Health Home Implementation Update

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					      Statewide Webinar-June 6,2012

Downstate Town Hall Meeting-June 19, 2012
 Upstate Town Hall Meeting-June 22, 2012
   Address Health Home concerns
    ◦ List assignments
    ◦ Reporting requirements
    ◦ Contracting
    ◦ Billing and payment

   Provide a progress report on Health Home
    implementation



                                               2
  New Implementation Timeline
           Phase I Implementation (10 Counties) Bronx, Brooklyn, Nassau,
Jan 1,     Schenectady, Clinton, Essex, Franklin, Hamilton, Warren, Washington.
2012       Existing case management (COBRA and TCMs) providers begin billing using
           Health Home rates.
Feb 1,
           List assignment begins
2012

           Application deadline for Phase II (13 Counties) Dutchess, Erie, Manhattan,
Feb 15,    Monroe, Orange, Putnam, Queens, Richmond (Staten Island), Rockland,
2012
           Suffolk, Sullivan, Ulster, Westchester
           Phase II implementation (retro billing back to 4/1 for CIDP programs)
April 1,   Existing CIDP providers begin billing using Health Home rates. MATS begin
 2012
           billing using Health Home rates TBD.
           Application deadline for Phase III (39 counties) Albany, Alleghany, Broome,
           Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Columbia,
June 1,    Cortland, Delaware, Fulton, Genesee, Greene, Herkimer, Jefferson, Lewis,
 2012      Livingston, Madison, Montgomery, Niagara, Ontario, Oneida, Onondaga,
           Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schoharie, Schuyler,
           Seneca, St. Lawrence, Steuben, Tioga, Tompkins, Wayne, Wyoming, Yates
July 1,     Phase III implementation (tentatively)                                       3
 2012
           High Risk Health Home 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

                                                                                                          Angina
                                                                                                         & Ische-
                                      Severe              Subst-         Hyper-                Congest-       mic                            COPD &
                                      Mental    Mental     ance Hyper- lipidemi                ive Heart    Heart                    Osteo- Bronch-                   Kidney
Condition                 Total       Illness   Illness   Abuse tension       a Diabetes Asthma Failure Disease         HIV Obesity arthritis iectasis Epilepsy   CVD Disease
Severe Mental Illness      43.5       100.0      74.7      77.2     33.8        28.1    23.2    34.1     6.8     8.5     9.6    14.8    23.2     13.9     20.1     31.9    10.9
Mental Illness             46.2        70.4     100.0      70.9     42.0        33.7    28.0    35.8    11.0    12.6     8.7    16.9    29.9     17.8     19.4     41.0    16.4
Substance Abuse            54.4        61.9      60.3     100.0     35.4        25.9    21.4    32.8     7.5     9.4    11.2    10.7    23.1     14.5     16.4     34.4    11.2
Hypertension               37.6        39.1      51.6      51.1    100.0        47.4    41.4    30.7    28.2    22.1     5.6    17.8    29.3     22.6     13.9     62.2    30.8
Hyperlipidemia             29.8        41.0      52.2      47.1     59.8       100.0    54.9    37.7    27.8    33.4     5.6    23.6    30.9     25.1     15.0     70.4    31.5
Diabetes                   27.8        36.3      46.5      41.8     56.0        58.8   100.0    35.4    25.7    25.3     5.4    24.3    28.1     22.8     13.2     64.9    34.3
Asthma                     28.3        52.4      58.5      62.9     40.8        39.7    34.8   100.0    15.3    17.4    12.3    22.0    34.3     33.0     16.7     47.7    18.4
Congestive Heart Failure   13.4        22.1      37.9      30.6     79.5        61.9    53.5    32.3   100.0    41.2     4.1    21.1    26.1     33.9      8.9    100.0    50.3
Angina & Ischemic HD       12.2        30.5      47.8      41.8     68.2        81.5    57.6    40.3    45.1   100.0     4.6    24.1    33.8     31.5     11.7    100.0    41.9
HIV                          8.3       50.2      48.4      73.5     25.2        20.0    18.1    41.9     6.7     6.8   100.0     4.9    26.6     16.4     13.2     31.1    17.9


