Medicaid Health HomesWebinar #2

Tim McNeill, RN, MPH

Health Homes in the ACA

Who can be a Health Home provider

Health Home services and hospitals

Conclusion

1

2

3

4 Collaboration Models

What is a Health Home?

3

• A Health Home is a optional Medicaid benefit created

by Section 2703 of the Affordable Care Act

• Person-Centered care coordination model that

integrates primary, acute, behavioral health and LTSS

to treat the whole person

• Health Home is not a physical home

• It is also not synonymous with a Patient-Centered

Medical Home (PCMH)

Are Health Homes and Medical

Homes the same

4

• Health Homes provide care coordination for a target population

• Health Homes do not provide medical management or medical

interventions for the population

• Disease self-management is a key component of Health Home

services

• Medical Homes focus on the implementation of medical

interventions to address the health needs of the population

• Health Homes will provide support for the consumer to comply

with the medical interventions prescribed by the Medical Home

– Transportation

– CDSME

– Social Supports

Do all States Offer Health

Homes?

5

• Health Homes is an optional Medicaid benefit.

• States that wish to participate must submit a State Plan

Amendment (SPA) to establish the Health Homes

benefit in their State

• There ae Twenty (20) approved State Plan

Amendments for Health Homes

• Additional States are in the process of submitting their

SPA to establish Health Homes

– California Assembly Bill 361, authorized California to

submit a Section 2703 application

States with an approved Health

Home amendment

6

Alabama Idaho

Iowa Kansas

Maryland Maine

Michigan Missouri

New Jersey New York

North Carolina Ohio

Oklahoma Rhode Island

South Dakota Vermont

Washington West Virginia

Wisconsin District of Columbia

Matrix of Approved SPAs

7

• The following link will provide a summary matrix of each of

the currently approved State Plan Amendments for Health

Homes.

– https://www.medicaid.gov/state-resource-center/medicaid-state-

technical-assistance/health-homes-technical-

assistance/downloads/hh-spa-at-a-glance-3-19-14.pdf

• The categories in the Matrix are as follows:

– State

– Target Population

– HH Providers

– Enrollment (Opt-In vs Opt-Out)

– Payment

– Geographic area (defined region vs Statewide)

How is the Health Home benefit

paid for

8

• States have great flexibility in how they set up the

reimbursement model for health homes.

• Most of the States and the District of Columbia have

set up Per Member Per Month (PMPM)

reimbursement models

• States receive a 90% enhanced Federal Medical

Assistance Percentage (FMAP) for the first eight

quarters (2 years)

What are Health Home Services

9

• Comprehensive Care Management

• Care Coordination

• Health Promotion

• Care Transitions

• Patient and Family Support

• Referral to community & social support services

Who is eligible for a Health

Home

10

• States have great flexibility in defining the target

population to participate in the Health Home benefit

• A beneficiary must have Medicaid to be eligible to

participate

• General requirements include one or more of the

following criteria:

– Beneficiaries that have two (2) or more chronic conditions

– Beneficiaries with one (1) chronic condition and is at-risk

for second chronic condition

– Have one serious and persistent mental health condition

Are Duals Included

11

• States can not exclude people with both Medicaid and

Medicare from Health Home Services

• If a Dual Eligible, meets the clinical criteria set by the

State, then they are eligible to receive the Health

Home benefit.

• Alignment of financial incentives

– Health Home Services for Duals with chronic depression

• Duals with 2 or more chronic conditions

• Duals in an ACO

• Duals in Bundled Payment

Evaluation Measures

12

Measure

Adult Body Mass Index (BMI) Assessment

Screening for Clinical Depression and Follow-up Plan

Plan All-Cause Readmission Rate

Follow-up After Hospitalization for Mental Illness

Controlling High Blood Pressure

Evaluation Measures (cont.)

