1. Jennifer Vermeer, Iowa Medicaid Director Iowa Medicaid Enterprise

2. Objectives The presentation will provide an overview of Iowa’s strategy to strengthen, build upon, and align Federally Qualified Health Centers with IowaCare, an 1115 demonstration waiver, in order to create a health system better able to meet the state’s and national health care goals. The presentation will include information about: IowaCare Iowa’s FQHCs IowaCare Medical Home Model 2Jennifer Vermeer

3. 3

4. IowaCare History IowaCare Act (House File 841) passed FY2005 IowaCare is a 1115 demonstration waiver Goals of IowaCare are to: Expand access to health care coverage for low-income, uninsured adults who are not eligible for Medicaid Provide financial stability for safety net hospitals who have high amounts of uncompensated care Experiment with health care innovations IowaCare has provided necessary health care for over 72,000 Iowans from FY2005-2010. 4Jennifer Vermeer

5. IowaCare Members IowaCare covers single adults and childless couples ages 19-64, up to 200% FPL, who do not qualify for Medicaid or other insurance More than 80% of IowaCare members have income below 100%FLP Members are required to pay a monthly sliding scale premium if above 150% FPL 5Jennifer Vermeer

6. IowaCare Provider Network From SFY 2005 – 2010, the provider network included: University of Iowa Hospitals and Clinics (UIHC) Located in Iowa City (serves population Statewide) Broadlawns Medical Center Located in Des Moines (serves Polk County residents only) 39,000 enrolled as of August 2010 6Jennifer Vermeer

7. IowaCare Services IowaCare services include: Inpatient and outpatient hospital services Physician and advanced registered nurse practitioner services, including annual preventive physicals Limited dental services Smoking cessation IowaCare providers donate prescription drugs and some durable medical and equipment with their own funds. 7Jennifer Vermeer

8. Problems Access - Long travel distance to access care at UIHC High incidence of unmanaged chronic disease 25% have never had health insurance; 66% have not had insurance for more than 2 years 80% of patients have one or more chronic conditions (diabetes, chest pain, coronary artery disease, cancer, high blood pressure, pain) IowaCare patients self report poorer health status than the general Medicaid population Long wait times to access physician services at UIHC due to lack of reimbursement for UIHC physician services Unreimbursed emergency care at non-IowaCare hospitals Unmet needs due to program/funding limitations – i.e. no mental health, no drugs, no podiatry, etc. 8Jennifer Vermeer

9. IowaCare Expansion Goals Improve geographic access of IowaCare members to quality healthcare Reduce duplication of services Enhance communication among providers/family and community partners Improve the quality of healthcare to IowaCare members through the patient-centered medical home model. Promote and support a plan for meaningful use of health information exchange (HIE) in accordance with the Federal Register requirement Expansion enacted in SF 2356 to begin in 2010. 9Jennifer Vermeer

10. Expansion Specifics (SF 2356) Local Access: Adds 13 FQHCs to IowaCare provider network Primary care services expansion will be phased in through the network of Federally Qualified Health Centers in Iowa Sioux City and Waterloo first two sites for expansion, October 1, 2010 Improved access to UIHC: Adds partial reimbursement for UIHC physicians to reduce wait times for appointments Medical home model to improve care delivery for chronic disease Capped $2M reimbursement for emergency services at non-IowaCare hospitals (associated with inpatient stay) 10Jennifer Vermeer

11. IowaCare Phase Out Program will transition to Medicaid Expansion under the Affordable Care Act January 1, 2014 when Medicaid will cover all persons 133% FPL and below Vast majority of the IowaCare population is below 100% of FPL The expansion of IowaCare serves as transition period and an opportunity to pilot the medical home model in Medicaid with the goal of replication. 11Jennifer Vermeer

12. 12Jennifer Vermeer

13. Why Expand IowaCare in FQHCs? Presence in and knowledge of their communities Experience working with current member and potential new member population – mission to serve this population and willingness to provide subsidies, i.e. prescription drugs Provide comprehensive primary care services (medical, oral, and behavioral health) as required by federal grant Provide high quality of care made evident through national performance and outcome reporting requirements Implemented a Population Patient Health Management System/Registry in 2007 Implementing a comprehensive electronic medical record Progressing towards becoming a patient-centered medical home 13Jennifer Vermeer

