Medicaid Medical Home and Care Management Initiatives

1. Medicaid Medical Home and Care Management Initiatives STAKEHOLDER FORUM September 28, 2011 Presented on behalf of the Nevada Division of Health Care Financing and Policy (DHCFP)

2. Topics for today’s conversation • Background • Medicaid Health Home Option • Recognized Medical Homes • Care Management Organization • Proposed Future Reforms

3. BACKGROUND

4. Background • DHCFP operated a Primary Care Case Management Program (PCCM) model in the 1980s and 1990s. The program ended in 1997. • DHCFP contracted with a vendor to operate a Disease Management (DM) program for high cost populations in fee-for-service Medicaid in 2008. The program ended in 2010. • DHCFP has been exploring options to serve high-cost populations, particularly those with complex medical and social needs complicated by chronic diseases and multiple co-morbidities, including a high rate of behavioral health diagnoses. • Options researched and considered include: • Patient Centered Medical Home • Administrative Services Organization • Networks and/or Accountable Care Organizations

5. Background (continued) • A medical home is an enhanced model of primary care in which a team of health professionals attend to the multifaceted needs of patients and provide comprehensive and coordinated patient-centered care. • DHCFP conducted a Request for Information (RFI) process regarding a Medical Home Collaborative in early 2010. • The proposed Nevada Medical Homes Collaborative was designed around a framework to place individuals into one of three levels of care based on their current health status: • Level I – Healthy with minimal medical needs or expenses • Level II – Chronic diagnose(s) that are relatively managed but are at moderate risk for future hospitalizations and could benefit from some education and preventative services. • Level III – Chronic diagnoses, multiple co-morbidities, behavioral health issues, high hospital and emergency room utilization, complex medical and social needs and in need of comprehensive case management

6. Background (continued) • DHCFP engaged PCG in late 2010 to help Nevada organize its options on how to most effectively and efficiently provide care for its most chronically ill clients. • PCG concluded that while some opportunities appear to exist with certain providers, there is limited statewide readiness and unclear support from the provider community at large. • PCG recommended DHCFP take a dual-pronged “hybrid” approach: • Implement healthhomes on a pilot basis. • Procure a Care Management Organization to realize savings while a healthhome program is established. • A decision unit in the FY12 – FY13 Biennial Budgetadds $4.6M in state funds for cost savings from care management of the Medicaid aged, blind, and disabled population. • Based on an estimate of cost savings done as part of the PCG assessment

7. MEDICAID HEALTH HOME OPTION

8. Medicaid Health Home Overview • Section 2703 of the Patient Protection and Affordable Care Act (PPACA) adds section 1945 to the Social Security Act to allow States to elect a “Medicaid Health Home” option under the Medicaid State plan. • The minimum criteria for eligible individuals include Medicaid clients with: • Two or more chronic conditions, • One condition and the risk of developing another, or • At least one serious and persistent mental health condition. • The chronic conditions listed in PPACA*, include: • A mental health condition, • A substance abuse disorder, • Asthma, • Diabetes, • Heart disease, and • Obesity (a Body Mass Index > 25). *States may add other chronic conditions with Federal approval from CMS.

9. Medicaid Health Home Services • 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. • The health home services are defined in PPACA, and include: • Comprehensive care management; • Care coordination and health promotion; • Comprehensive transitional care from inpatient to other settings; • Individual and family support; • Referral to community and social support services; and, • Use of health information technology, as feasible and appropriate. • Increased federal matching percentage for health home services. • 90 percent for the first eight fiscal quarters that a State plan amendment is in effect. • 90 percent match does not apply to other Medicaid services a beneficiary may receive.

10. Medicaid Health Home Quality Reporting • Designated providers of health home services are required to report quality measures to the State as a condition for receiving payment. • States are required to collect utilization, expenditure, and quality data for an interim survey and an independent evaluation. • CMS will expect States to report on the core set of quality measures Examples of key quality metrics may included: • Preventable/ambulatory care-sensitive emergency room visits,; • Ambulatory care-sensitive condition admission; • Follow-Up After Hospitalization for Mental Illness; • Hospital readmissions within 30 days, and • Other established quality measures (e.g. HEDIS, National Quality Forum, National Quality Measures Clearinghouse,etc.). • Some CMS core measures can be drawn from claims data, but certain measures in the core set require data extractions from medical records.