13

Measure

Care Transition

Initiation and Engagement of Alcohol and Other Drug

dependence Treatment

Prevention Quality Indicator for Chronic Conditions

Ambulatory Care – Emergency Dept. Visits

Inpatient Utilization

Nursing Facility Utilization

What if we have Medicaid

Managed Care

14

• If a State has implemented Medicaid Managed Care,

beneficiaries that are enrolled with a MCO are eligible to

receive the Health Home benefit

• Beneficiaries receiving LTSS are eligible for Health Home

services

• Duals in a Medicaid MLTSS plan are eligible

• Duals in a Medicaid wavier program are eligible

• Medicaid beneficiaries receiving OAA services are eligible

• Duals receiving OAA services are eligible

Will the State Have Increased

Cost for Health Homes

15

• States will receive a enhanced 90% FMAP for the first

8 quarters of implementation of Health Homes

• The evaluation measures closely monitor expenditures

for the population during the 90% FMAP period

• If evaluation measures are achieved, the State will

receive more in cost savings than the cost of the

program, when it reverts to the standard FMAP

Where are the Savings?

16

• Multiple groups are in search of creating savings under the

transforming healthcare landscape

• Two Medicaid groups have the highest expenditures:

– Dual Eligibles

– Aged, Blind, and Disabled

Reform impacting Duals

17

• Value-Based Payment Reform

– ACOs

– Bundled Payment (BPCI)

– CJR

• Medicaid Managed Care

• MLTSS

• Health Homes

• Duals Demonstrations (high opt-out rates)

• D-SNP/C-SNP/I-SNP plans

• PACE programs

Which Population has the most

chronic disease?

18

• Most chronic conditions were more prevalent for dual-eligible

beneficiaries

– 72% of dual-eligible beneficiaries had two or more conditions

– Dual eligible beneficiaries were 1.7 times as likely to have 6 or more

chronic conditions

– 1.7 times more likely to have COPD

– 1.6 times more likely to have heart failure

– 1.4 times more likely to have diabetes

• 98% of readmissions, in 2010, were for Medicare beneficiaries

with two or more chronic conditions– CMS Chronic Conditions Among Medicare Beneficiaries, Chartbook – 2012 Edition.

Available Online: https://www.cms.gov/research-statistics-data-and-systems/statistics-

trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf

What are the characteristics of

Duals?

19

• According to the CBO, in 2009, there were 9 million

dual eligibles and they cost Federal and State

governments more than $250 billion in healthcare

benefits.

• Medicaid provides health care coverage to low-income

people who meet requirements for income and assets

• All Duals qualify for full Medicare benefits, but they

differ on the Medicaid benefits they qualify for

Duals and Chronic Disease

20

• Full duals are twice as likely as non-dual Medicare

beneficiaries to have at least three chronic conditions

• Duals are nearly three times as likely to have been

diagnosed with a mental illness, including chronic

depression

– Many more have undiagnosed or untreated chronic

depression

• In 2009, total average healthcare spending:

– Nonduals - $8,300 per year

– Full Duals - $33,400 per year

LTSS for Duals

21

• Less than 0.5% of partial duals are institutionalized

• 15% of full duals are institutionalized

• Partial duals often transition to a full dual after

completing the spend down period after a SNF/nursing

home admission.

• Full duals are five times as likely to use LTSS as non-

duals

• Full duals are twice as likely to use LTSS as the non-

dual ABD population

Health Homes and Mental Health

Populations

22

• Many States have targeted their Health Homes efforts to

beneficiaries with a mental illness

– Eligibility requires a mental illness and one other chronic

physical health condition

• What are some of the diagnoses that are included in the

Health Homes Mental Health diagnostic criteria

– Chronic Depression

– Bipolar Disease

– Psychizophrenia

– Schizoaffective Disorder

Experience with populations affected

by Mental Illness?

