Posted by Professor John Billings
New York, like most states, is moving rapidly to implement a new initiative to provide care coordination/management to high risk Medicaid patients. Stimulated by the 90-10 federal match rate that was established in the Patient Protection and Affordable Care Act, the New York Health Home Initiative is initially targeted at more than 700,000 Medicaid recipients who have at least two chronic conditions or a serious and persistent mental health condition. In 2009, New York spent more than $8.7 billion for these patients, and the goal of the initiative is to improve health outcomes and reduce costs through improved care management and coordination that lowers rates of hospitalization and emergency department use.
In New York, the Medicaid program will pay a monthly fee to a “Health Home” to manage and coordinate care for each qualifying patient. The fee is expected to range from about $50-$350 per patient per month depending on the level of risk as determined by the patient’s CRG acuity score and predictive modeling on the risk of a hospital admission in the next 12 months. As currently envisioned, for patients enrolled in managed care, the fee will paid to the managed care plan where the patient is enrolled, and the plan will determine where the “Health Home” will be located and how the care coordination fee will be distributed. For fee-for-service patients, the state has asked for submission applications from providers interested in qualifying as a Health Home, and the state will assign patients to a Health Home based on prior outpatient utilization patterns (based on a “loyalty” analysis), or based ED/inpatient use or geographically for patients with no recent outpatient utilization. The program will be implemented in three phases beginning with 12 counties (including Brooklyn and the Bronx) in January, 2012, with an additional 14 counties expected in April, 2012, and the remaining 35 counties expected in June, 2012. For further information on New York’s plans, see: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/.
From a policy perspective, this initiative and its roll-out are of significance along multiple dimensions. First the level of interest among providers has been enormous – the State received more than 200 letters of intent for applications to become a Health Home, with more than 90 in New York City alone. Of course, with new money on the table in a time of Medicaid cutbacks, perhaps that’s not all that surprising. But of more policy import is the extent to which the letter of intent process generated an unprecedented level of dialogue among medical, behavioral health, and social service providers, many of whom had no prior history of interaction. Again, perhaps this is not so surprising – these are complex patients, with multiple conditions, often with a history of substance abuse or mental illness, many with housing problems, and many isolated with little or no social support structure. Some potential applicants went solo or brought and handful of providers and community based organizations together. But most applicants listed scores of medical provider organizations, behavioral health providers, social service providers, and other community based organizations, with four from New York City listing more than 100 organizations coming together for a potential Health Home application.
On one level, watching this diverse group of providers crawl out of their silos and begin to talk about what would be needed to coordinate the health and social needs was quite exciting. But it also demonstrates the extent to which the current “system” is fragmented, with little integration within the medical care sector, but also little existing coordination (forget integration) between and among medical care providers, behavioral health providers, and community based organizations interested in the health and welfare of this vulnerable population.
This response also illustrates some of the challenges facing prospective Medicaid Health Homes (and the rest of health care services for that matter). What will it take to be successful? Optimally Health Homes would have the following capabilities and characteristics:
- A multidisciplinary approach for individualized needs assessment and care planning for participating patients;
- Integrated/organized/coordinated health and social service delivery system;
- Some sort of care/service-coordinators/arrangers, with a reasonable caseload size, a clear mission (to improve health and to reduce costs), an ability to engage and build trust with the patient, and a capability of respond to non-medical issues/needs
- Core IT and care coordination support capacity to track patient utilization in close to real time and to mine administrative data to help target interventions/outreach, provide feed-back to participating providers, and to examine utilization patterns that will allow continuous improvement and re-design intervention strategies;
- Ability to provide real time support at critical junctures, including ED visits (to help prevent “social admissions”, hospital discharge (to help develop effective community support/management planning), and or patient initiated contact for help for an emerging crisis; and
- Incentives/reimbursement policies to encourage and reward “effective and cost efficient care”, most notably to reduce hospital admissions and ED visits.
