A Close Look at Care Coordination within Patient-Centered Medical Homes:

West Virginia’s Experience

Web SeminarWeb Seminar

May 9, 2013May 9, 2013

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Building Health Information Exchanges to Support Accountable Care Organizations and Medical Homes: Delaware’s Experience

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Today’s Event Moderator

James Becker, MDJames Becker, MD

Medicaid Medical Director,

West Virginia Bureau for Medical Services

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How Rural Are We?How Rural Are We?

We are a state of 1.8 million individualsWe are a state of 1.8 million individuals Yet, our two largest cities approach 50 K in numberYet, our two largest cities approach 50 K in number Many parts of the State are geographically isolated and Many parts of the State are geographically isolated and

medically underserved medically underserved Medicaid currently serves 410,000 individualsMedicaid currently serves 410,000 individuals Over 200,000 individuals are uninsuredOver 200,000 individuals are uninsured Many patients cross borders to receive careMany patients cross borders to receive care

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What Are Our Health Challenges?What Are Our Health Challenges?

Chronic diseasesChronic diseases Mental health, substance abuseMental health, substance abuse Aging populationAging population Poverty, unemploymentPoverty, unemployment Low educational achievementLow educational achievement Lifestyle issuesLifestyle issues Health literacy issuesHealth literacy issues

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What’s Working?What’s Working?

Prevention programs and wellness, especially for Prevention programs and wellness, especially for selected conditionsselected conditions

Federally Qualified Health Centers and the rural health Federally Qualified Health Centers and the rural health network meet much of the region’s need and are widely network meet much of the region’s need and are widely accepted in their communities accepted in their communities

Comprehensive behavioral health systemComprehensive behavioral health system University outreach networks with satellite services, University outreach networks with satellite services,

technology and grant supporttechnology and grant support

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What Is Our Direction?What Is Our Direction?

In 2009 we adopted the “Triple Aim” and began building In 2009 we adopted the “Triple Aim” and began building Patient-Centered Medical Homes (PCMH) around the Patient-Centered Medical Homes (PCMH) around the state with grant supportstate with grant support

The legislature endorsed PCMH and a state plan for The legislature endorsed PCMH and a state plan for health improvementhealth improvement

Since then, each private health carrier has adopted some Since then, each private health carrier has adopted some elementselements

No central payment methodology is establishedNo central payment methodology is established

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Currently….Currently….

West Virginia has a series of state plan amendments (SPAs) West Virginia has a series of state plan amendments (SPAs) in development related to Health Homes (ACA 2703)in development related to Health Homes (ACA 2703)

The first will involve bipolar individuals with/or at risk of The first will involve bipolar individuals with/or at risk of hepatitishepatitis

Future SPAs expected for diabetes, obesity, asthma, mental Future SPAs expected for diabetes, obesity, asthma, mental illness, Alzheimer’s, congestive heart failure, chronic illness, Alzheimer’s, congestive heart failure, chronic obstructive pulmonary diseaseobstructive pulmonary disease

SPAs broadly define care coordination, care managers and SPAs broadly define care coordination, care managers and care coordinatorscare coordinators

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In Our Experience…In Our Experience…

Care coordination Care coordination is a highly individual skillis a highly individual skill– Flexibility and creativityFlexibility and creativity– Sense of “mission”Sense of “mission”– Experience-basedExperience-based

Best delivered “face-to-face”Best delivered “face-to-face”– Shared coordinators and telephonic careShared coordinators and telephonic care

Best in the setting of team careBest in the setting of team care

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In Our Experience…In Our Experience…

Requires leadership and resourcesRequires leadership and resources Is effective when there is data to guide Is effective when there is data to guide

decisionsdecisions– Electronic health records and care coordinationElectronic health records and care coordination– Information technology for population managementInformation technology for population management

We’ve found no single credential or skill set that We’ve found no single credential or skill set that best identifies a care coordinatorbest identifies a care coordinator

Care Coordination ModelsCare Coordination Models

The ‘Health Home’The ‘Health Home’ Patient-Centered Medical HomePatient-Centered Medical Home Targeted Case ManagementTargeted Case Management Managed Care OrganizationsManaged Care Organizations Community Health WorkersCommunity Health Workers Other community services…Other community services…

