CMHC Health Home activities, efforts and progress in implementing Health Home services; 13. Maintain compliance with all of the terms and conditions as a CMHC Health Home provider or face termination as a provider of CMHC Health Home services; and 14. Present a proposed Health Home delivery model that the state determines to have a reasonable likelihood of being cost-effective. 28

29 1. Within 3 months of Health Home service implementation, have developed a contract or MOU with regional hospital(s) or system(s) to ensure a formalized structure for transitional care planning, to include communication of inpatient admissions of Health Home participants, as well as maintain a mutual awareness and collaboration to identify individuals seeking ED services that might benefit from connection with a Health Home site, and in addition motivate hospital staff to notify the CMHC Primary Care Nurse Manager or staff of such opportunities. The state will assist in obtaining hospital/Health Home MOU if needed; 2. Develop quality improvement plans to address gaps and opportunities for improvement identified during and after the application process; 3. Demonstrate continuing development of fundamental medical home functionality at 6 months and 12 months through an assessment process to be applied by the state; - Demonstrate significant improvement on clinical indicators specified by and reported to the state; 4. Provide a Health Home that demonstrates overall cost effectiveness; and 5. Meet NCQA level 1 PCMH requirements as determined by a DMH review or submit an application for NCQA recognition by month 18 from the date at which supplemental payments commence OR meet equivalent recognition standards approved by the state as such standards are developed. 29

30  Primary Care Physician Consultant – 1hour/enrollee/year ◦ Provides medical leadership.  Healthcare Home Directors – 1 FTE/500 enrollees ◦ Provide leadership in the implementation and coordination of Healthcare Home activities; ◦ Champions practice transformation based on Healthcare Home principles; and ◦ Develops and maintains working relationships with primary and specialty care providers, including inpatient facilities.  Nurse Care Managers – 1 FTE/250 enrollees ◦ Develop wellness and prevention initiatives, provide trainings, track required assessments, administrative support, etc.,  Administrative Support – 1 FTE/500 enrollees ◦ Referral tracking, training, data management, reporting, care coordination. 30

31 MeasureDefinition SourceData SourceBenchmark Goal *Gap Closing Goal * Quality Prescribing Psychiatric Medications- % prescriptions flagged as potentially inconsistent with quality practices MissouriClaims >10%Decrease by 5% All-cause 30-day readmission rate NoClaims NCQA’s most recently published 50 th percentile regional rate for Medicaid managed care Decrease by 10% Preventable admissions per 1000 (i.e., Ambulatory Care- Sensitive Conditions (ACSC) admissions) NoClaimsNCQA’s most recently published 50 th percentile regional rate for Medicaid managed care Decrease by 10% ED visits per 1000 NoClaims NCQA’s most recently published 50 th percentile regional rate for Medicaid managed care Decrease by 10% % of hospitalized patients who have clinical, telephonic or face-to- face follow-up interaction with the care team within 2 days of discharge during the measurement month Missouri Claims & monthly report80%Increase by 25% 31

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33  Health homes mailbox for any questions or comments -  11/16/10 Health Homes State Medicaid Director Letter  12/23/10 CMCS Informational Bulletin on Web-Based Submission Process for Health Home SPAs 33


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