14. Iowa’s 14 FQHCs 14Jennifer Vermeer

15. 15Jennifer Vermeer

16. IowaCare Medical Home SF2356 mandates that providers in the network (UIHC, Broadlawns, FQHCs) comply with certification requirements of a Medical Home Must meet equivalent of NCQA Level 1 certification by the end of the year (September 30, 2011) Providers complete self-assessment tool Transition to state designated certification process when available IME specified minimum standards include: Provide Provider Directed Care Coordination Services Designate a Care Management/Care Coordination staff person 16Jennifer Vermeer

17. IowaCare Medical Home, cont. Implement a Disease Management Program Diabetes Disease Management is required during the first year. Subsequent studies will be added based on disease burden. Implement a Wellness/Disease Prevention Program with quarterly reporting on quantities and activities Demonstrate evidence of acquisition, installation and adoption of an electronic health record (EHR) system Establish a plan for meaningful use of health information exchange (HIE) in accordance with the Federal Register requirement Electronic system must include a Registry Function/Immunization Registry 17Jennifer Vermeer

18. IowaCare Medical Home Payment System Methodology Level of Certification/Year Monthly Care Coordination PMPM Performance Based Reimbursement Possible Total Reimbursement PMPM Year 1$3.00$1.00$4.00 Year 2Level 1$1.50 $3.00 Level 2$2.50$1.50$4.00 Level 3$3.50$1.50$5.00 18Jennifer Vermeer

19. Selection of Performance Measures All of the IowaCare providers will qualify for HITECH Medicaid EHR incentive payments Selected measures that align with coming meaningful use standards Selected measures that are used by largest commercial payor in their quality measurement program to align data collection for the provider Combination of measures than can be collected from claims data and clinical measures providers will need to collect from their EHR 19Jennifer Vermeer

20. IowaCare Medical Home Designations 20Jennifer Vermeer

21. Medical Home Coverage Current IowaCare enrollment is approximately 38,000 adults First phase of Medical Home will have 4 sites Over half of enrolled (23,456) will be in medical home as of October 1, 2010: 11,740 – Broadlawns 7,740 – UIHC 533 – Siouxland FQHC (Sioux City, NW Iowa) 3,476 – Waterloo FQHC (Northeast/North Central Iowa) We expect enrollment to grow significantly in the regions of the state where FQHCs are added 21Jennifer Vermeer

22. Phase-in Schedule FY2011 October 1, 2010: Sioux City, Siouxland Community Health Clinic; Waterloo, Peoples Community Health Clinic January 1, 2011: Fort Dodge, Fort Dodge CHC; Ottumwa, River Hills CHC May 1, 2011: Council Bluffs, Council Bluffs CHC; Storm Lake, United CHC FY 2012 – Dates not specified Phase 1: Burlington, Southern Iowa CHC; Primary Health Care, Inc. (for outside Polk County only) Phase 2: Dubuque, Crescent CHC; Marshalltown, Primary Health Care, Inc. Phase 3: Davenport, Community Health Care; Cedar Rapids, Linn Community Care 22Jennifer Vermeer

23. Medical Home Requirements Members will be assigned to the Medical Home based on county of residence Members will have to access care through their medical home – referral required to access UIHC specialists Prescription drugs will be covered by the Medical Home – through their own funds, so provider sets requirements All of the providers have 340B drug programs 23Jennifer Vermeer

24. Integration with UIHC FQHCs do not have specialty or hospital care – that care still provided by UIHC Model is to deliver as much care as possible in local setting (Medical Home) to avoid travel to UIHC New role for UIHC and the other providers – need to create a network Necessary for close coordination between medical home and UIHC specialists/hospital 24Jennifer Vermeer

25. Strategies Strategies to support coordination (in addition to care coordination): Electronic exchange of information between IowaCare providers – test case for HIE development Specialist support of primary care provider - Reimbursement for peer to peer consultation (to encourage collaboration among UIHC and medical home Future – telemedicine Established referral protocols between providers to reduce duplication of testing and evaluation, streamline process for members 25Jennifer Vermeer

26. Questions? 26Jennifer Vermeer