Medicaid Health Homes In Context

1. Medicaid Health Homes In Context December 12, 2011 Lansing, Michigan Health Management Associates

2. Overview • Impact of multiple chronic conditions • Medicaid and behavioral health • Duals spending • The business case for coordinated care • Integrated care models • State/local strategies Health Management Associates

3. U.S. Department of Health & Human Services findings: • More than one in four Americans have multiple concurrent chronic conditions (e.g., arthritis, asthma, chronic respiratory conditions, diabetes, heart disease, human immunodeficiency virus infection, and hypertension) • Chronic conditions also include behavioral health problems (e.g., substance use disorders, mental illnesses, dementia, and developmental disabilities) • Chronic conditions “last a year or more and require ongoing medical attention and/or limit activities of daily living” • Prevalence increases with age • Chronic conditions result in: mortality, poor functional status, unnecessary hospitalizations, adverse drug events, duplicative tests, and conflicting medical advice Health Management Associates

4. Why Medicaid programs care about behavioral health Nationally: • Medicaid is the single largest payer for mental health services and the dominant purchaser of antipsychotic medications in the U.S. • By 2014, Medicaid spending is expected to increase annually by 8.3% for mental health services and by 6.2% for substance use disorder (SUD) treatment services. • About 12% of Medicaid beneficiaries received mental health or SUD treatment services in 2003, accounting for almost 32% of total Medicaid expenditures. • Nearly 27% of all inpatient hospital days paid for by Medicaid in 2003 were for mental health and addiction treatment. • Beneficiaries with mental illness and SUD are more likely than other Medicaid beneficiaries have one or more costly co-occurring physical health conditions. Health Management Associates

5. Duals Spending • Beneficiaries dually eligible for both Medicare and Medicaid (Duals) have historically been the costliest, with most complex beneficiaries, and have gotten the least attention • Controlling Medicare and Medicaid costs is now the single most important and most difficult economic and political issue in the US Health Management Associates

6. National Medicaid and Medicare Spending Per Dual with Physical, Mental, Cognitive Conditions Health Management Associates

7. Example: The Ohio Medicaid Business Case for Coordinated Care • The Best Practices in Schizophrenia Treatment (BEST) Center of the Northeast Ohio Medical University (NEOMED) and the Health Foundation of Greater Cincinnati commissioned a study led by HMA to document the business case for integrated physical and behavioral health care. • Findings are available at http://www.neoucom.edu/bestcenter/index.php/news/49/58/Report-shows-Medicaid-Beneficiaries-with-mental-illness-also-likely-to-have-chronic-physical-problems Health Management Associates

8. Example: The Ohio Medicaid Business Case for Coordinated Care • Ohio’s adult Medicaid beneficiaries with serious mental illness (SMI): • Represent about 10% of total Medicaid beneficiaries and account for 26% of total Medicaid expenditures; • Have co-occurring chronic physical health conditions at rates higher than adult Medicaid beneficiaries without SMI (heart disease, hypertension, diabetes, chronic respiratory conditions, dental disease); • Have more than twice as many hospitalizations for certain ambulatory care sensitive conditions (asthma and diabetes) than non-SMI adults; and • Have two times higher rates of emergency department visits for asthma than non-SMI adults. Health Management Associates

9. Example: The Ohio Medicaid Business Case for Coordinated Care • As a subset of the SMI population, Ohio’s adult Medicaid beneficiaries with schizophrenia: • Have three times more hospitalizations for uncontrolled diabetes and twice the number of hospitalizations for pneumonia and chest pains compared with non-SMI adults; • Have twice the number of hospital emergency department visits for hypertension and uncontrolled diabetes as non-SMI adults; and • Have three times higher costs for skilled nursing facility, prescription drug and home health services than non-SMI adults. Health Management Associates

10. Example: The Ohio Medicaid Business Case for Coordinated Care • Thirty-two percent of SMI adults (82,454) are Duals compared with 31% ABD and 37% CFC. • The majority of individuals with schizophrenia and psychosis are Duals. • Total Medicaid expenditures and per person costs are higher for individuals with ABD and Dual eligibility status than individuals with CFC eligibility status. Health Management Associates

11. Modified Integrated Care Models – Health Management Associates (Conway, Vachon, Lyon & Smith) • Enhanced collaboration between primary care and behavioral health • Primary care screening in behavioral health setting • Primary care treatment in behavioral health setting • Mental health consultation services in primary care setting • Behavioral health screening in primary care setting • Behavioral health treatment in primary care setting • Unified behavioral health and primary care • Comprehensive care management • Shared care planning/joint treatment plan development Health Management Associates

