Policy Initiatives to Achieve Better Care Medical Homes and Health Homes
Medical Homes A medical home is a coordinated care model focused on acute care for all populations. 2
Medical Home Outcomes: Lowers health costs; Increases quality; Reduces health disparities; Achieves better outcomes; Lowers utilization rates; and, Improves compliance with recommended care. 3
Health Homes - Policy Health homes are a population-based integrated care model targeting consumers with chronic conditions, which coordinate medical and behavioral health care, and community and social supports. Health care reform legislation (Section 2703) established health homes as a new state Medicaid option for service delivery specifically for enrollees with chronic conditions. 4
Health Home Strategy From cost perspective, the member populations are split 5% with multiple chronic conditions and 95% with less complex conditions This 5% accounts for half (49%) of health care spending. Strategy: For the 95% with less complex conditions, access to better medications, internet-based services, integrated and coordinated care 5
Health Homes: Seeking Better Care to Achieve Additional Savings Policy Rationale: Rigorous prior authorization and reduction of provider rates cannot produce the savings and improve the care for the 5% of population with chronic conditions. Strategy: For the 5%, policy is driving managing the wellness of this population with chronic health conditions (physical and mental) and their social support needs. Examples (Rhode Island Mandatory Health Homes for SMI Pop and Missouri Health Homes for persons with SMI/SPMI) 6
Section 2703 of the Affordable Care Act State Option to Provide Health Homes for Enrollees with Chronic Conditions. Health homes qualify for 90% Federal medical assistance percentage (FMAP) rate for first eight fiscal quarters. CMSs overarching approach (also know as The Triple Aim ) to improve health care by: Better Healthcare for Individuals Improving the Health of Populations Reducing the Per Capita Costs of Health Care 7
Overview: Healthcare Reform Opportunities and Challenges 1. CBHO Healthcare Homes - Integration of primary care, and behavioral health needs available through and coordinated by the CBHO 2. IT capacity to fully integrate EHRs with all other providers 3. Provide care management/care coordination for all integrated health care needs 8
Overview: Healthcare Reform Opportunities and Challenges CBHO Healthcare Homes - Two Types of Involvement: 1. Participation in development and deployment of bi-directional integrated care projects. 2. Become a health neighbor to a health home as a high performing specialty MH/SU provider organization. 9
Policy Initiatives to Achieve Better Care Quality Improvement
Quality Improvement Policy Healthcare Effectiveness Data Information Set (HEDIS) used by 90% of health plans. New Medicaid HEDIS performance measures for behavioral health. The seven new measures fall into three categories medication adherence, hospital follow up, and physical health management (specifically around cardiovascular screenings, diabetes screenings, cervical cancer screenings, and follow-up after hospitalization). To be added in 2013. 11
Quality Improvement National Quality Forum (NQF) performance measures for consumers with chronic complex conditions. Optimizing patient function, maintaining function, or preventing further decline in function. Seamless transitions between multiple provider organizations and care sites. Access to a usual source of care. Shared accountability across patients, families, and provider organizations. Patient clinical outcomes in terms of morbidity and mortality. Avoidance of inappropriate, non-beneficial end-of-life care. Cost transparency. Shared decision-making. 12
Policy Initiatives to Achieve Better Care Integrated Care
Horizontal and Vertical Integration: Opportunities for Collaboration Horizontal Integration within and between programs Assessments & Protocols designed to identify healthcare risk Self help programs to promote well care and healthy living Vertical Integration within and between provider agencies Coordination and integration of care across disciplines and providers HIT alert system for crises occurrences 14
Integrated Care Simply put, it's a coordinated system that combines medical and behavioral services to address the whole person, not just one aspect of his or her condition. Medical and mental health providers partner to coordinate the detection, treatment, and follow ]up of both mental and physical conditions. Combining this care allows consumers to feel that, for almost any problem, they have come to the right place. 15
At a Cross Roads of Future Behavioral Healthcare Service Capacity 1. Community Behavioral Health Organizations (CBHO) focus on serving SED/SMI populations in a carve-out funding model North Carolina 1915b/c Medicaid waivers for MH/SU/IDD Michigan 1915b/c Medicaid waivers for MH/SU/IDD Missouri 25 CBHOs becoming Healthcare Homes Connecticut Specialty Care Medical Homes for Adult SPMI Population Kansas CBHOs becoming Health Homes New Jersey CBHOs becoming Health Homes for SMI/SPMI Population 2. CBHOs focus on serving all clients in a carve-in service delivery funding model New Jersey Four Statewide Accountable Care Organizations Michigan Statewide Accountable Care Org. For Dual Eligibles Arkansas Medical- Care Partnerships New York Age 55 Plus Carve-In, Health Home Initiative for persons with Behavioral Health, Carve-In for SPMI/SMI Adults 16
So How does the Behavioral Health Delivery System Fit into the new Healthcare Ecosystem? 17
Strategic Initiatives for North Carolina Providers Enhanced Access, Increased Results from Care, Cost Management
