Making Medicare and Medicaid Work for Dually Eligible Beneficiaries: “The Medical Home Model” Anthony Rodgers Deputy Administrator, Center for Strategic Planning Centers for Medicare & Medicaid Services

ACA Provisions & Medical Home Medicare  Shared savings (ACOs)*  Community-based care transitions**  Independence at Home (D)  Patient financial incentives for beneficiaries who see high quality physicians (D) Medicaid  Pediatric ACO (D)  Health homes for chronically ill  Incentives for prevention of chronic disease*** * Flexibility to implement innovative payment ** Program conducted for 5 years *** Grants to states (D) = Demonstration

Section 3021: Center for Medicare and Medicaid Innovation Section 3021: Center for Medicare and Medicaid Innovation  “Test innovative payment and service delivery models to reduce program spending while preserving or enhancing quality. The Secretary shall give preference to models that also improve the coordination, quality, and efficiency of services.”  Center begins no later than January 1, Tasks include:  Identify initial models to review  Evaluate the evidence that a model reduces spending  Prioritize among models that meet evidence threshold for testing  Test models  Evaluate demonstrations of models  Determine which models to expand to the program  Reports to Congress every other year

CMS Innovation Design, Demonstration, and Evaluation Staging Trend Analysis Prototype Design and Modeling Collaborative Innovation Lab Best Practice Analysis Publication and Collaborative Learning Collaborative Design Laboratory Stage 1 Program Trials and Demo development Technology Beta Testing Results evaluation Finding sand Recommendations Publications Demonstration and Program Trial Stage 2 Demo and Program Policy Translation Analysis and Evaluation Legislation/policy development Regulation and Rule Development Policy Execution and Implementation Re Evaluation/ Publication Program Policy Translation Evaluation and Program Execution Stage 3

Explicit References to Medical Home in CMI Statute The ACA law says to consider models that: The ACA law says to consider models that: Promote broad payment and practice reform in primary care including patient-centered medical home models, and comprehensive payment of salary-based payment models.Promote broad payment and practice reform in primary care including patient-centered medical home models, and comprehensive payment of salary-based payment models. Establish community–based health teams to support small practice medical homes by assisting the primary care practitioner in chronic care management, including patient self-management activities.Establish community–based health teams to support small practice medical homes by assisting the primary care practitioner in chronic care management, including patient self-management activities. Allow States to test and evaluate fully integrating care for duals, including management and oversight of funds under both programs, and systems of all-payer payment reform for their medical care.Allow States to test and evaluate fully integrating care for duals, including management and oversight of funds under both programs, and systems of all-payer payment reform for their medical care.

Section 2602: Federal Coordinated Health Care Office Goals: Provide access to benefits entitled under Medicare and Medicaid,Provide access to benefits entitled under Medicare and Medicaid, Simplify processes,Simplify processes, Improve quality of health and long term care,Improve quality of health and long term care, Increase understanding and satisfaction with coverage,Increase understanding and satisfaction with coverage, Eliminate regulatory conflicts between programs,Eliminate regulatory conflicts between programs, Improve continuity and ensure safe and effective care transitions,Improve continuity and ensure safe and effective care transitions, Eliminate cost-shifting,Eliminate cost-shifting, Improve performance.Improve performance.

Federal Coordinated Health Care Office Responsibilities: Responsibilities: Provide States, MA special needs plans, physicians, etc., with tools to develop programs that align benefits for dual eligible populations,Provide States, MA special needs plans, physicians, etc., with tools to develop programs that align benefits for dual eligible populations, Support State efforts to align acute and long term care services with other Medicare benefits,Support State efforts to align acute and long term care services with other Medicare benefits, Provide support for coordination of contracting and oversight,Provide support for coordination of contracting and oversight, Consult and coordinate with Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission regarding enrollment in and provision of benefits under both programs,Consult and coordinate with Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission regarding enrollment in and provision of benefits under both programs, Study provision of drug coverage for new full benefit dual individuals; monitor and report total annual expenditures, health outcomes, and access to benefits.Study provision of drug coverage for new full benefit dual individuals; monitor and report total annual expenditures, health outcomes, and access to benefits.