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Payment for Care CoordinationPayment for Care Coordination

Under the state plan amendments, Medicaid will use a fee-for-service Under the state plan amendments, Medicaid will use a fee-for-service plus per member per month modelplus per member per month model

A private carrier is promoting a move to an Accountable Care A private carrier is promoting a move to an Accountable Care Organization with pay for performance (P4P) and pay for value Organization with pay for performance (P4P) and pay for value featuresfeatures

Another insurer is adopting a comprehensive payment model with a Another insurer is adopting a comprehensive payment model with a P4P shared savingsP4P shared savings

A network in the state operates under grant-based paymentA network in the state operates under grant-based payment So you see….. So you see…..

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Everyone likes care coordination, but Everyone likes care coordination, but we’re not sure how we should pay for we’re not sure how we should pay for

it!it!

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A Bit of Strategy…A Bit of Strategy…

Adopt consistent or similar payment modelsAdopt consistent or similar payment models Capture similar measures in similar waysCapture similar measures in similar ways Allow flexibility within practices as long as Allow flexibility within practices as long as

they are moving toward accepted standardsthey are moving toward accepted standards Recognize the unique features of practices Recognize the unique features of practices

and communitiesand communities

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RespondentRespondent

William Golden, MDWilliam Golden, MD

Medical Director, Arkansas Medicaid Enterprise Medical Director, Arkansas Medicaid Enterprise

at Arkansas Department of Human Servicesat Arkansas Department of Human Services

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Rural ChallengesRural Challenges

Workforce variation; team, alternatives, Workforce variation; team, alternatives, accessaccess

Practice infrastructure; capitalizationPractice infrastructure; capitalization Socioeconomics, health literacySocioeconomics, health literacy Perverse incentivesPerverse incentives

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Evolving EnvironmentEvolving Environment

WorkforceWorkforce Practice ownership, managementPractice ownership, management Health Information TechnologyHealth Information Technology

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Arkansas Payment ReformArkansas Payment Reform

Harmonize economic incentives: multi-payer, promote local Harmonize economic incentives: multi-payer, promote local innovation, care coordinationinnovation, care coordination

Episodes of careEpisodes of care– Gain sharing for total cost of care, quality metricsGain sharing for total cost of care, quality metrics– Reward more effective providers; break cycle of payment Reward more effective providers; break cycle of payment

regardless of practice variationregardless of practice variation Medical home: New per member per month for transformation/care Medical home: New per member per month for transformation/care

coordination; gain sharing for total cost of care, quality metricscoordination; gain sharing for total cost of care, quality metrics

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Quality Standards and Quality Standards and Shared SavingsShared Savings

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Upside Only Gain-SharingUpside Only Gain-Sharing

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Concepts: Medical Home Concepts: Medical Home versus Health Homeversus Health Home

Medical Home: The Clinical Game PlanMedical Home: The Clinical Game PlanCare coordination/coaching for high priority patients; Care coordination/coaching for high priority patients; medically frail, complex psychosocial, literacy concernsmedically frail, complex psychosocial, literacy concerns

Health Home: Community Coordination for Select Health Home: Community Coordination for Select PopulationsPopulationsDevelopmental disabilityDevelopmental disabilitySignificant mood disorderSignificant mood disorder

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Payment InitiativePayment Initiative

▪ Ensure care provision is efficient and based on client needs

– Align resources provided with level of need

– Expand plan customization options for clients

▪ Minimize resources / time not focused on delivering client care

▪ Increased care coordination

– Integrate care across medical, behavioral, health

– Reduce unnecessary medical and behavioral health spending

– Promote wellness activities

Initial phase:7,020 clients1

Service Episode Care Coordination Within Health Home

$300 M Adult Developmental

Disability Expenditures$35 M

Halo expenditures for adults1 (e.g.,

medical, behavioral)1

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1 Includes clients ages 18+ with development disabilities not currently enrolled in public school, excludes 22 clients receiving therapy only2 Includes all medical and behavioral spending (in-patient, out-patient and pharmacy)