And how much of this currently exists? How much is achievable in the short run? Well, items 1 and 3 seem do-able. The care coordination fee can help support the needs assessment and the costs of care coordinators. The rest, not so much. The biggest challenge will be coping with the fragmented medical, behavioral health, and social service delivery non-system. It’s fine to come together on a letter of intent (talk remains fairly cheap) – it’s another matter to actually function as at least a quasi-organized, coordinated “system”. The challenges of exchanging data among the non-integrated Health Home participants will be also daunting – just sharing and updating a patient care plan is likely to be difficult for some orgnaizations. Assuring that the care coordinator knows in real time that a patient is in the ED or about to be discharged from the hospital present much bigger challenges, especially for the 30% or more Health Home patients not currently enrolled in managed care. Of course, when the Medicaid card is swiped, Albany knows, but getting that information to the Health Home and its care coordinator is not currently including in the planning.
And what about incentives? Clearly hospitals have the most to lose here, since the goal is to knock out hospital and ED visits. In a managed care world where the hospital is included in some global capitation arrangement, incentives are somewhat aligned since the hospital can share in the savings. But that sort of arrangement is relatively rare for most of managed care, and for fee-for-service patients, it is not existent. Some form of shared savings arrangement for the Health Home Initiative is contemplated by the State, but currently it is just that: contemplated. Progress here will be critical to success of the initiative.
And as to success, what do we know about similar initiatives? Well, another important policy issue related to Health Homes is that once again we are embarking on a major initiative without much evidence that it is likely to work. It certainly sounds good on paper – care coordination makes sense and there is plenty of evidence that a lot of hospitalizations and ED visits are preventable/avoidable. But less is known about how to do the preventing and avoiding. This faith-based approach to policy making is actually pretty typical for Medicaid and most of health care. Think back over the last 10-15 years for the last great Medicaid initiative: enrollment of massive numbers of Medicaid patients in managed care. What did we know about the effectiveness of managed care in improving outcomes and reducing costs then? About as much as we know now for Health Homes. And what do we know about how Medicaid managed care has worked so far: shockingly little on some dimensions.
What is a bit frustrating on Heath Homes is that New York currently has an initiative that looks and smells a lot like Health Homes: the Chronic Illness Demonstration Project (CIPD). A monthly fee is paid to six demonstration sites to coordinate and manage care for fee-for-service patients at high risk of future hospitalization. There is even a shared savings pool for projects that actually reduce costs (after including the costs of the intervention care coordination fee). Unfortunately, the federal funding for Health Homes came along before we know how well and for whom CIDP is working. We are going from a demonstration with a couple thousand patients to a ramp-up that ultimately may involve more than 700,000 patients. Pretty classic.
This is not to say moving ahead with the Health Home Initiative is a bad idea. The State has moved forward in a refreshingly open and transparent way, trying to keep the health community well-informed and trying to respond where possible to concerns of those likely affected as it rolls out the initiative. And new federal money is new federal money. And more coordination can’t be a bad thing. And getting a broad range of medical, behavioral health, and community based social services providers to work together is fabulous, and it may stimulate more lasting and broader integration or at least coordination among these providers. Perhaps even the first baby steps toward something that feels like an Accountable Care Organization? One can only hope. But what is fairly certain is that things are likely to get a bit messy along the way. With the magnitude of change required to make Health Homes work, no one will get it all right the first time. The goal should be to learn as much as possible along the way. And it is important the State remain flexible and make necessary adjustments as the initiative is rolled out – the speed at which the initiative is being implemented should not be allowed to foreclose opportunities to encourage more lasting and fundamental change. But stay tuned, it will be an interesting ride.
John Billings is an Associate Professor of Health Policy and Public Service, and the director of Wagner’s Health Policy and Management Program. His research focuses on understanding the nature and extent of barriers to optimal health for vulnerable populations. He can be reached at firstname.lastname@example.org.