Medical Home Demonstrations in Progress Multi-Payer Advanced Primary Care Practice Demo (Secretary’s authority)—Applications from States due Aug. 17 Multi-Payer Advanced Primary Care Practice Demo (Secretary’s authority)—Applications from States due Aug. 17 Federally Qualified Health Center Advanced Primary Care Practice Demo (Secretary’s authority)—in development Federally Qualified Health Center Advanced Primary Care Practice Demo (Secretary’s authority)—in development Medicare Medical Home Demo (Sec. 204, Tax Relief & Health Care Act of 2006, amended by MIPPA)—on hold pending selection of states for MAPCP Medicare Medical Home Demo (Sec. 204, Tax Relief & Health Care Act of 2006, amended by MIPPA)—on hold pending selection of states for MAPCP

General Scope of Medical Home Services and Capabilities Develop & implement plan of care Develop & implement plan of care Coordinate care across all physicians & settings Coordinate care across all physicians & settings Offer non-visit-based access & care Offer non-visit-based access & care Use evidence-based medicine & decision-support tools to promote patients’ goals Use evidence-based medicine & decision-support tools to promote patients’ goals Actively promote patient self- management Actively promote patient self- management Meaningful Use of EHR Meaningful Use of EHR

Overview Demonstration Medicare Medical Home Demonstration (TRHCA Sec. 204) Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Federally Qualified Health Centers (FQHC) Advanced Primary Care Practice Demonstration Geographic Scope Up to 8 states (urban, rural, underserved areas) Expect 6 statesUp to 500 clinic sites Participants Individual physician practices (attract small practices, <3 FTEs) Practices (MD & NP) participating in state health care reform initiatives promoting APCP FQHCs (and “look-alikes”) serving relatively large numbers of Medicare beneficiaries Practice Qualifications NCQA PPC-PCMH-CMSDependent on state program To be determined Targeted Beneficiaries 1 or more chronic conditions Dependent on state program Medicare beneficiaries receiving primary care from FQHC Payment Medicare fee-for-service plus monthly care management fee plus shared savings Established by state multi- payer reform initiative Medicare all-inclusive rate plus monthly care management fee

Implications for Dual Eligible Individuals Challenge: Coordination of care across providers, settings, and benefits (Medicare/Medicaid; Federal/State) Challenge: Coordination of care across providers, settings, and benefits (Medicare/Medicaid; Federal/State) Opportunity:—Reorganization of healthcare delivery system and alignment of benefit structures to better serve this population through Pilots/Demos under CMI and FCHCO. Opportunity:—Reorganization of healthcare delivery system and alignment of benefit structures to better serve this population through Pilots/Demos under CMI and FCHCO.

Mechanisms to Explore HIT—Create linkages and share data, HIT—Create linkages and share data, Incentives—Promote the desired behavior from the healthcare system and patients, Incentives—Promote the desired behavior from the healthcare system and patients, Patient activation—Empower a population that has not felt in control by giving them tools, resources, and training to improve their health literacy and self efficacy, Patient activation—Empower a population that has not felt in control by giving them tools, resources, and training to improve their health literacy and self efficacy, Community support—Involve community organizations in the process, Community support—Involve community organizations in the process, Sustainability—Maintain and optimize what works. Sustainability—Maintain and optimize what works.

Focus of CMI Build on the current foundation of Medical and Healthcare Homes. Build on the current foundation of Medical and Healthcare Homes. Integrate patient centered medical homes with Accountable Healthcare Organization strategies. Integrate patient centered medical homes with Accountable Healthcare Organization strategies. Invest in advance optimization of medical and healthcare homes scope of service, capacity, and capabilities. Invest in advance optimization of medical and healthcare homes scope of service, capacity, and capabilities. Continue to test various payment methods to support medical home expansion. Continue to test various payment methods to support medical home expansion.

14 Medical Home 1.0 Medical Home 1.0 E- Prescribing Individual Patient Care Plans Care Coordination Capable Electronic Medical Record

15 Medical Home 2.0 Medical Home 2.0 Advance Chronic Disease Mgmt Patient Registry Databases E-Clinical Decision Support Electronic Patient Access and Communication Electronic Eligibility System Interface Two way Quality Reporting Public Health Bio Surveillance Connected EHR/HIE Connected Integrate E-prescribing And COES

16 Medical Home 3.0 Medical Home 3.0 Fully E-Health Capable Advanced Care Management Capable Community Practice Translational Research Site Connected to Community Resource Databases Patient E-Learning Center Psycho/Social Evaluation And Intervention Community Health Surveillance Interfaces Horizontally Integrated With Interoperable HIT Remote Bio-metric Monitoring Capable

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