Medicaid Health Plans and the Medical Home

Medicaid Health Plans of America mhpa2014 October 27, 2014 Tricia Marine Barrett VP, Product Development, NCQA

About NCQA

Private, independent non-profit health care quality oversight organization founded in 1990 Our Mission • To improve the quality of health care

Our Method • Measurement We can’t improve what we don’t measure • Transparency

We show how we measure so measurement will be accepted • Accountability Once we measure, we can expect and track progress

Largest health plan accreditor,

roughly 170 million lives in

HEDIS

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The Medical Home

Patient-Centered Medical Home 2014 (6 standards/27 elements)

1) Patient-Centered Access (10) A) *Patient-Centered Appointment Access (4.5) B) 24/7 Access to Clinical Advice (3.5) C) Electronic Access (2)

2) Team-Based Care (12) A) Continuity (3) B) Medical Home Responsibilities (2.5) C) Culturally and Linguistically Appropriate Services

(2.5) D) *The Practice Team (4)

3) Population Health Management (20) A) Patient Information (3) B) Clinical Data (4) C) Comprehensive Health Assessment (4) D) *Use Data for Population Management (5) E) Implement Evidence-Based Decision Support (4)

4) Care Management and Support (20) A) Identify Patients for Care Management (4) B) *Care Planning and Self-Care Support (4) C) Medication Management (4) D) Use Electronic Prescribing (3) E) Support Self-Care and Shared Decision Making (5)

5) Care Coordination and Care Transitions (18)

A) Test Tracking and Follow-Up (6) B) *Referral Tracking and Follow-Up (6) C) Coordinate Care Transitions (6)

6) Performance Measurement and Quality Improvement (20)

A) Measure Clinical Quality Performance (3) B) Measure Resource Use and Care

Coordination (3) C) Measure Patient/Family Experience (4) D) *Implement Continuous Quality

Improvement (4) E) Demonstrate Continuous Quality

Improvement (3) F) Report Performance (3) G) Use Certified EHR Technology (0)

*Indicates Must Pass Element

NCQA PCMH Clinician Recognitions

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As of 9/30/2014

Policy Landscape Supports PCMH

• Section 2703 of the ACA ‘Health Homes’ provides states additional funding for core medical-home related activities

• Medicare: Medicare Advanced Primary Care Practice Demonstration, Comprehensive Primary Care Initiative, other demos

• State legislation & regulation supporting PCMH: MD, MT, CT, MA, NY, etc.

• Congressional Proposals: SGR-repeal includes support for PCMH & PCSP 6

37 States* Have Public and Private Patient-Centered Medical Home (PCMH) Initiatives That Use NCQA Recognition

WA

OR

AZ

NV

WI

NM

NE

MN

KS

FL

CO

IA

NC

MI

PA

ME

VT

OH

RI NJ

MD VA

MA

MO

HI

OK

GA

SC TN

MT

KY

WV DE

AR

LA

MS AL

IN IL

SD

ND

TX

ID WY

UT

AK

CA

CT

NH

DC

Public (7)

Private (13)

Both – Including Multi-Payer (17)

NY

*Includes the District of Columbia

Key findings: Must-pass elements

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• Most difficult must-pass elements (from PCMH 2011) to achieve 100% credit: – Use of Data for Population Management (2D) – Care Management (3C) – Referral Tracking and Follow up (5B)

Key Findings

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• Elements with >85% full credit: – Continuity (1D) – Implement Evidence-Based Guidelines (3A) – Use Electronic Prescribing (3E) – Demonstrate Continuous Quality Improvement (6D)

• Elements with <50% full credit: – After-Hour Access (1B) – Electronic Access (1C) – Provide Referrals to Community Resources (4B) – Measures of Performance (6A) – Patient Experience Data (6B)

What makes a successful PCMH?

• Resources • Health information technology • Team-based care • Formal Approach to Quality Improvement • Practice Culture & Leadership References: 1. Scholle et al. Support and strategies for change among small patient-centered medical home practices. Ann Fam Med. 2013. 2. Tirodkar et al. There’s more than one way to build a medical home. Tentatively accepted at AJMC. 3. O’Malley et al. Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study. Tentatively accepted at JGIM.

PCMH transformation is challenging without...

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• Changing the payment model – Practices need to be reimbursed for care management, care

coordination activities – Only in 2015 will CMS start paying for chronic care management

(CCM), unclear if Medicaid programs will adopt news CCM codes • The right information about utilization, especially super-users

– Practices often don’t have access to specialty, hospital discharge, behavioral health and pharmacy data, unless they are part of a system

– Sharing information can guide care management efforts, support care coordination

• Staff to support additional responsibilities – Physicians, nurse practitioners and physician assistants need to be

able to practice to the fullest extent of their license – Care managers, care coordinators and other (often non-medical staff)

can add enormous value, allow clinical staff to focus on complex patients

What Medicaid plans can do

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Changing the payment model

• Monthly care coordination fees preferred by practices because of flexibility

• Enhanced fee-schedule

• Quality bonus & shared savings

• See CMS, NY, MD, RI experiences for guides for amount

Sharing data for care management

• Identify and share list of high risk patients in need of care management

• Act as middle-man among providers and hospitals; ensure admit/discharge information gets to PCPs

• Share pharmacy information

Supporting additional staff

• Work with other payers to build care management hubs that are shared resource among practices (VT)

• Align additional reimbursements with new staff costs

• Can delegate some complex care management activities to save $

States need to encourage and support these activities, need alignment across plans, the right financing

Lessons from working with states

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• Attribution: conversation with practices about panel important to get on the same page

• Money: states may tie provider reimbursement to fee schedule, may not include additional incentive payments in cap rate

• Churn: expansion should help you retain some beneficiaries while you may lose others; need to help practices understand coverage

• Data merge: helps practices if they get one report from all (Medicaid) payers

• Provider buy in: key component of PCMH is building connections to specialists, they also need to be engaged and willing to support better care

• Expectations: if you want to reduce ER use, need to measure it, tie incentives to it, share data with practices

Key take-away points

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• Evidence for PCMH is building and it is generally positive for key outcomes (reducing utilization and cost; improving clinical quality and patient satisfaction).

• Transformation is a journey and there are many ways to get there; we are learning about what makes a successful PCMH.

• Health plan can play an important role.