Succeeding In A World Of Integrated Care: Discussion Panel (Week 2)
Below you will find the Q&A discussion from the Week 2 live session:
“Health Home Management”
Guest presenter: Boris Vilgorin, Assistant Vice President, FEGS
Originally presented: April 14, 2015 at 2:00 p.m.
View the Q&A transcript from weeks 1-4 using the links below:
- Week 1: “Integration Of Services In Optum’s Pain & Depression Management Program”
Guest presenter: Irvin “Pete” Brock III, M.D., Senior Vice President, Optum - Week 3: “Business & Legal Aspects Of Making Medical/Behavioral Integration Work”
Guest presenter: Michael Goldberg, PhD, Director, Child & Family Psychological Services, Inc. - Week 4: “A Medical/Behavioral Integration Model Case Study”
Guest presenters:- Courtney Esparza, Senior Director, Behavioral Solutions, Optum
- Daniel Wilkes, Care Coordination Director, Northwest Primary Care Sellwood
- Helen Kurre, Director, Quality & Medical Practice Integration, Providence Health Plans
Clicking a question below will expand to reveal the answer and discussion during the live session.
How many states have implemented health homes to date?
Dustin: Just a reminder that the Week 1 recording does expand more on the Medicaid health home numbers. As of March 2015, 27 states were operating or planning to launch Medicaid health homes including 15 with approved State Plan Amendments (SPAs) and 12 with approved Health Home Planning Requests that includes about 1 million enrollees.
George: If you look at the number of organizations that are getting accreditation, what we saw on the first presentation was almost 9,000 organizations in 42 states from NCQA. What you’re looking at are some models other than Medicaid that are evolving towards even more health homes. Boris’ group, as an example, is not being driving not by state Medicaid alone. There’s also a New England group, discussed in the presentation, developing a commercial sector health home model with high per member per month (PMPM) rates. I think it’s evolving faster than just Medicaid, but Medicaid has been the primary driver up to this point.
How could a Professional Counselor provide services within this model and be reimbursed for services?
Boris: With the New York State health home model the state pays separately for care coordination. The clinical services are still paid predominately, especially in behavioral health, as a separate ongoing fee-for-service billing. From the payment perspective they are two separate bills that both go to Medicaid. In coming months that is changing; managed care will be picking up most of the bills.
What advice would you give organizations that offer some of the services similar to FEGS but haven’t launched down the path of health homes. What would be the first step?
Boris: For FEGS it was a natural progression – we were a large targeted case management provider. Probably 20 years prior to this we served over 2000 clients, and case management, at least in the mental health world, was something we’d done well and done for many years. When health homes came around it was a natural progression to help the health home system which now incorporates not just mental health, but the whole individual and the whole line of services. And now we also serve individuals who do not have mental health diagnoses. As providers ask me this type of question we have to step back and discuss where your starting point is. Do you currently provide these services? What is the current infrastructure and how will that be different in the new model? Does that, in your particular area, impact the clinical and rehabilitation services that you are providing? It’s a multi-level approach. We’ve had a number of agencies who have never done case management and are trying to use this as an opportunity to get into it and they haven’t been that successful because it requires a certain knowledge base and infrastructure to do this.
How do you share information within an electronic medical record without sharing information about substance use or HIV status if the member does not want that information shared?
Boris: New York State made the decision that the consent the individual signs actually specifically states that all information is going to be shared. One of the things we have to do in a consent signing is to list the providers who the individual is allowing us to share the information with. It’s not which portions of the information, but who can see the information. When the individual signs the consent it really is all or nothing. However, they can specify that a particular provider cannot have any information.
George: I’d like to add that this will be a state by state regulatory issue to some extent. Some people have been very hesitant because of 42 CFR regulations. However, there are times, and Boris it sounds like your state addressed it, that there has to be a way of getting information to members of that coordinating team so that the coordination can come about, and this includes alcohol and drug utilizations. There has to be some way of working through those regulatory issues, obviously with the consent of the consumer, otherwise if you’re coordinating you’re creating a serious problem by leaving that information out.
Boris: That was exactly the thinking in New York. It would be hard if people could pick what was in and what was out of the information being shared, particularly once you start looking at this state wide. Being able to coordinate care, especially when some of the agencies provide multiple services, it becomes really tricky for them if they have a single chart to decide what they are sharing and what they are not sharing. To truly be able to integrate and coordinate care the person has to have the full picture.