                                         Health Home High Risk
Obesity                    12.7        50.5      61.4      45.8     52.6        55.4    53.1    49.0    22.2    23.1     3.2   100.0    39.3     25.7     16.5     60.1    27.2
Osteoarthritis             22.1        45.7      62.7      56.8     49.9        41.8    35.5    44.0    15.8    18.7    10.0    22.7   100.0     25.5     15.1     52.0    24.9
COPD & Bronchiectasis      15.5        38.8      53.0      50.6     54.7        48.1    40.7    60.1    29.2    24.8     8.7    21.0    36.1    100.0     14.0     67.2    27.0
Epilepsy                   13.5        65.1      66.6      66.3     38.8        33.2    27.2    35.1     8.9    10.6     8.1    15.6    24.8     16.2    100.0     41.1    16.3
CVD                        41.9        33.2      45.3      44.6     55.9        50.2    43.1    32.3    32.0    29.2     6.2    18.3    27.4     25.0     13.2    100.0    35.4
Kidney Disease             18.8        25.2      40.4      32.4     61.5        49.9    50.6    27.6    35.8    27.2     7.9    18.3    29.1     22.3     11.7     78.6   100.0
                    Total 100.0        43.5      46.2      54.4     37.6        29.8    27.8    28.3    13.4    12.2     8.3    12.7    22.1     15.5     13.5     41.9    18.8
Note: Diagnosis History During Period of July 1, 2010 through June 30, 2011.


                                                                                                                                                                             4
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.


                                                               5
   Loyalty analysis goal – keep members with
    meaningful (ambulatory) provider
    connections
   State reviewed where eligible Health Home
    members seek care:
    ◦ Current Case Management services
    ◦ Ambulatory care
    ◦ Emergency or inpatient use
   Members assigned to Health Homes where
    they have the most connectivity

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Eligible for Health Home services with either two or more chronic
conditions, HIV/AIDS or serious persistent mental illness;
members given a risk score and an ambulatory connectivity score
 Risk Score
   ◦ Scale of 0-100
   ◦ High score means a higher chance the member would have an
     adverse event (inpatient or nursing home admission, death)
   ◦ Based on John Billings algorithm at NYU
 Ambulatory connectivity
   ◦ Scale of 0-100
   ◦ The fewer ambulatory care visits the higher the score
 Risk and Ambulatory score added together = DOH Composite
   Score-members with scores 125 and above (for initial launch)
   assigned to Health Homes based on loyalty


                                                                    7
   Will explore assigning members with higher risk
    scores but higher ambulatory connectivity.

   Converting TCM members will be included on May
    rosters (due to DOH in June)

   Dual eligibles will be assigned

   Contracts are being expedited to facilitate
    assignment of Managed Care members

   Guidance on accepting community referrals is
    being developed

                                                      8
Health Home FFS Assignments To Date




                                  9
Potential Assignments from
Managed Care Plans-Phase 1




                             10
   New referrals (via HRA, county, SPOA, care management
    agency, practitioners, hospital, prisons, BHO, etc) meeting
    Health Home criteria must be assigned to Health Homes to
    ensure access to care management
   For Managed Care Members, the referring entity will contact
    the Plan to actuate the Health Home assignment
   For FFS members, the referring entity will contact DOH
    (contact information to be provided shortly) to actuate an
    appropriate Health Home assignment. Process will include
    collaboration with OMH, AIDS Institute, and OASAS to
    ensure these assignments best serve member needs


                                                                  11
   State assigned FFS members to Health Homes based on
    their score and loyalty analysis
   Managed Care Plans will assign MC members to Health
    Homes based on similar information
   Tracking file lists are not perfect
    ◦ State ‘cleaned up’ lists but challenges remain
    ◦ Medicaid eligibility and MC enrollment status changes
      daily
    ◦ List Generation is in the process of being more automated
   Health Homes identify the members for outreach and
    enrollment through the Member Tracking System


                                                              12
   Initial lists went out to Managed Care Plans and Lead Health
    Homes 2/21 – 2/22
   Updated lists of members w/ composite scores >125 sent
    Health Homes 3/28
   Loyalty files sent to Health Homes 4/9
   Addresses and last 5 claims sent to Health Homes 4/12
   Health Homes were sent members enrolled in converting case
    management programs 5/9
   Managed Care Plans were sent members currently enrolled in
    converting case management programs 5/15 – 5/16
   May lists from HH for FFS due in June 5th.
   Next Submission Date for Managed Care and FFS – July 3rd.
   Working on capacity to give recent claims and encounters to
    HHs for assigned members.


