Primary Care and Behavioral Health 2/4/2011 CIBHA
Promising Provisions Affordable Care Act – Prevention and Public Health Trust FUND--PCBHI – Section 2703 Health Homes for Individuals with Chronic Conditions – Medicare Accountable Care Organizations Shared Savings Program – Dual Eligible Demonstration Projects
Health Homes States can currently amend Medicaid State Plan 90% match for 8 quarters for following health homes services: – Comprehensive Care Management – Care Coordination and Health Promotion – Patient and Family Support – Comprehensive Transitional Care – Referral to Community and Social Support Services
SAMHSA’S PCBHI PROGRAM Focus on coordination between primary care and specialty care: – Significant enhancements to primary care Workforce enhancements Increased funding to SAMHSA, HRSA and IHS Bi-directional – MH/SUD in primary care – Primary care in MH/SUD settings – Services and technical assistance – Pharmacy opportunities through partnering (340b program)
SAMHSA’S PCHBI PROGRAM 2009—Grant award to 9 sites 2010—Expanded to another 44 sites 2010—Developed the Training and Technical Assistance Center in cooperation with HRSA Worked with ASPE to develop specific outcome measures for participants
Health Homes For Medicaid enrollees with – two or more chronic conditions, – one condition and the risk of developing another, or – at least one serious and persistent mental health condition Conditions include: – a mental health condition, – a substance use disorder, – asthma, diabetes, – heart disease, and – being overweight* *as evidenced by a body mass index over 25.
Health Homes Providers: – Team of health care professionals physicians nurse care coordinator nutritionist, social worker, behavioral health professional – Can operate in a variety of settings Free standing teams, Virtual teams Hospital-based Community health center Community behavioral health centers Rural clinics Group practice Academic health center
Health Homes Flexibility in defining the service Flexibility in reimbursement strategies Outcomes are defined by state:
Medicare ACOs Organizations that may become an ACO – Physicians and other professionals in group practices – Physicians and other professionals in networks of practices – Partnerships or joint venture arrangements between hospitals and physicians/professionals – Hospitals employing physicians/professionals – Other approved by Secty.
Medicare ACOs Requirements of ACOs – Have a formal legal structure to receive and distribute shared savings – Have a sufficient number of primary care professionals for the number of assigned beneficiaries (to be 5,000 at a minimum) – Agree to participate in the program for not less than a 3-year period – Can match physicians and patients – Have a leadership and management structure – Have defined processes to (a) promote evidenced-based medicine, (b) report the necessary data to evaluate quality and cost measures (c) coordinate care – Demonstrate it meets patient-centeredness criteria, as determined by the Secretary
Dual Eligibles Why focus on dual eligibles? – Approaching $300 B in expenditures in 2010 – Most have 2-5 chronic conditions – More likely to be institutionalized/hospitalized – States have incentives, but no plausible strategies to connect information or payment – 60% of all duals have a ID/BH condition
Dual Eligible Demos Two Current Initiatives: – Sharing Medicare Part A, B and D data with states—get a composite look at what persons gets/gaps – $15 million in design grants to States (2/1). Goal—identify and validate service delivery and payment integration models Models can be rapidly tested Spread to other states