Better Care for Medicaid Beneficiaries through Health Homes

You have to put up dollars if you want to change business as usual.  That’s the message that attendees at NASHP’s 24^th Annual Conference in Kansas City, Missouri heard from John Michael (Mike) Hall of the Centers for Medicare & Medicaid Services (CMS).  Hall, speaking during aCommonwealth Fund-supported session on health homes, said he sees the new Medicaid health home state plan option as an opportunity to provide those dollars.
What are health homes?  Section 2703 of the Affordable Care Act (ACA) created a new Medicaid state plan option to provide health homes for individuals with chronic conditions.  States creating health homes under this authority will receive two years of enhanced federal financial participation (FFP) for health home services.  Rather than the state’s typical Medicaid match rate, states with approved health home plans will receive 90% FFP for health home services.  The legislation specifies a number of services that health homes must provide while reserving considerable discretion for states.  In general, health homes can be thought of as medical homes– but medical homes that offer a more intensive set of services targeted at high-need and high-risk individuals.  According to the statute, health homes must deliver the following “timely high-quality” services:

• comprehensive care management
• care coordination
• health promotion
• comprehensive transitional care
• patient and family support
• linkages to community and social support services

Health information technology, the statute specifies, should be used to link services.
Hall explained that the health home authority will allow Medicaid programs to better serve people who have historically had difficulty accessing the right care, at the right time, in the right place.  Health homes may enable care managers to reconcile medications immediately after chronically ill patients are discharged from the hospital, or allow individuals with serious mental illness to receive regular phone calls between in-person appointments to preemptively address any emerging problems.  Through health homes, states can pay for this sort of critical “in-between care” that has historically gone unreimbursed.  Here are several key considerations for states seeking to develop health homes in Medicaid:

• CMS has not issued regulations thus far.  Rather, CMS has defined broad “guardrails” through a state Medicaid director letter.  States submit their state plan amendments through a template that CMS has developed.  CMS wishes to see a diversity of innovative approaches and believes this is the best approach to achieving that end.
• While the health home state plan option is not technically a pilot or demonstration, a great deal of work is being done at the federal level to evaluate each state model (and the state plan option in general).  Additionally, states are required to measure the impact of their programs in several domains immediately, and expectations for evaluation will increase in subsequent years of each state’s program.  In time, CMS hopes to determine which models are worth sustaining and replicating.
• According to CMS’s interpretation of the statute, health homes must serve patients across the lifespan.  Requiring health homes to serve all patients with a given set of conditions concerns some state officials who wish to target efforts more narrowly (e.g., to serve pediatric diabetic patients rather than all diabetic patients).  The issue is still being analyzed and negotiated.
• CMS is eager to work with states on their health home proposals before formal submission.  Contact information for the CMS health homes team is available in the last slide of Hall’s presentation.

As of this writing, only Missouri’s health home state plan amendment has won approval from CMS.  Missouri’s health home model focuses on individuals with behavioral health needs served by community mental health centers (CMHCs).  CMHCs providing health home services will receive per member per month payments of about $75 for each eligible Medicaid member, as well as a variety of other supports (such as learning collaboratives and practice coaching). Missouri’s model builds on its previous efforts to integrate behavioral health and physical health for CMHC patients.  Missouri is also planning on submitting a second health home state plan amendment focused on the broader chronically ill population, including those without behavioral health conditions.
Other states are working on distinct health home models:

• One of Rhode Island’s health homes proposals would enhance existing CEDARR Family Centers that serve children and youth with special health care needs and their families.  (CEDARR stands for Comprehensive, Evaluation, Diagnosis, Assessment, Referral, and Re-evaluation.)
• Iowa’s health homes program will build on the state’s existing IowaCare medical homeprogram.  The state plans to co-locate physical health providers with behavioral health providers.

Is your state building health homes?  What populations are you looking to serve?  What are some of the key design considerations you are working through?  How are previous efforts to improve primary care informing your efforts?  Share your progress on your state’s medical home milestone page, or share general thoughts using the blog comments feature below this post.