23

• Many Community-Based Organizations state that they have no

experience working with populations that have mental illnesses

so they could not serve a Health Home population

– Dual Eligible Beneficiaries are more than twice as likely to

have depression

– Persons with two or more chronic conditions are more likely

to have a depression co-morbidity

– Depression is the most common mental health problem

among older adults

– If you are working with Older Adults and persons with

disabilities and/or dual eligibles then you are likely also

working with persons with mental illness

Alignment of Incentives

24

• Goal: Reduce per capita costs

– Readmissions, Inpatient utilization, ER utilization

• MACRA

– Physician Participation in APMs for Medicare beneficiaries

to include Duals

• Hospital Readmissions Penalty

• ACO Shared Savings

• Bundled Payment for Care Improvement (BPCI)

• Comprehensive Joint Replacement (CJR)

• Health Homes

Operationalizing the concept

25

• District of Columbia

– Health Homes started January 1, 2016

– Population must have a Mental Illness and one or more

chronic physical health conditions

– Payment rate based on acuity

• High Acuity $481 PMPM

• Low Acuity $350 PMPM

– Must have Medicaid

– Dual Eligibles are included

Hospital Collaboration Model

26

• Hospital begins screening for depression for admitted patients

with one or more chronic diseases

• Medicaid patients that screen positive for depression are

referred for Health home enrollment

• Care transitions team completes enrollment and provides a 30-

day care transitions intervention

• Consumers are linked with all relevant evidence-based

programs:

– CDSME

– Fall prevention program

– PEARLS

DC Health Home Example

27

• George Washington University Medical Center

– Hospital is closely tracking their readmission rates

– Physicians are participating in the BPCI bundled payment

program

– Dual eligibles and consumers that face social determinants

of health are of particular concern

Goals Align

28

• Case managers are screening consumers with a physical health

condition for social determinants of health and chronic

depression or other SMI

– Focused on Duals and the Medicaid ABD Population

• Consumers hat screen positive are referred to the Health Homes

program

• A care transitions intervention is initiated

• Post transition, the consumers can be referred to community-

based evidence-based programs:

– CDSME

– Fall Prevention

– HCBS

Who is Paying for the Service

29

• Medicaid is the Payer for Health Home services

• GWU is the benefactor by partnering with the community

provider to serve Duals

• Both are incentivized to reduced readmissions, reduce inpatient

admissions, and improve health outcomes for a target

population of Duals

– GWU limits their risk for bundled payment and readmission

penalties for high-risk duals

– CBO receives an ongoing PMPM payment to provide care

coordination to the target population

– Community-Base Organization executes an agreement to expand

Health Home services to all admitted consumers that meet the

criteria.

Are Health Homes coming to my

State?

30

• States that intend to implement Health Homes must submit a

State Plan Amendment to CMS.

• The State Plan amendment is submitted by the Division of

Medicaid

• The Division of Medicaid must obtain stakeholder input

• Notice of submission of the SPA and the content must be made

available to the public

– Generally available on the State Division of Medicaid

website

– Monitor for notices of intent and make sure you attend the

planning meetings

Health Homes are in my State

31

• If you are in a State that has an approved State Plan

Amendment for Health Homes you should:

– Review the State Plan amendment from the Division of

Medicaid

– Read closely to determine the population that the State

included in the benefit

– Analyze the requirements to become an approved Health

Home provider

– Review the list of currently approved Health Home

providers

– Complete a GAP analysis to determine if you can be a

Health Home provider or partner with an existing provider

Key components of the Health Home

provider RFQ?

32

• What types of organizations can provide Health Home

Services?

• What is the application process to become a Health Home

provider?

• What are the staffing requirements to become a health home?

• What are the target populations for health home services?

• Are health homes limited to a defined geographic region in the

State?

What if I am not Eligible to be a

Health Home provider

33

• Identify an eligible population that you are currently serving

• Develop a scope of services you would expand under Health

Homes

• Define the cost to deliver the program

• Develop a pricing plan based on the market rate in comparison

to the Health Home rate

Health Home Collaboration Model

34

• Implement a service delivery model targeted to the population

you serve

• Develop a model to jointly deliver services to the target

population

• Propose a pricing/reimbursement model where costs are

allocated first.

Questions and Resources

• Tim McNeill, RN, MPH

– Phone: (202) 344-5465

– E-mail: tmcneill@me.com