Interest in Medicaid medical homes is surging, despite budget challenges
Interest in Medicaid medical homes is surging, despite budget challenges
The challenges of budget shortfalls aside, interest in medical homes continues to grow as evidence of their effectiveness accumulates and state Medicaid programs seek to manage costs over the long term.
A medical home is "an enhanced model of primary care in which care teams attend to the multifaceted needs of patients and provide whole person comprehensive and coordinated patient-centered care," according to the Portland, ME-based National Academy for State Health Policy's (NASHP) June 2009 report, "Building Medical Homes in State Medicaid and CHIP Programs."
"There is a lot of state interest in this at the moment," says Neva Kaye, NASHP's senior program director. "I have definitely seen an increased interest in medical home initiatives over the last two years."
Budget shortfalls mean that some planned medical home initiatives are being delayed, however, since an initial investment is required. "This really varies by state and how bad their situation is and how far along in development the infrastructure is. Or the budget may be in such bad shape that they have no way of making an investment," she explains. "But I have certainly not seen any lessening of interest, even if they have to delay what they are doing."
Jeff Schiff, MD, medical director of Minnesota Health Care Programs and division director at the Minnesota Department of Human Services, says budget shortfalls haven't adversely affected the state's planned medical home initiative.
"We have had a terrible budget year with a big deficit. But because there has been enough momentum on this, we haven't been derailed," he reports. "The legislature and our administration have supported us continuing with this project. Everyone believes it is worthwhile to go forward."
The medical home program is expected to be budget-neutral. "We can do that if we run this tightly and carefully enough," says Dr. Schiff. "Some studies say that if you alter the ratio of physicians even slightly from specialist toward primary care, you find a significant improvement in quality and decrease in cost in the broader population. But I don't think the models are developed enough at this point to say we will save or lose a certain amount."
Oklahoma's Medicaid director, Lynn Mitchell, MD, says over the long term, she expects their medical home program will help members access health care for preventive measures and see their provider earlier during an illness.
"We anticipate earlier care will mean care delivered in the more appropriate place, and that would lead to a decrease in emergency room usage and inpatient days," she reports. "Decreasing the frequency and severity of illness is a huge enhancement to quality of life for the Oklahomans we serve. It's too early to tell if any of that will take place, but that's what we're hoping for."
Dr. Mitchell also hopes the medical home program will serve as a good model for other payers to promote good health care for their members. "We are anxious to obtain some experience in the model, which we anticipate will result in more satisfied providers and members, as well as enhanced care and wellness," she says. "It makes sense to deliver health care in this integrated fashion."
'Complicated' patients targeted
As principal investigator for the State Consortium to Advance Medical Homes for Medicaid and Children's Health Insurance Program (CHIP) Beneficiaries, Ms. Kaye surveyed state officials and found 31 states had implemented at least one medical home initiative since 2006 that included Medicaid and CHIP beneficiaries.
"This isn't a new issue, particularly for Medicaid, but some states are slightly ahead of the curve," he reports.
Medical home programs varied, ranging from programs focusing on smaller populations, such as adults with chronic conditions, to programs that ultimately aim to change the delivery system for everyone in the state, such as those under way in Minnesota, Oregon, and Iowa.
Most of the programs started by covering a particular subset of the population, such as adults with complex needs or children. For example, Colorado's Medicaid agency set up a program for all children covered by Medicaid in the state. Currently, 88,000 Medicaid and 62,000 Child Health Plan Plus children are enrolled in a medical home, and 97 practices representing 310 physicians are designated as medical homes.
Some of the medical home programs were explicit in indicating they planned to eventually expand to all state residents, but of those, several intended to start with the Medicaid and CHIP programs.
Both Minnesota and Rhode Island are developing medical home initiatives for people with complex needs, and individuals must have multiple chronic conditions to qualify. "Their intent is that once they get everything worked out for the subpopulation, they will have a process to build on so they can expand it to capture more populations in the state," says Ms. Kaye. "To me, that makes perfect sense, because before going that broad with a program, you want a chance to tweak it and adjust it. You might want to do things differently."