SOURCE: Medicaid claims data for claims incurred in SFY 2010

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New ActivitiesNew Activities

Provider report cards; data supported Provider report cards; data supported changechange

Health Information Technology (HIT) Health Information Technology (HIT) expansionexpansion

Vendor options for care coordinationVendor options for care coordination

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IssuesIssues

Engaging all practices; not just early adoptersEngaging all practices; not just early adopters Engaging patientsEngaging patients Pooling practice data; statistical, actuarial necessityPooling practice data; statistical, actuarial necessity Diverse installed electronic medical record base; Diverse installed electronic medical record base;

limitations of data extractionlimitations of data extraction Accountability for use of per member per month Accountability for use of per member per month

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Unknowns: Value, Pricing of Unknowns: Value, Pricing of New ServicesNew Services

Avoid new economic silosAvoid new economic silos TelemedicineTelemedicine Care coordination; for whom, how Care coordination; for whom, how

intensiveintensive

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Brighter FutureBrighter Future

Providers and payer agree that change is Providers and payer agree that change is needed needed

Pain of change becoming less than pain Pain of change becoming less than pain of status quoof status quo

Opportunity window to create smarter, Opportunity window to create smarter, more effective health caremore effective health care

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Today’s Event ModeratorToday’s Event ModeratorDavid Meyers, MDDavid Meyers, MD

Director of the Center for Primary Care, Director of the Center for Primary Care,

Prevention, and Clinical Partnerships, AHRQ Prevention, and Clinical Partnerships, AHRQ

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AHRQ ResourcesAHRQ Resources

PCMH.AHRQ.GOVPCMH.AHRQ.GOV

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PCMH BasicsPCMH Basics

Defining the PCMHDefining the PCMH Evidence and evaluationEvidence and evaluation Tools and resources: care coordination, quality and safety, Tools and resources: care coordination, quality and safety,

patient-centeredness, and morepatient-centeredness, and more Implementation: A How-To Guide on Developing and Implementation: A How-To Guide on Developing and

Running a Practice Facilitation Program, new case studiesRunning a Practice Facilitation Program, new case studies

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White Papers and Briefs on White Papers and Briefs on Care CoordinationCare Coordination

The Roles of Patient-Centered Medical Homes The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in And Accountable Care Organizations in Coordinating Patient CareCoordinating Patient Care

Coordinating Care in the Medical Neighborhood: Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms Critical Components and Available Mechanisms

Coordinating Care for Adults with Complex Care Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Needs in the Patient-Centered Medical Home: Challenges and SolutionsChallenges and Solutions

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Measuring Care CoordinationMeasuring Care Coordination

AHRQ Care Coordination Measurement AtlasAHRQ Care Coordination Measurement Atlas

http://www.ahrq.gov/qual/careatlas/http://www.ahrq.gov/qual/careatlas/ Review and Recommendations on the Best Tools for Review and Recommendations on the Best Tools for

Accountability and Assessing Care CoordinationAccountability and Assessing Care Coordination

http://www.ahrq.gov/research/findings/final-reports/http://www.ahrq.gov/research/findings/final-reports/pcpaccountability/index.htmlpcpaccountability/index.html

Caveat: Patient and Family SurveysCaveat: Patient and Family Surveys

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PCMH CAHPSPCMH CAHPS

Consumer Assessment of Healthcare Providers and Systems Consumer Assessment of Healthcare Providers and Systems (CAHPS) program (CAHPS) program https://www.cahps.ahrq.gov/Surveys-Guidance/CG/PCMH.aspxhttps://www.cahps.ahrq.gov/Surveys-Guidance/CG/PCMH.aspx

Released in late October 2011Released in late October 2011Built on existing, well-validated clinician and group surveyBuilt on existing, well-validated clinician and group surveyCovers topics such as provider-patient communication, coordination Covers topics such as provider-patient communication, coordination of care, and shared decision makingof care, and shared decision making Available in English and Spanish; adult and child versionsAvailable in English and Spanish; adult and child versions

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