Is there a role that, from a peer specialist’s standpoint, consumers can play in health homes?
Boris: Oh, definitely. So FEGS, the state health department, the mental health department, and the substance abuse department, all hire consumers and encourage consumers to be part of the team approach (and the health home structures vary). They do an incredible job with outreach and engagement for individuals and those who have been lost to care. There is a tremendous push by managed care companies and the provider community to support this within the state. Depending on how it’s structured and on the peer, you can sometimes get the same level of reimbursement as a care coordinator within New York State.
George: Generally speaking there’s a variety of roles, and this is not just true within New York, that include a designation that comes from training and some education of a peer support counselor, where some individuals are recognized as being able to be reimbursed for their services and be a case manager at some level or a full level. There are peer run services that do some of the health promotion activities that have to be part of the full service of packages associated with a health home. I think peers can be embedded in a service system or as an independent function and they can play a major role. From my experience, if you don’t have peers involved working with people who have real serious mental illness, the ability to retain individuals in intensive programs like this significantly decreases unless they are being engaged by their peers.
Boris: That’s absolutely true. Getting more peers involved is now a push in the state. Peers play a big role in this and are a huge contribution to the whole program and its success.
How will the new system affect referrals and authorizations process?
Boris: We haven’t seen much effect in the referral process because individuals still have the choice of where they want to go. They are either bound by the network of the managed care, if they are still straight Medicaid they have to go to the Medicaid provider. Health homes prefer to keep individuals within the network, however because the health home does not pay for the services within New York the individual is free to choose any provider as long as it meets the health plan and Medicaid rules. The claims process for the medical side and for the health home side is separated and independent – it follows a standard claiming process on both ends.
George: The health home is always a voluntary activity. The models that I have seen have identified people based on a certain sets of clinical and other criteria. Once they are designated as eligible they have to agree to participate and that becomes a key element of being an effective care coordinator in the system –engaging and retaining people in the health home model. Some models I’ve seen have built in incentives to get people to participate in some of the health promotion activities and in doing things like smoking cessation or diet and exercise. There are ways of incenting people to get involved. All of this is voluntary so that this model, even though every health plan will most likely have a designated population that is eligible, have to agree to participate and getting their willingness to participate becomes one of the key jobs of the care coordinator.
Boris: Definitely, it’s a voluntary model. We have probably a 1-2% that opt out that we have to identify and let the plan and the state know. Even when they do enroll in New York State it is their choice for who they go to for their referrals.
When you first developed your health home model, did you do so at the behest of a managed care provider or did you do so because it looked like that was where the system was going and then a payer came along and further encouraged the growth?
Boris: For New York, case management for the seriously mentally ill has been in place in Medicaid for many years and FEGS had been providing those services. So when the health homes came around we saw the opportunity to expand that and move away from just the mental health focused case management into more integrated care. It was something natural for us, and made sense. We saw that as not just an opportunity to grow the program or change it, but really saw it as where the health care system was moving. It was really New York and the state pushing this forward with the provider community and the plans getting on board.
George: The reason I ask is because in some of the integrated care coordination projects I’ve worked on, what has happened was that certain populations get presented in pilots and formats where it is natural to look for someone to do the coordinated care. For example, if a managed care company is in the state focusing on Medicaid/Medicare populations with a higher number of people with more serious disabilities and complex problems – a lot of time they are looking for someone to do the care coordination work and one of the ways to do that is to find someone who’s already doing targeted case management. Another way this has come about is when states have done pilots on dual-eligibles (Medicaid and Medicare) because that population happened to be high-need high-risk and it’s not just the mentally ill. There are times where there are drive is from the state but also some times when the drive is from managed care companies who are looking for behavioral health companies – who probably have the most experience in doing complex work with complex people- to be care coordinators. It sounds like that’s one of the ways that those who are listening may be able to find a way to get involved in a service model like this.
Boris: Just to add, even though this did start through the state, our current relationship with Optum and United – We’ve taken what is a state product and have worked together on expanding it and creating a more synergistic approach between care management entities and health plans. We have moved it further along the spirit of what the state hoped for not just the letter of the law. That’s very exciting for us because we could just go along in care management and submit our bills but we’re now in a different phase. It’s more about how do we work together to provide the best service to these members and create the best outcomes we can together.