12. Generally, what are states doing/planning? • Missouri – Incentivizing CMHC and primary care health homes to act on existing electronic health information. • Rhode Island – Acknowledging role of CMHOs as health home for SPMI and restructuring program and service delivery to comply with health home requirements. • Ohio–Governor’s office requiring that health homes are developed as the foundation upon which additional structures will be placed (i.e., Integrated Care for Duals, ACOs). Focus first on health homes for SPMI. • Los Angeles County – Departments of Health Services, Mental Health and Public Health exploring health home services for the 9.8 million residents who utilize publicly-funded services. Health Management Associates

13. LA County Medi-Cal Data Most Frequently Found Medical Diagnoses Per SMI Adult Beneficiary Health Management Associates

14. LA County Medi-Cal Data Most Frequently Found SMI Diagnoses Per SMI Adult Beneficiary Health Management Associates

15. LA County Medi-Cal Data Most Frequently Found Prescription Rx Per SMI Adult Beneficiary Health Management Associates

16. LA County Medi-Cal Data Most Frequently Primary Care Service Providers Treating SMI Adults Health Management Associates

17. Health Management Associates Questions and discussion

18. Medicaid Care Coordination Services for Individuals with Chronic Conditions Health Management Associates December 12, 2011 Lansing, Michigan Health Management Associates

19. Overview of Health Home Services • Enumerated in Title XIX of Section 1945 of the Social Security Act • Provides states the option to cover care coordination for individuals with chronic conditions through health homes • Eligible Medicaid beneficiaries have: • Two or more chronic conditions, • One condition and the risk of developing another, or • At least one serious and persistent mental health condition Health Management Associates

20. Overview of Health Home Services Provides 90% FMAP for eight quarters for: • Comprehensive care management • Care coordination • Health promotion • Comprehensive transitional care • Individual and family support • Referral to community and support services Health Management Associates Payment is for 6 components of “health home” care coordination services and NOT direct treatment

21. Examples of Service Definitions • Comprehensive care management services are conducted with high need individuals, their families and supporters to develop and implement a whole-person oriented treatment plan and monitor the individual's success in engaging in treatment and supports. • Care coordination is the implementation of the individualized treatment plan (with active involvement of the individual served) for attainment of the individuals' goals and improvement of chronic conditions. • Health promotion services encourage and support healthy ideas and concepts to motivate individuals to adopt healthy behaviors. Health Management Associates

22. Examples of Service Definitions • Comprehensive transitional care services focus on the transition of individuals from any medical, psychiatric, long-term care or other out-of-home setting into a community setting. Designated members of the health home team work closely with the individual to transition the individual smoothly back into the community and share information with the discharging organization in order to prevent any gaps in treatment that could result in a re-admission. • Individual and family support services are provided by community support professionals and other members of the health team to reduce barriers to individuals' care coordination, increase skills and engagement and improve health outcomes. Health Management Associates

23. Examples of Service Definitions • Referral to community and social support services provide individuals with referrals to a wide array of support services that will help individuals overcome access or service barriers, increase self-management skills and improve overall health. Health Management Associates

24. Federal Guidance No immediate CMS plans to issue regulations. Instead guidance is available through: • SSA Sec. 1945 (Sec. 2703 of the ACA) • November 16, 2010 Dear State Medicaid Director letter issued by CMS available at https://www.cms.gov/smdl/downloads/SMD10024.pdf • Medicaid SPA Pre-Print available at https://www.cms.gov/smdl/downloads/SMD10024b.pdf • Informal feedback from CMS and SAMHSA • Content of approved SPAs (Missouri and Rhode Island) Health Management Associates

25. How are health homes different from patient centered-medical homes? Health Management Associates

26. How are health homes different from patient centered-medical homes? Health Management Associates

27. Reimbursement Methods Considerations Start-up costs Training Health team composition Sustainability • Case rate • PMPM (based on delivery of a service) • Base rate • Tiered by severity • Performance incentive • Other Health Management Associates

28. Cost Savings • Most savings accrue to physical health • Consider how savings can be applied to sustaining health home services • Costs may increase for a period before savings estimates achieved • Consider a longer tail (e.g., savings or slower rate of increase over 5 years) Health Management Associates

29. Likely Feedback From the Feds From SAMHSA From CMS Choice and opt-out No age restrictions (under review by CMS) No exclusion of Duals Provider and client notification Leveraging existing services (e.g., TCM, HCBS waiver) Non-duplication of payment Developing goals and quality measures Need help (e.g., quality measures, reimbursement)? • Use of a chronic care model • Provider qualifications • Health team members • Engaging behavioral health / primary care • Addressing substance use • Capacity for new service users • Need help (e.g., screening tools, integration models)?

30. Overarching Message from CMS • States should present their best case and rationale for health home services. • States should explain the problem, how health home services would fix the problem and how a state would be able to tell the difference through changes in clinical outcomes, quality of care and experience of care using quality measures as well as other metrics that show changes in service utilization and costs. • CMS is not interested in the status quo and expects health homes to show value. Health Management Associates

31. Health Management Associates Questions and discussion