NYS Health Home Program
Presentation to the National
Academy for State Health Policy
June 14, 2012
View from New York
o Many of the over five million Medicaid
enrollees are relatively healthy and obtain only
episodic & preventive healthcare.
o However, several population groups contain
complex medical, behavioral and long term care
needs and have difficulty navigating the system.
o The high need members drive up high cost services
including inpatient & long term institutional care.
2
Care Management History in NY
o
Other care management initiatives are disease specific
Targeted Case Management (TCM) – Mental Health
AIDS/COBRA - for HIV+ individuals Managed Addiction
Treatment Services (MATS).
o
During 2009, New York funded six FFS Chronic Illness
Demonstration Projects to provide care coordination for
individuals exempt or excluded from mandatory managed
care.
o
Governor Cuomo’s vision for Medicaid reform is care
management for all.
o
The MRT recommended Health Homes as one of 79
recommendations.
3
NYS Objectives
• PRIMARY GOAL: Comprehensively address the
complex needs of Medicaid beneficiaries who qualify
for Health Home services including:
▫ Physical (primary care physicians & prevention)
▫ Behavioral (mental illness & chemical dependency)
▫ Social (such as housing and entitlement programs)
4
New York State’s 3-4 top policy
objectives for Health Homes
o
Effectively manage the health, behavioral
health and long term care needs of
complex, high-cost populations.
o
Breakdown traditional silos in care delivery and
create partnerships that shape a more coordinated
health care delivery system.
o
Align incentives with quality and cost effectiveness.
o
Bend the cost curve.
5
Why Health Homes?
o
Engaging and managing services for members with
complex chronic conditions is essential in controlling
future health care costs.
o
Section 2703 provides a new funding opportunity to
better provide coordinated services.
o
Health Homes are expected to reduce costs while
improving outcomes & patient satisfaction.
6
Complex Populations: All Ages
• 1) Developmental
Disabilities
• 2) Long Term Care
• 197,549 Recipients
• $5,163 PMPM
• 47,760 Recipients
• $9,919 PMPM
Total Complex
N =1,050,385
$2,366 PMPM
32% Dual
55% MMC
• 3) Mental Health/
Substance Abuse
• 418,677 Recipients
$1,540 PMPM
Time Period: July 1, 2010 – June 30, 2011
$5.6 Billion
44% Dual
11% MMC
$11.6 Billion
83% Dual
18% MMC
$28.2 Billion
$7.3 Billion
13% Dual
66% MMC
$3.7 Billion
23% Dual
67% MMC
• 4) All Other Chronic
Conditions
• 386,399 Recipients
$841 PMPM
7
NYS Medicaid Beneficiaries
with Multiple Chronic Illnesses
Chronic
Medical
31%
Behavioral
Health
42%
I/Developmental
Disability
5%
Long Term
Care
22%
8
Health Home High Risk Population
Chronic Episode Diagnostic Categories
Health Home Eligibles Adults 21+ Years
With a Predictive Risk Score 75% or Higher (n=27,752)
Percent of Adult Recipients with Co-Occurring Condition
Condition
Total
43.5
Severe Mental Illness
46.2
Mental Illness
54.4
Substance Abuse
37.6
Hypertension
29.8
Hyperlipidemia
27.8
Diabetes
28.3
Asthma
13.4
Congestive Heart Failure
12.2
Angina & Ischemic HD
8.3
HIV
12.7
Obesity
22.1
Osteoarthritis
15.5
COPD & Bronchiectasis
13.5
Epilepsy
41.9
CVD
18.8
Kidney Disease
Total 100.0
Severe
Mental
Illness
Mental
Illness
100.0
70.4
61.9
39.1
41.0
36.3
52.4
22.1
30.5
50.2
50.5
45.7
38.8
65.1
33.2
25.2
43.5
74.7
100.0
60.3
51.6
52.2
46.5
58.5
37.9
47.8
48.4
61.4
62.7
53.0
66.6
45.3
40.4
46.2
Angina
& IscheSubstHyperCongestmic
ance Hyper- lipidemi
ive Heart
Heart
Abuse tension
a Diabetes Asthma Failure Disease
77.2
70.9
100.0
51.1
47.1
41.8
62.9
30.6
41.8
73.5
45.8
56.8
50.6
66.3
44.6
32.4
54.4
33.8
42.0
35.4
100.0
59.8
56.0
40.8
79.5
68.2
25.2
52.6
49.9
54.7
38.8
55.9
61.5
37.6
Note: Diagnosis History During Period of July 1, 2010 through June 30, 2011.