North Carolina Provider Readiness Assessment to Measure CBHOs Value as a Partner to Improve Care 1. Access to treatment processes and costs and level of redundant collection of information and process variances 2. Centralized Schedule Management with clinic/program wide and individual clinician Back Fill management using the Will Call procedure 3. No Show/Cancellation management principles and practices using an Engagement Specialist to provide qualitative support 4. Re-engagement/transition procedures for current cases not actively in treatment more 19
North Carolina Provider Readiness Assessment to Measure CBHOs Value as a Partner to Improve Care 5. Internal levels of care/benefit package designs to support appropriate utilization levels for all consumers 6. Outcome Assessment Capacity (i.e., PHQ-9, DLA-20, 10 X 10 Wellness Indicators, etc.). 7. Level of key performance indicators for all staff including cost-based direct service standards and ability to measure Key Performance Indicators 8. Use of Collaborative Concurrent Documentation more 20
North Carolina Provider Readiness Assessment to Measure CBHOs Value as a Partner to Improve Care 9. Current level of internal utilization management functions including: Pre-Certs, authorizations and re-authorizations Referrals to clinicians credentialed on the appropriate third party/aco panels Co-Pay Collections Timely/accurate claim submission to support payment for services provided 10. Payer mix enhancements including third party payers more 21
North Carolina Provider Readiness Assessment to Measure CBHOs Value as a Partner to Improve 11. Revenue Cycle Management including co-pay collection processes 12. Public information and collaboration with medical providers in the community through an Image Building and Customer Service plan 13. Integrated physical and behavioral healthcare service delivery capacity 14. Change management history on time to change and effective implementation 22
Policy Initiatives to Achieve Better Care Value Based Purchasing
Value-Based Purchasing Model 1. Payment Reform is moving from paying for volume to paying for value/quality 2. VBP requires integration of clinical, quality and financial information and the ability to track and analyze costs by consumer, provider, team, program, and payor and can operate effectively under fee for service, case rate, and subcapitation payment models in order to succeed under a variety of Pay for Performance (P4) bonus arrangements. 3. Medicare Case Study: October 2011 Medicare will launch VBP for hospitals - +1% to 1% rate adjustment based on quality measures In 2017 = +2% to 2% Medicare rate adjustment based on benchmarks that getter higher each year race to the top in hospital quality 24
Behavioral Health Funding Policy Most health care funding will be through "payers" (rather than 'safety net' sorts of grant funding) and most payer models will be based on managed care and ACO model with reimbursement focused on "total cost of care" and "pay for performance." There will be three big "macro" shifts in allocation of funding by payers: Dollars will move from hospitals, institutional care to communitybased From specialists to primary care From face-to-face services to tech-enabled services and other technologies 25
Payment Reform: Specialty Care moving to Case Rate Payment Models U.S. Population with Serious Mental Health and Substance Use Disorders Payment Models to cover the Medical and Behavioral Health Prevention, Primary Care and Chronic Disease Management including Dedicated Funding for Uninsured; Bonus Structure for managing Total Health Expenditures Fully Integrated Medical/BH Health Care Home Medical/BH Health Care Home Partnership CBHO with links to multiple Medical Homes Linkages to High Performing Specialists that can support the management of Total Health Expenditures and minimize Error Rates; Case Rates with a Bonus Structure Clinic Food Mart CBHOs working with Health Care Homes through Partnerships or Linkages Clinic Food Mart Other Specialty CBHOs Linkages to Hospitals, Long Term Care Facilities & Supported Housing serving persons with MH/SU Disorders; Bundled Payments, Case Rates and Bonus Sharing Arrangements for management of Total Health Expenditures and minimize Error Rates 26
Value-Based Purchasing Attainment Levels: 1. We have educated ourselves and our members about the new payment models that will be unfolding under the rubric of Value-Based Purchasing and understand that payment reform is moving from paying for volume to paying for value. 2. Leveraging the integration of our clinical, quality and financial information, they are able to determine, in near real-time, the cost of each service provided in their organization. 3. Member centers have the ability to track and analyze costs by consumer, provider, team, program, and payor and can operate effectively under fee for service, case rate, and sub-capitation payment models. 4. Member centers are able to integrate clinical and financial data to succeed under a variety of Pay for Performance (P4) bonus arrangements. 27
Value-Based Purchasing Model Core Elements 1. Know cost per service/staff type 2. Identify clinically recommended service mix, frequency and duration per level of care/intensity of need (i.e., ICD-10 CM) to support determination of costs of bundled/episodic care needs 3. Provide outcomes to demonstrate reduction of high/disruptive cost services (i.e., reduction in ER visits) 28
Health Home Payment Methodology Section 2703 of The Affordable Care Act permits States to structure a tiered payment methodology that accounts for the severity of each individual s chronic condition and the capabilities of the designated provider, or the team of health professionals. Flexibility is afforded to States to propose alternative models of payment not limited to a PM/PM. 29
Medical Homes: Value-Based Purchasing Fee for Service is headed towards extinction Health Care Home models will begin with a 3-layer funding design with the goal of the FFS layer shrinking over time Being replaced with case rate or capitation with a pay for performance layer Person Centered Medical Homes 30
Q&A 31