This summer, Minnesota will start enrolling individuals with five or more chronic diseases in its Medicaid fee-for-service programs.
"Some of us believe that if you can do this for complicated patients, then you can do it for less complicated ones," says Dr. Schiff. "Half of the spending we have in fee-for-service Medicaid goes to one-eighth of the patients, who have the most complex needs. So, we felt like we should have the most positive impact on their health and in our costs by targeting that group. When we did our analysis of who was to be included, we identified 27,000 folks who fell into that category."
As of July 2010, the program will expand to all clients in state health care programs, state employees, and privately insured individuals. Dr. Schiff says he looks at this as "two waves hitting the shore."
Rhode Island, on the other hand, is focusing on all adults with chronic care needs who are served by certain primary care practices, without looking at a particular subset. "So, even looking at the states that targeted it, the way they targeted it varied quite a bit," says Ms. Kaye.
According to Chris Traylor, Texas' state Medicaid director, a medical home initiative will be rolled out within the next 12 months. "The initiative will test multiple medical home models to determine if health outcomes improve for children enrolled in Medicaid," he says. "Our agency will be consulting with a panel of experts to develop minimum standards for the models and evaluation criteria for the project."
Colorado's program started with children covered by Medicaid, with the intent to expand it to their CHIP program. One advantage of starting with Medicaid children involves the Medicaid Early & Periodic Screening & Diagnostic Treatment Benefit (EPSDT).
"EPSDT is set up as a benefit that's designed to not only offer good primary care, but also to support outreach enrollment and care coordination," says Ms. Kaye. "It's a benefit that is well designed for supporting medical homes within Medicaid, and it's a benefit that is only available to children."
By starting with a subset of patients with specific health care needs, you can see results more quickly. "I don't want to call them low-hanging fruit, because they are really not. Some of them don't have access to primary care at all, so moving them to a fully functioning medical home is not always the easiest thing to do," says Ms. Kaye. "But where you will see a potentially big benefit is in preventing some of those unnecessary ER visits and hospitalizations."
Ultimately, however, some of the biggest cost-saving benefits will come from primary care on the preventive side. "To establish a medical home for someone with diabetes is a good thing. There is a lot of benefit to be gained," says Ms. Kaye. "But if you can make sure somebody has access to a medical home, which can prevent the diabetes from happening, that has even greater potential. Vermont has done a lot with their Blueprint for Health program to emphasize the preventative side. I think that is where states ultimately have a vision of going."
Oklahoma's medical home program was implemented in January 2009. "While it's still early on, indications are that our members are very pleased," says Dr. Mitchell. "We've also gotten a lot of comments back from providers who say they have found this a comfortable and satisfying way to interact with our members."
Providers receive compensation through a payment structure that better reflects the value of what they do for patients. "This model improves our health care system by coordinating and integrating care and focusing on quality," says Dr. Mitchell. "Everyone wants to be cared for in an environment that embraces those tenets, and providers want to practice in that environment."
Initially, there was concern that Oklahoma's providers might choose not to renew their SoonerCare contracts, but the vast majority did. "We also attracted quite a few new providers who were anxious to practice within a patient-centered medical home model," says Dr. Mitchell. "And when we calculated our first incentive payments under Sooner Excel, 87% of our providers who served as medical homes qualified for the incentives."
Contact Ms. Kaye at (207) 874-6524 or [email protected], Dr. Mitchell at (405) 522-7365 or [email protected], Dr. Schiff at (615) 431-3488 or jeff.schiff@ state.mn.us, and Mr. Traylor at (512) 491-1867 or [email protected].
The challenges of budget shortfalls aside, interest in medical homes continues to grow as evidence of their effectiveness accumulates and state Medicaid programs seek to manage costs over the long term.Subscribe Now for Access
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