28.1
33.7
25.9
47.4
100.0
58.8
39.7
61.9
81.5
20.0
55.4
41.8
48.1
33.2
50.2
49.9
29.8
23.2
28.0
21.4
41.4
54.9
100.0
34.8
53.5
57.6
18.1
53.1
35.5
40.7
27.2
43.1
50.6
27.8
34.1
35.8
32.8
30.7
37.7
35.4
100.0
32.3
40.3
41.9
49.0
44.0
60.1
35.1
32.3
27.6
28.3
6.8
11.0
7.5
28.2
27.8
25.7
15.3
100.0
45.1
6.7
22.2
15.8
29.2
8.9
32.0
35.8
13.4
8.5
12.6
9.4
22.1
33.4
25.3
17.4
41.2
100.0
6.8
23.1
18.7
24.8
10.6
29.2
27.2
12.2
COPD &
Osteo- BronchHIV Obesity arthritis iectasis Epilepsy
9.6
8.7
11.2
5.6
5.6
5.4
12.3
4.1
4.6
100.0
3.2
10.0
8.7
8.1
6.2
7.9
8.3
14.8
16.9
10.7
17.8
23.6
24.3
22.0
21.1
24.1
4.9
100.0
22.7
21.0
15.6
18.3
18.3
12.7
23.2
29.9
23.1
29.3
30.9
28.1
34.3
26.1
33.8
26.6
39.3
100.0
36.1
24.8
27.4
29.1
22.1
13.9
17.8
14.5
22.6
25.1
22.8
33.0
33.9
31.5
16.4
25.7
25.5
100.0
16.2
25.0
22.3
15.5
20.1
19.4
16.4
13.9
15.0
13.2
16.7
8.9
11.7
13.2
16.5
15.1
14.0
100.0
13.2
11.7
13.5
Kidney
CVD Disease
31.9
41.0
34.4
62.2
70.4
64.9
47.7
100.0
100.0
31.1
60.1
52.0
67.2
41.1
100.0
78.6
41.9
10.9
16.4
11.2
30.8
31.5
34.3
18.4
50.3
41.9
17.9
27.2
24.9
27.0
16.3
35.4
100.0
18.8
Health Home Infrastructure
o
Health Homes include designated providers working
with multidisciplinary partners.
o
Provider qualification standards were developed
working with hospitals, clinics, physicians, mental
health experts, chemical dependency experts &
housing providers, as well as other state agencies.
o
Care managers will lead multidisciplinary teams to
assure member needs are met.
10
Provider Qualification Standards
General Qualifications
o
Must be enrolled (or be eligible for enrollment) in
the NYS Medicaid program and agree to comply
with all Medicaid program requirements.
o
Can either directly provide, or subcontract for
the provision of, health home services.
Responsible for all health home program
requirements, including services performed by the
subcontractor.
11
Provider Qualification Standards
General Qualifications (continued)
o
Care coordination and integration of heath care services
will be provided to all health home enrollees by an
interdisciplinary team of providers, where each individual’s
care is under the direction of a dedicated care manager
who is accountable for assuring access to medical and
behavioral health care services and community social
supports as defined in the enrollee care management plan.
o
Must meet standards for delivery of six core health
home services as described in following slides. Must
provide written documentation that clearly demonstrates
how the requirements are being met.
12
Provider Qualification Standards
Health home providers will be required to follow
Federal and State requirements for Health Homes:
o
o
o
o
o
o
Comprehensive care management;
Care coordination and health promotion;
Comprehensive transitional care;
Patient and family support;
Referral to community and social support services;
Use of health information technology (HIT) when feasible.
13
Payment Methodology
o
Payment is made on a PMPM basis in two
increments:
 Outreach & Engagement
 Delivery of Active Care Coordination
o
HH bills NYS directly for FFS members and then
funnel payments as appropriate to partner.
o
TCMs, MATS & CIDPs bill directly to State.
o
Managed Care Plans keep up to 3% for
administrative services and pay the lead HH.
14
Care Integration/Coordination
o
Health Homes are not held to specific models but
will be held to meeting quality standards.
o
Each Health Home has partners that can meet both
physical and behavioral health needs.
o
Care Coordinators are responsible for managing the
whole person not specific conditions.
o
Health Homes are held responsible for meeting
quality not process measures.
15
Health Home Services
• Health home providers will be required to provide the following health
home services in accordance with federal and State requirements:
▫
Comprehensive care management
 An individualized patient centered care plan based on a comprehensive health risk
assessment – must meet physical, mental health, chemical dependency and social
service needs.
▫
Care coordination and health promotion
 One care manager will ensure that the care plan is followed by coordinating and
arranging for the provision of services, supporting adherence to treatment
recommendations, and monitoring and evaluating the enrollee’s needs. The health home
provider will promote evidence based wellness and prevention by linking patient enrollees
with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery
resources, and other services based on need and patient preference.