11. Medicaid Health Home Payment • The Medicaid Health Home option provides States with considerable flexibility in designing the payment methodology. • Current Health Home from other states (not yet approved by CMS) range dramatically in terms of per member per month (PMPM) payments. There are multiple reasons for the variations. • DHCFP envisions medical homes would combine different reimbursement systems that would include: • Fee-for service for office visits; • Monthly care coordination fees, and • Performance-based reimbursement.

12. Review of Medicaid Health Home Option • DHCFP intended to implement a Health Home Pilot Program in January 2012, where providers in the pilot would meet core standards based on Patient-Centered Medical Home (PCMH) accreditation, certification, achievement and recognition programs from: • National Committee for Quality Assurance (NCQA), • The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations), • URAC (formerly known as the Utilization Review Accreditation Commission), or • The Accreditation Association for Ambulatory Health Care (AAAHC). • Discussions with CMS have raised several issues (e.g. potential exclusion of HCBS waiver clients, limitations in per member per month payment arrangements) that make the Medicaid Health Home option not a practical solution for Nevada. • DHCFP will implement a medical home program that incorporates features of the Medicaid Health Home option, but seek authority from CMS that allows greater flexibility.

13. RECOGNIZED MEDICALHOMES

14. Medical Home Recognition & Accreditation Programs • Several organizations have developed or in the process of developing programs that recognize and/or accredit various health care organizations as medical homes according to specified sets of standards. • The industry leader in developing an assessment tool has been the National Committee for Quality Assurance (NCQA), used for the national Multi-Payer Advanced Primary Care Practice Demonstration. • Each separate “off the shelf” medical home recognition program has its own, unique set of standards.

15. Major PCMH Recognition Programs SOURCE: Burton, R., Devers, K. and Berenson, R (May 2011) Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Survey’s Content and Operational Details, The Urban Institute, Washington, DC.

16. CARE MANAGEMENT ORGANIZATION

17. Care Management Organization Rationale • Nevada Medicaid’s FFS population as a whole has high utilization rates. • Particularly high in population of clients with multiple co-morbidities, is beset by numerous chronic illnesses, and has a high prevalence of mental illness. • Little coordinated care management exists for this FFS population, which, at least partially, may explain the high utilization of inpatient admissions and emergency rooms. • PCG’s analysis shows that clinical interventions can achieve savings and improve quality of care in the near-term. • PCG’s assessment is that the statewide implementation of a medical homes model would be difficult. • A Care Management Organization (CMO) could achieve near-term improvements and support future medical homes development.

18. Care Management Organization Structures • Nevada experience, like other states, has shown that what seems to work best in chronic care management to have the PCP’s in the center of the focal point. • Traditional primary care case management (PCCM) programs focus on delivering basic primary and coordinating access to specialty care. A number of States have enhanced their PCCM models to provide more intensive care management for patients with complex needs. • Enhanced PCCM models offer a variety of added features including: • Tailored, evidence-based care management, • Additional provider payments/targeted provider incentives, • Access to health information technology, and • Increased use of performance measures. • Newer models for more holistic, integrated structures are emerging to promote accountable care that build on medical homes, emphasize evidence-based practice and facilitate adoption of health information technology.

19. Care Management Organization Scope • DHCFP intends to contract with a Care Management Organization (CMO) in July 2012 to allow for broader implementation of medical homes services with providers that may need support to integrate the medical, mental health and social needs of the recipient. • The CMO would provide an essential medical home “infrastructure” that can be utilized by providers that do not have the resources to build a medical home capacity. Examples of support provided by the CMO: • Identifying admissions in real-time and providing notification to the health home, • Providing information regarding best practices and continuing education, and • Linking patients to community resources (e.g., Diabetes Self-Management Training, Assertive Community Treatment). • The CMO will also directly provide specific care management programs for Medicaid clients without a medical home.

20. PROPOSED FUTURE REFORMS

21. Future Reforms for Medical Homes • DHCFP will seek to expand implementation of medical homes and address broader payment reforms, such as capitating medical home providers for medical services, than permitted under the Medicaid Health Home option. • DHCFP will seek an 1115 Research and Demonstration Waiver (1115 Waiver) which is required to obtain the flexibility to institute cost-effective payment arrangements with the new medical homes. • Payment reforms, including shared savings arrangements, would be addressed in the 1115 Waiver submitted to CMS. These cost savings will be tied to tangible utilizations metrics (e.g., hospitalizations rates for ambulatory care sensitive conditions, avoidable readmissions, utilization of emergency room for non-emergent conditions, etc.). • The 1115 Waiver will also seek authority to mandate clients enroll with the Care Management Organization and/or medical homes for the provision of evidenced-based, cost-effective delivery of medical services.