New consortium finds common ground in quest to advance medical homes
New consortium finds common ground in quest to advance medical homes
Eight state teams are setting out to increase their Medicaid and Children's Health Insurance Program (CHIP) enrollees' access to high-performing medical homes. They will do so, in part, by learning from the experience of eight state teams who came before them.
The new teams, from Alabama, Iowa, Kansas, Maryland, Montana, Nebraska, Texas, and Virginia, are participants in the Portland, ME-based National Academy of State Health Policy's (NASHP) Consor- tium to Advance Medical Homes for Medicaid and CHIP. Last year's teams, from Colorado, Minnesota, New Hampshire, Oklahoma, Washington, Idaho, Louisiana, and Oregon, will share what they learned as part of the original consortium.
For example, the teams helped to identify what states could do to support and facilitate Medicaid access to medical homes, an enhanced model of primary care that provides comprehensive and coordinated patient-centered care.
"There is such incredible enthusiasm on the part of Medicaid and CHIP agencies on advancing this. And the first group of eight were really on the leading edge and made good progress," reports Neva Kaye, senior program director at NASHP.
"Now, a second group of states has made a firm commitment to advancing medical homes. This really will be like putting their projects in a hothouse," says Ms. Kaye. "The lessons learned by that first round are now being given to the second round, who I'm sure will come up with their own innovations as well. This new round of states will be building on that, but will also bring their own ideas."
Different approaches used
While the exact criteria for a medical home might differ somewhat from state to state, Ms. Kaye says that "there is a lot of commonality. Their criteria really does center around the primary care physician serving as the main point of contact for the patient."
However, Ms. Kaye says that the variation in reimbursement models used by states was somewhat surprising to her. "I went into this thinking they would probably coalesce around one reimbursement model, but they didn't. Essentially, there are three major models they are using to reimburse providers for billing as a medical home, with other elements, such as pay-for-performance and shared savings, that can be used within each of those three."
Ms. Kaye says the reimbursement approaches chosen by states often reflect the specific goals they wish to achieve. For example, if they want to encourage providers to actually see the patient, they may give a visit rate incentive, in addition to paying for the administrative cost of being a medical home.
States also varied widely in their targeted population. "I expect variation when I look at states, but not as much as I saw in this," says Ms. Kaye. "And I think there are reasons for that variation." As with reimbursement, this too depends on the particular goals of the state. While Minnesota started with individuals with the most complex needs, it is now looking to expand to other populations. Other states focused on children first, because they thought they could achieve success most quickly with that population.
"The other thing that surprised me is that several states intend to continue to expand this, so the work not only ultimately impacts Medicaid and CHIP beneficiaries, but individuals with private coverage as well," says Ms. Kaye. "This is a real deliberate strategy on the part of the states."
Evaluation is challenge
"What states are really trying to get at is, does this make a difference in outcomes? And I clearly see that is a struggle for them," says Ms. Kaye.
A diabetic being less likely to visit an ED is one clear indication of savings, but even more dramatic savings are possible over the long term if a primary care physician is able to keep that patient healthy in the first place.
However, short-term change needs to happen quickly enough so that the state can determine in the next year or two whether they are going in the right direction. "My sense is that the states really do look at this as an investment," says Ms. Kaye. "They understand that the outcomes they are working on take time to produce, particularly when you consider that one of the outcomes is the delay or prevention of conditions such as diabetes."
Another challenge is how to support patients in being part of a medical home, in order to empower them to more actively participate in their own health care. "The patient needs to play more of an active role in the interaction with their primary care physician, to be part of the decision making. States are clearly interested in that," says Ms. Kaye.
Using practice coaches to help primary care physicians (PCPs) consider different ways to help patients become more engaged is one possible approach. Another involves learning collaboratives, which bring practices together to become higher-functioning medical homes.
The bottom line, says Ms. Kaye, is that "there is clearly an evidence base that says this will make a difference. There are always questions as to how it would roll out in each individual state. But there is solid evidence that this is the right direction to go in."
Iowa plans to spread its primary care medical home model as a standard of care for all citizens as a major component of its health care reform, beginning with children enrolled in Medicaid. However, budget shortfalls may hinder the state's progress to some degree. Due to a 10% across-the-board cut ordered by the state's governor, $132 million will be lost by the department, half of it in Medicaid.
"We believe implementation of medical homes is critical to improving coordination and management of care for Medicaid members with chronic disease," says Iowa's Medicaid director Jennifer Vermeer. "We expect to see better quality of care and improved outcomes for our members. But the biggest challenge will be implementation of a new strategy with very limited ability to provide financial incentives for providers, due to the shortage of state funds."
Alabama is looking to strengthen its well-established Medicaid primary care case management program, Patient 1st, in place since 1997. The program already includes designated primary care providers, sharing of information via electronic medical records, and payment incentives.
"The biggest thing we are going to get from this is the ability to take it to the next level," says Kim B. Davis-Allen, director of the Alabama Medicaid Agency's Transformation Initiatives Division. "It has always been a very informal type of program, and this is the chance for us to formalize it. We will also be partnering with the CHIP program, which is administered by the Alabama Department of Public Health, to create synergy among our common providers."
Although the program's concept has changed little since its inception, it's become evident that providers require additional tools. "A classic example of that is data," says Davis-Allen. "We want them to be able to manage patients, and to do so, providers need good, usable, timely information about those patients."
For this reason, Alabama is going to focus on identifying what resources its practices need to be high-functioning medical homes and also developing quality measures to demonstrate results.
In some cases, practices are providing care consistent with the medical home model but aren't getting recognized as such. For example, rural physicians may do a great deal of care coordination with other providers, including addressing the transportation needs of patients who have to travel to see specialists. "Once we can come up with a really good definition and key indicators, I think we'll find a lot more of our physicians can be classified as a medical home," says Davis-Allen.
Nancy Wikle, care management supervisor for Montana's Department of Public Health & Human Services, says that her state plans to implement systemwide change with its established medical home programs. "A medical home allows patients to become more involved in their health care. A cost savings can be realized when tests are not repeated, urgent and emergent care services are decreased, and referrals to specialists are only given when medically necessary," she says.
However, Montana also faces unique challenges, because it is a geographically large state with a limited number of PCPs. "We do frequent site visits and trainings and share information with providers about how they can serve as an effective medical home to their clients," says Ms. Wikle. "We encourage and support only medically necessary referrals to providers other than the PCP, when the PCP cannot furnish such services. But we want more guidance on other ways to support practice change."
Better client outreach is needed to educate individuals about the importance of a medical home, and why the utilization of one primary care provider will improve their health. "We want to explore enhanced reimbursement, in order to get providers on board with the medical home concept and define methods to certify a physician's practice as a medical home," says Ms. Wikle. "We expect to see healthier Montanans and a cost savings."
Contact Ms. Kaye at (207) 874-6524 or [email protected], Ms. Davis-Allen at (334) 242-5011 or [email protected], Ms. Vermeer at (515) 725-1123 or [email protected], and Ms. Wikle at (406) 444-1834 or [email protected].
Eight state teams are setting out to increase their Medicaid and Children's Health Insurance Program (CHIP) enrollees' access to high-performing medical homes. They will do so, in part, by learning from the experience of eight state teams who came before them.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.