▫ Comprehensive transitional care
 Prevention of avoidable readmissions to inpatient facilities and oversight of proper and
timely follow-up care.
16
Health Home Services (cont’d)
▫
Patient and family support
 Individualized care plan must be shared with patient enrollee and family
members or other caregivers. Patient and family preferences are considered.
▫
Referral to community and social support services
 Provider will identify and coordinate community and social supports
▫
Use of health information technology (HIT) when feasible
 Health home providers will be encouraged to utilize RHIOs or a qualified entity
to access patient data and to develop partnerships that maximize the use of HIT
across providers. Health home provider applicants must submit a plan with their
application for achieving compliance with the final health home HIT requirements
within 18 months of program implementation
17
Health Information Technology
• Initial standards must be met at start-up:
▫ Structured information systems, policies, procedures &
practices for individual plans of care;
▫ Systematic process to follow-up on tests, treatments,
services and referrals;
▫ Have health record system to allow PHI and plan of care
accessible to interdisciplinary team for management &
analysis;
▫ Make use of available HIT and access member data thru
RHIO or QE to conduct all processes.
• Providers have 18 months to achieve final standards in
SPA.
18
Health Home Implementation
Program Status
o
To date there are 34 designated Health Homes:
▫ Phase 1 encompasses 10 counties with 13 HH;
▫ Phase 2 contains 13 counties with 21 HH;
▫ Phase 3, not yet designated, will serve 39 counties.
o
Of the almost one million eligible members, about
6,000 members are either in Outreach and
Engagement or active Care Management.
o
NYS is working closely with Plans and Health
Homes.
20
How Eligible Members are Being
Identified and Assigned
• New York State Health Home Analytical Products
▫ CRG Based Attribution – For Cohort Selection
▫ CRG Based Acuity – For Payment Tiers
▫ Predictive Model - Predicts future negative events
(Inpatient, Nursing Home, Death) using claims and
encounters – For Assignment Priority
▫ Ambulatory Connectivity Measure – For Assignment
Priority
▫ Provider Loyalty Model – Establishes Patient Connectivity
to Existing Care Management, Ambulatory (including BH),
ED and Inpatient – For Matching to Appropriate HH and to
Guide Outreach activity.
21
Monthly Care Management
Tracking Elements
• Patient Demographic information, Health Plan
• Assigned Health Home, Health Home Care
Management Provider
▫ TCM, COBRA, MATS, CIDP, MCO, CBO
• Enrollment/Disenrollment Status, Various Dates
▫ Consent
▫ Enrollment/disenrollment
• Patient Profile (e.g., Risk Score, Acuity Score,
Ambulatory Connectivity and Loyalty)
22
Health Home Assignments:
Managed Care Workflow
23
Functional Assessment
o
NYS is evaluating a functional self-assessment tool
based on the FACT-GP to assess each Health Home
participant on a range of measures. Please see:
http://www.health.ny.gov/health_care/medicaid/progra
m/medicaid_health_homes/forms/
o
Validated tool administered face-to-face upon
enrollment, annually thereafter and at discharge;
results are reported to the State.
o
Results of assessments used to adjust initial rates,
which were based on calculated acuity and risk
scores.
24
Cost Saving Estimates
o Initial
Savings to come from converting current
care management programs.
o Estimated
savings are @ $40 million this FY.
o Long
term savings must come from quality of
care improvements:
▫ Reduction in ER utilization and Hospitalization;
▫ Reduction in nursing home admissions;
▫ Effective primary care utilization.
25
Barriers/Challenges
o FFS
Member Lists
o Finding
people - DIFFICULT
o Contracts
with Plans
o Guidance
to Converting
o Community
Referrals
o Medicare/Medicaid
Gainsharing
26
Successes/Lessons Learned
o
Proudest achievements:
▫ Offered an opportunity for direct care providers and
community-based organizations to partner
▫ Opportunity to improve communications
o
Advice for other states in planning stages or thinking
about pursuing 2703:
▫ Include providers and plans on development
▫ Communication with all stakeholders
▫ Administrative functions and resources
o
In hindsight, what would you have done differently?
▫ Include Managed Care Plans earlier in process
27
Need More Information?
Have Questions/Comments?
o
NYS Health Home Web site (links to many relevant
materials including accessing applications):
http://nyhealth.gov/health_care/medicaid/program/m
edicaid_health_homes/index.htm.
o
Questions and/or comments regarding New York's
implementation of Health Homes can be directed to
hh2011@health.state.ny.us.
28