Key Considerations in Designing the Medicaid Health Home SPA

Alicia D. Smith, MHA

Senior Consultant

Health Management Associates

Discussion Points

• Defining health homes• CMS expectations• Key planning and

implementation considerations

• Submitting the SPA

• Measures• Reimbursement• Cost savings• States’ proposed

approaches• Parting thoughts

Defining health homes

• Enumerated in Sec. 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

Defining health homes

• 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

• Services by designated providers, a team of health care professionals or a health team

Defining health homes

• Beneficiaries choose the provider, team of health professionals or health team

• States may apply for matchable planning grants up to $500K

• Reimbursement may be on a PMPM or alternative basis

Guidance

No immediate CMS plans to issue regulations. Guidance from:

• SSA Sec. 1945 (Sec. 2703 of the ACA)• November 16, 2010 Dear State Medicaid Director letter

issued by CMS• Medicaid SPA Pre-Print• Informal feedback from CMS and SAMHSA

CMS Expectations

• Client choice• Whole-person service orientation• Person-centered care that improves outcomes • Services provide value for State Medicaid programs• Support CMS’ three areas for improvements

(experience of care, health status, reduce costs)• Reduce hospital and nursing facility admissions, lower

hospital ED use

Planning Considerations• Transformation vs. match-grab• Define the health home model• It is okay to:

• Convert existing services to be claimable under health home• Stagger implementation (must track unique users)• Ramp up services on a less than statewide basis

• Determine the role managed care will play• Complement vs. duplicate existing services• Coordinating services for the whole-person • Measuring outcomes

Implementation Considerations

• States’ ability to make the SPA operational • Payment for coordination and linkage; not treatment• Data sources to calculate measures• Consider use of HIT to facilitate HIE• Developing transitional care agreements with local

hospitals• Partnering with primary care providers (e.g., FQHCs)

Submitting the SPA

• SAMHSA consultation• Single state Medicaid agency as lead (or “hall pass” to SMHA)• Overview of health home model• Areas of consultation• Available dates for teleconference

• Suggested draft SPA documents to CMS• Cover letter• SPA template• Client process narrative• Graphic depiction of model

Key SPA Sections

• Geographic area• Population criteria• Provider infrastructure• Service descriptions / HIT• Provider standards• Assurances

• Hospital referrals• SAMHSA coordination• Report evaluation results

• Monitoring• Tracking avoidable

hospitalizations• Cost savings• Proposal for using HIT

• Quality measures• Clinical outcomes• Experience of care• Quality of care

• Evaluations

States Should Spend Time Addressing

Use of HIT• Identify sources and uses of

existing data (e.g., claims and MCO encounter data)

• Leverage EHR use• Explore connections with

statewide HIE initiatives• Identify options for HIE between

behavioral health and primary care providers (e.g., National TA Center)

Quality Measures• Clinical outcomes relate to

changes in health status• Experience of care measures

should derive from client surveys• Quality of care measures relate

to processes of care• CMS will assist states in

mapping measures to service definitions

Measures

• Leverage data already being collected (e.g., NOMS)• Claims-based data for clinical outcomes measures• Survey data for experience of care• Care management and registry data for quality

outcomes (suggest limiting record reviews)• CMS is aligning measures across the ACA • CMS will provide guidance on a core set of measures

states can use for health homes

Likely feedback from SAMHSA and CMS

From SAMHSA• Use of a chronic care model• Provider qualifications• Health team members• Engaging primary care • Addressing SUD• Capacity for new service users• Use of HIT• Interim outcome measures• Need help (e.g., screening tools,

integration models)?

From CMS• Choice and opt-out• No age restrictions• No exclusion of duals• Provider and client notification • Leveraging existing services

(e.g., TCM, HCBS waiver)• Non-duplication of payment• Mapping quality measures to

services• Need help (e.g., quality

measures, reimbursement)?

Reimbursement

Methods

• Case rate• PMPM

• Base rate• Tiered by severity• Performance incentive

• Other

Considerations

• Start-up costs• Training• Health team composition• Sustainability

Cost Savings

• Most savings accrue to physical health• Consider how savings can be applied to sustaining

health home services • Unlikely that states will experience two-year savings• Costs likely to increase for a period before savings

estimates achieved• Consider a longer tail (e.g., savings or slower rate of

increase over 5 years)

Some Proposed ApproachesState Designated Provider Population Criteria

Missouri Community mental health centers

SPMIMental health +SUD +

Primary care practices (FQHC, RHC, public hospital clinics)

Asthma, CVD, diabetes, DD, BMI > 25, other high risk

Rhode Island Community mental health organizations

SPMI

North Carolina Patient-centered medical home (initial focus)

A number of conditions (e.g., CVD, asthma, etc.)

Parting thoughts

• Leadership and buy-in is paramount for planning and SPA development

• Start with a model and develop the SPA; not the other way around

• Ask CMS early and often about confounding issues (i.e., how demonstrate cost savings for duals)

• Everything takes 3 times longer than time estimates