How have you found it to work with primary care providers and the medical community in general? As you’re working with certain populations, how have you been able to put together the network you need to have in order to make this work?
Boris: Like in many places, New York is becoming dominated by huge healthcare systems. We still have a number of individual providers, but that of course is shrinking. That has been one of our barriers and hurdles. Behavioral health providers in New York are somewhat familiar to the care management system that has been in place and for them it’s not that unusual to see a care manager with a client. On the primary care side that has been an unknown entity and an unknown service; they aren’t sure what to do with it or how to access it. What we’re embarking on is how do we use the communications and network ability of the plan to help educate the primary care providers and get us through the door. Sometimes we have a hard time even getting through. Having a partner like this, we are just getting through the stages of developing a plan for that, but I think on our own we have made some strides one-by-one but that’s a long road. We’re hoping this relationship will open more doors and speed up that process.
George: That’s a helpful perspective to provide to the people that are listening. It doesn’t all fall into place easily and you need important allies like the insurance companies to put together the networks. Especially if the people you are coordinating care for have a wide range of service providers in the medical community. I know that in general, when I’ve looked at other models that have pulled together, our first thought and our best solution is to find a willing Federally Qualified Health Center (FQHC) to be the center base of the medical services. They often have some kind of link with dental service and so forth. They sometimes have problems getting people into specialists, but at least that’s the primary care. If you have a wide range of primary care providers to work with, some of whom are in their own private practices, I can imagine that can make it difficult.
Boris: Yes, definitely. What we found when dealing with the large healthcare systems you can have a wonderful agreement and meeting on the high level senior leadership of the hospital or healthcare system but when you call the particular clinic or medical office it doesn’t seem to reflect what was agreed upon.
So how do you engage some of these private providers in working with you? Where do you find your common ground?
Boris: The first thing is to identify if a particular provider has multiple members they are serving. What we’ve started to do is find FQHC and group practices that have multiple clients. Since this is the starting phase we’re hoping that will lead to better outcomes. We’ll see how successful we are at that before we move on to individuals that maybe have one member on their panel.
George: That makes sense. Generally speaking, FCHQs and clinics have the higher need population coming through so they’re looking for a behavioral health backup more often than the private practices with a lot of commercial insurance plans.
So right now are your indicators primarily involved with just looking at how well you’re getting people engaged and in the system?
Boris: Yes that’s the primary starting point. We want to move on further down the line to get more into information on what’s on the doctor’s office chart and some of the HEDIS indicators. However, because we’re just starting to build relationships and we have to do this step-by –step especially because the care coordinators are non-professional staff which creates a whole other dynamic when they talk to the doctor.
George: I’m reminded in looking at some of the initial data coming out of the states with statewide health home models like Missouri – the initial efforts were in cultural shifting so that the models were effectively looking at the whole person. They were starting to do some work with measuring BMI and hypertension and blood pressure, but they really hadn’t gotten to some of the major medical interventions yet because the first steps are making sure the person is engaged, in the system, the parts of the system are working, and the culture of the system is effective.
How long will the fee-for-service model converting to the other payment models take for private practitioners? Will those practitioners be required to contract with medical homes, versus the usual process of getting referrals by traditional sources?
George: Second question first. That will depend upon the payer you are working with. It depends on whether they are paying for just general services by providers credentialed in their system. What we’re encouraging is to learn enough about these models in order to determine if it is advantageous to you to be part of one of these models above and beyond your normal practice. In terms of converting the payment structure, if you remember in the first presentation from last week, we emphasized the need to do some basic work on learning what’s going on with your unit of service cost and how reimbursements are actually paying you on a unit basis. If you have those fundamentals down then you can take a look at any reimbursement models whether it be case rate or per member per month and convert it to a unit of service and it’ll tell you whether it’s advantageous or not. It usually takes provider systems, depending on experience and variety of models you’ve been under, 6 months to convert from fee-for-service to some form of risk.
What state does Optum plan to go to next to participate in developing a Health Home?
Debbie Court, Optum: Kansas, Texas, Florida where we have some Medicaid integrated plains.