                                                                   13
   Weekly calls to provide technical assistance
    with Member Tracking System logistics
   Development of an OHIP Datamart Portal for
    Member Tracking
   Restriction codes to identify potential
    candidates for Health Home services and to
    indicate Health Home assignments
   Design of portals to allow real-time access
    to member-level Medicaid data


                                                   14
   TCMs identify the Health Homes that best
    meet their members’ needs
   DOH will make assignments to Health
    Homes based on these recommendations
    Managed Care Plans and Health Homes will
    receive member tracking sheets that reflect
    assignments



                                                  15
   TCMs identify the Health Homes that best
    meet their members’ needs
   TCMs make Health Home assignment and
    sends assignment information DIRECTLY to
    Health Homes
   Health Homes send member tracking file
    collected from downstream providers to
    DOH for FFS members and to Managed Care
    Plans for MC members


                                               16
   Transitioning TCMs bill Medicaid directly for all
    Health Home services provided

   Transitioning TCMs can bill for members
    enrolled in Managed Care without signed MC
    contracts

   Health Homes can negotiate upstream
    payments to cover administrative costs

   Transitioning TCMs only submit tracking file
    information to Health Homes, not DOH directly

                                                    17
   Guidance on retroactive billing will be
    provided

   DOH (with OMH, OASAS, and the AIDS
    Institute) are scheduling conference calls
    with the TCM provider community to discuss
    Health Home tracking system and billing
    issues

   Ground rules for referrals, transitions from
    shelters and criminal justice system are
    being developed

                                                   18
   Key provisions for Plans to use in executing
    Health Home contracts were approved by
    DOH
   Several plans submitted contracts that went
    beyond the key provisions
   Plans have been directed to limit contracts
    with Health Homes to the key provisions
   Once contracts are in place Plans can assign
    Managed Care members to Health Homes


                                                   19
   Health Homes must provide at least one of the
    five core Health Home services per month

   There will be no requirement for minimum face-
    to-face contacts, however, there must be active
    outreach or active care management and evidence
    of activities that support billing, including:
    ◦   Contacts (face-to-face, mail, electronic, telephone)
    ◦   Patient assessment
    ◦   Development of a care management plan
    ◦   Active progress towards achieving goals




                                                               20
   Detailed billing guidance provided in the
    Health Home Special Edition of the Medicaid
    Update (April 2012) for billing guidance
      http://www.health.ny.gov/health_care/medicaid/program/
      update/2012/april12muspec.pdf

   Provider enrollment assistance is available
    ◦ TCM providers-automatically enrolled for Health Home
      Category of Service 0265
    ◦ Lead Health Homes can contact the Health Home team for
      assistance with provider enrollment

   Provider manual in development

                                                               21
   Process metrics will be collected to assess
    the level of case management services
    provided and the degree to which the core
    Health Home services have been delivered
    as required
   Outcome metrics will be derived in part
    from claims data and other variables. State
    outcome metrics are included in the SPA,
    guidance still pending from CMS on
    specifications for additional measures


                                                  22
   Statewide Health Home and Managed Care Plan
    workgroups are being established to develop
    recommendations for a standardized set of
    process and outcome measures
   DOH is developing a customized reporting
    module based on CMART, an case management
    reporting utility for reporting to Managed Care
    Plans, as the framework for all Health Home
    process metrics
   Goal is to have a uniform platform and a
    standard set of metrics in place by Fall 2012

                                                      23
   State is finalizing instructions and scoring
    criteria for a functional self-assessment tool
    based on the FACT-GP to evaluate each Health
    Home participant on a range of measures. See:
    http://www.health.ny.gov/health_care/medicaid
    /program/medicaid_health_homes/forms/
   Validated tool administered upon enrollment,
    annually thereafter and at discharge; results
    reported to the State
   Results of assessments used to adjust initial
    rates, which were based on calculated acuity
    and risk scores

                                                     24
   Adding a Health Home administrative
    payment to Plan capitation rate

   Ensuring equitable distribution of
    members and payments

   Adjusting payment rates for homelessness
    and predictive risk of negative event

   Medicare and Medicaid gainsharing

   Assignment of duals

                                               25
   Updating partner lists to refine loyalty
    analysis
   Medicaid eligibility (uninsured, spend
    downs)
   Separating Health Homes from TCM
    rules and regulations
   Having biweekly calls with the larger
    Health Home community to hear
    concerns and answer questions


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Discussion




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