State and Local Policy Update: How states can (and are) advancing medical homes Presented by: Neva Kaye Senior Program Director National Academy for State Health Policy August 2008 1
NASHP 20 year old non-profit, non-partisan organization Academy members Peer-selected group of state health policy leaders No dues commitment to identify needs and guide work NASHP staff Develop, identify, and disseminate promising practices Work informed and guided by members Working together across states, branches and agencies to advance, accelerate and implement workable policy solutions that address major health issues 2
The Evidence for Medical Homes Improve quality Good evidence that longitudinal care Increases needs recognition, Results in more accurate/earlier diagnosis; Decreases emergency room use and hospitalization Starfield. Primary Care: Balancing Health Needs, Services, and Technology. 1998 Adults who are sent reminders more likely to receive preventive screening; g;patients with medical homes more likely to receive reminders Commonwealth Fund 2006 Health Care Quality Study Reduce cost A primary care entry point produced >50% reduction in ambulatory episode of care expenditures Forrest and Starfield. Fam Pract 1996 3
Improve Equity GETTING NEEDED CARE: Racial and Ethnic Differences Are Eliminated When Adults Have Medical Homes Percent of adults 18 64 reporting always getting g care they need when they need it 100 Medical home Regular source of care, not a medical home No regular source of care/er 75 74 74 76 74 50 52 38 53 44 52 31 50 34 25 0 Total White African American Hispanic Note: Medical home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running on time. Source: Commonwealth Fund 2006 Health Care Quality Survey. 4
The Patient Centered Medical Home Four major primary care physician groups support the Patient Centered Medical Home Model (PCMH) a health care setting that facilitates partnerships p between individual patients, and their personal physicians, and when appropriate, the patient s family Patient Centered Primary Care Collaborative (PCPCC) is a coalition formed to develop and advance the PCMH 5
The Task Force for Implementation of the Patient-centered Medical Home Model in State Medicaid and SCHIP Programs Partnership of PCPCC & NASHP Supported by the Commonwealth Fund Focus on developing/disseminating i i state policy options and providing group technical assistance to states 6
Questions? Comments? 7
In Theory What states can do to advance medical homes for Medicaid and SCHIP beneficiaries and why 8
Why Focus on Improving Medical Homes in Medicaid/SCHIP now? Medicaid agencies have a long-standing interest in providing medical homes to program participants Circumstances are right for making major advances in Medicaid s implementation of medical homes New opportunities There are existing structures on which to build State agencies already developing new models/approaches/ strategies 9
New Opportunities Creation of Patient-Centered Medical Home (PCMH) model and Patient Centered Primary Care Collaborative (PCPCC) NCQA: process and standards for assessing if practice functions as medical home Increase in use and usefulness of Health Information Technology Medicare medical home demonstration 10
Existing Structures That Can Support Mdi Medical lhomes Unique benefits that support medical homes Managed Care Disease Management Health Information Technology 11
Medicaid Benefits Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) States must provide to all children under age 21 Includes outreach and patient education, well-child visits, broad benefits, and support for accessing services Targeted Case Management (TCM) States may provide to defined groups of beneficiaries Includes assessment; care plan development; referral to services; and monitoring/follow-up activities Hurdles EPSDT is not available to adults Need better connection between TCM and primary care Definition of allowable services in flux at federal level 12
How Managed Care Can Support Mdi Medical lhomes Delivery system/payment y structure PCCM programs (e.g., North Carolina) Performance incentives for both HMOs and PCCM Quality improvement infrastructure Measure performance HEDIS, CAHPS, and others Change plan and provider behavior HMO programs required to contract with external quality review organizations (EQRO) and conduct performance improvement projects Infrastructure has already been used to support practice change in other areas Many states working with clinicians in public/private partnerships 13
Medicaid Use of HMO and PCCM, 2006 Source: CMS Medicaid Managed Care Enrollment Report # Medicaid Agencies with Program (N=52; incl. DC and PR) # Medicaid Beneficiaries Enrolled (Total Mediciaid = 45.6 million) # 'states' 50 40 30 20 10 0 39 28 # people e enrolled (m millions) 30 20 10 0 19.3 65 6.5 HMO PCCM HMO PCCM 14
Changing Managed Care To Support Medical Homes How to implement model through HMO Contract requirements? Payment incentives? How to modify existing QI infrastructure What to measure? How to use reporting to support decision-making and improvement by providers and patients? How to support practice change? Best ways to enhance standard PCCM model Change common perception: not gatekeeper but home? Change expectations of practices? Change reimbursement: additional coordination fee for practice? Create stronger connection to specialty care and care coordination? Better, more timely feedback on practice performance tied to payment? 15
Disease Management to Health Management In 2004, 22 Medicaid agencies had disease management programs, most disease-specific By 2007, some moved toward approach envisioned in medical home model, more are interested Connection to primary care: Indiana, Rhode Island Population-based: Illinois, Indiana, Rhode Island, Vermont Pay-for-performance: Illinois, Washington One manager/multiple chronic diseases: Illinois, Indiana, Pennsylvania, Rhode Island, Vermont, Washington Big remaining i hurdles Very few connected to physician practice or PCCM program Most still disease specific management model contracted to private company 16
