New York State Medicaid: Medical Home Foster Gesten, MD

1
New York State Medicaid Medical Home

• Foster Gesten, MD
• Medical Director
• Office of Health Insurance Programs
• fcg01_at_health.state.ny.us

2
What is Medical Home?

• Some old concepts of primary care, modernized
  with..
• Chronic care model
• Electronic health records and exchange of
  clinical information
• Team care
• Population health management
• Responsibility for health outcomes
• Monitoring and measurement
• Active role of patient/family patient
  engagement

3
What does Medical Home mean for patients?

• Better coordination of care between physicians
  (primary care and specialists)
• 24 hour access to physician
• Patient education and engagement in prevention
  and care for chronic conditions
• Convenience and safety associated with electronic
  prescribing
• Patient reminder systems

4
Why Medical Home

• Evidence to suggest that cost/quality (value)
  crisis in health care linked to primary care
  access and quality
• Preventive Quality Indicators (hospital
  admissions)
• Overuse of specialized services without
  commensurate improvement in health outcomes
• Primary care capacity is shrinking
• Challenges of chronic care
• Need for better care model
• Need to develop payment reform that pays for
  services without codes, not billable

5
Why Medical Home for Medicaid

• Invest more in ambulatory/primary care and
  improve care
• Invest in HIT/HIE and improve care
• Continuity/coordination challenges
• Institutional settings
• Population
• Chronic disease burden
• Potential impact on disparities

6
Medical Home

• Joint Principles of ACP, AAFP, AAP, AOA
• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and integrated
• Quality and safety
• Enhanced access
• Payment

7
NCQA Patient-Centered Medical Home

• Recognition program built on Joint Principles
• Began January 2008
• Tiered recognition
• Three levels of recognition
• Level One without EHR
• Level Two requires some electronic functions
• Level Three requires fully functional EHR

8
Legislation Statewide

• By December 1st
• Develop and implement standards
• Consider existing standards
• Develop and implement payment for those standards
• Placeholder for pay for performance
• Evaluation
• Quality
• Access
• Costs/utilization

9
The State Program Standards are the NCQA Standards

• Incentive payments to those practices/providers
  who are recognized by NCQA Patient Centered
  Medical Home Program

10
Implementation

• FFS Approach
• Will pay institutional providers
  5.50/11.25/16.75 per visit and professional
  providers 7/14.25/21.25 per visit (per
  qualified provider) for each level as an add on
  (for selected EM codes)
• 99201-99205 and 99211-99215
• 99381-99386 and 99391-99396
• Managed Care
• Premium support based on 2/4/6 pmpm (per
  qualified provider)
• Level one (1) payments will end December 2012

11
Medicaid Plans Implementation

• Plans will use NCQA recognition as criteria for
  which physicians/practices receive incentive
  payments
• Plans will have 3 payment levels appropriate for
  recognition level
• Plans will be paid through premium support (for
  MMC and FHP members)
• Payment must go to recognized physicians/practices
  
• CANNOT be kept by plans, or used for supportive
  activities
• Unspent funds may be rolled over for following
  year incentives
• CANNOT be kept by plans to be spent elsewhere

12
Principles

• Program will evolve crawl, walk, run
• Recognize diversity of practice sites and where
  most practices are with respect to (any
  definition) of medical home
• Customizing approach risks non-alignment with
  other payers
• Program will be consistent across fee for service
  and Medicaid managed care
• Evaluation and on-going input vital
• Medical home incentive will not, by itself, pay
  for all that is needed for transformation
• Medical home will not fix everything that is
  broken in health care or in Medicaid