Health Information Technology Transformation Grants Established in Deficit Reduction Act (DRA) Grant program for states t to improve effectiveness and efficiency of providing Medicaid Many used to implement HIT/HIE/EHR and otherwise support medical homes Medicaid Information Technology Architecture (MITA) Initiative A national framework to support improved systems development and health care management for the Medicaid enterprise 90% Federal funding for design, development, or installation (need pre-approval from CMS) 17
Questions? Comments? Suggestions? 18
In Practice What States are Doing to Advance Medical Homes 19
Medicaid/SCHIP Programs Already Working to Implement/improve Medical Home WA CA OR NV ID UT MT WY CO ND SD NE KS MN IA MO WI IL MI IN KY OH WV NY PA VA ME VT NH MA RI NJ DE MD DC AZ NM OK AR TN SC NC MS AL GA TX LA AK FL HI Source: Preliminary results of NASHP scan States working on medical home initiative for Medicaid or SCHIP program participants 20
Identified Efforts Vary Widely Most starting w/children or subgroups of people w/complex needs Most have legislative authority/mandate or active support of Governor Efforts being developed for both PCCM and MCO delivery systems 21
Five Areas of Activity Forming key partnerships Defining and Recognizing a Medical Home Purchasing and Reimbursement Support for Changing Practices Measuring Results 22
Developing Key Partnerships Involving providers and consumers in planning Ongoing involvement in developing plans Feedback on plans from broad group Partnering with other payers Formal Multi-Payer Purchasing Initiatives Private sector: CO, ME, NH, PA, RI, VT Medicaid/SCHIP and state employees: WA All-in via legislation: MN, OR Other efforts 23
Defining Medical Home LA, NH, OK use PCPCC Joint Principles Most modified dto allow non-primary care providers (PCPs) to serve as medical homes, if meet criteria Others have own definitions CO, MN, OR, and WA defined in Bills or Statute Idaho defined by Task Force in recommendations to Governor All definitions reviewed include core elements of primary care 24
Developing Criteria and Processes to Recognize Medical Homes Four will use criteria and process in NCQA/PPC: LA, NH, CO (adults), VT Colorado (children) draft criteria offers options to practices Practice certification to verifiably ensure quality of care NICHQ Medical Home Index, Cooley and McAllister this tool is more aligned with Colorado standards and requirements in medical home legislation EPSDT 416 CAMHI Colorado Child Health Survey NCQA/PPC for those providers/health plans already using it (i.e., in adult effort) Minnesota s proposed criteria include: Participating in learning collaborative Use of internal registry for patient population management Keeping updated care plans Including patient/parent on care teams 25
Themes in payment policies Many plan to pay PCPs fee-for-service + PMPM payment for administration Five considering pay for performance to providers (CO, LA, NH, OK, WA) Five considering multiple structures, capitation, global fee, DRGs, risk adjustment.(la, MN, NH, OR, WA) Two considering how to use purchasing through health plans to increase access practices (CO, OR) Many interested in developing incentives for consumers 26
Other Payment Policies Colorado will pay enhanced reimbursement for EPSDT/well child visits Idaho pays py enhanced payment py for identifying diabetic patients on registry Minnesota plans to vary payment by severity of patient condition Oklahoma considering transition payments to assist PCPs 27
Arizona Medicaid MCO Purchasing RFP required proposals to include vision of medical home Plans to award additional funding to one MCO to work w/state to implement vision Oregon Public Employee Purchasing Board Included medical home as domain of RFP Plans established medical home pilots 28
Support for Changing Practices Provider adoption of good practices Learning collaboratives for practices (MN, WA) In office training (CO) Four developing means to inform providers about their performance (CO, LA, NH, WA) All developing means for giving providers information about individual beneficiary needs/past utilization 29
Three States Reported That Measures Were Under Consideration Louisiana HEDIS Rates of hospitalizations for ambulatory care sensitive conditions New Hampshire Practice level structure and process measures, consistent with Medicare s Physician Quality Reporting Initiative (PQRI) program 30
Three States Reported That Measures Were Under Consideration Washington: structure, process and outcome, including Primary care provider ability Rate of clinics with specified structures in place that support performance Rate of adherence to clinical practice guideline performance measures Utilization changes Emergency department utilization for non-emergent and emergent/primary care-treatable care Hospitalizations for ambulatory care sensitive conditions Patient experience Parent assessment of medical home through annual clinic-based patient surveys Parent perception of quality of care 31
What Health Plans Can Do Support and spread practice change Support and spread changes in consumer behavior Provide resources for care coordination Reward practices that deliver effective primary care Provide information to primary care practices and consumers Collaborate (or coordinate) with others 32
For More Information E-mail nkaye@nashp.org www.nashp.org www.pcpcc.net pp Join NASHP listserve for people working to advance medical homes in states E-mail acullen@nashp.org Forthcoming Products Webcast examining i multi-payer efforts Report of state opportunities and experience Webcast summarizing report findings 33