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Policy Innovation Profile

State Medicaid Program Pays Additional Capitated Fee to Integrated Primary Care and Mental Health Homes, Leading to Better Outcomes and Lower Costs


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Snapshot

Summary

The Missouri Medicaid Health Home program provides a per-member–per-month payment to medical homes, including primary care clinics and mental health centers, that adopt an integrated staffing model to meet the medical and behavioral health needs of patients with chronic conditions and mental health/substance abuse issues. Through two amendments to the State Medicaid plan, the State Medicaid authority pays these medical homes for care coordination, health promotion, and other services. This payment is in addition to the usual reimbursement for direct care. The payment covers the costs of new staff who provide these services, including health home directors, nurse care managers, behavioral health consultants (in primary care sites), primary care consultants (in mental health centers), and clerical/care coordinators. Health homes remit a portion of the payments to their trade associations, which in turn organize and fund program oversight and initiatives to support the health homes, including training and a data registry. Since implementation of the new payments, the health homes have provided the vast majority of enrollees with access to needed medications, improved performance on various process and outcome measures related to management of chronic conditions, and reduced utilization and costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on access to medications and pre- and post-implementation comparisons of performance on various process and outcome measures and hospital and emergency department utilization.
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Developing Organizations

MO (Missouri) HealthNet
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Date First Implemented

2012
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Patient Population

Vulnerable Populations > Co-occuring disorders; Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Medically or socially complex; Mentally ill; Substance abusersend pp

Problem Addressed

Low-income individuals with mental health conditions and substance use disorders frequently do not receive needed medical services, which increases their risk of morbidity and mortality. Those that do receive medical care often do so at primary care clinics that cannot identify and treat their mental and behavioral health needs. Because clinics serving low-income individuals are typically designated as either primary care or mental health care clinics (not both), they generally cannot receive additional reimbursement for investing in staff and other resources to allow the provision of both types of services (medical and behavioral health) at one site.
  • Inadequate access to medical care for those with mental illness: People with mental health conditions and substance use disorders, particularly low-income individuals who rely on public mental health facilities, often do not receive the medical services they need, including preventive services1 and care for a broad range of chronic medical conditions such as diabetes and asthma.2,3
  • Increased risk of illness and death: Lack of access to needed medical care increases the risk of illness and death for those with severe mental illness. Low-income mental health patients die as much as 25 years earlier than those without mental illness, with most premature deaths being the result of medical issues.4
  • Inability to handle mental health needs in primary care: People with chronic medical illnesses often face the need to make difficult behavioral changes, which can be particularly challenging for low-income individuals who already face many obstacles in their daily lives. They also face a higher risk of mental health conditions such as depression; for example, a 10-year study found that women with diabetes were 29 percent more likely to develop depression after taking into account other depression risk factors, and those taking insulin were 53 percent more likely to develop depression.5 Yet primary care clinics often cannot adequately address these mental and behavioral health needs.6
  • Few integrated programs, due in part to lack of reimbursement: Despite links between physical and mental health, most primary care and mental health clinics do not have integrated programs to assess or treat both categories of conditions. The failure to offer integrated services stems in large part from the unwillingness of payers to reimburse primary care clinics for behavioral health services or to pay mental health clinics for medical services.

What They Did

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Description of the Innovative Activity

The Missouri Medicaid Health Home program provides a per-member–per-month (PMPM) payment to medical homes, including primary care clinics and mental health centers, that adopt an integrated staffing model that meets the medical and behavioral health needs of patients with chronic conditions and mental health/substance abuse issues. The payment covers care coordination, health promotion, and other services provided by new staff, including health home directors, nurse care managers, behavioral health consultants (in primary care sites), primary care consultants (in mental health centers), and clerical/care coordinators. Health homes remit a portion of the payments to their trade associations, which in turn organize and fund program oversight and initiatives to support the health homes. Key elements include the following:
  • State plan policy amendments to authorize funding: Two amendments to the Missouri Medicaid plan authorized funding for the integrated staffing model. These amendments authorized PMPM payments from the State Medicaid authority (MO HealthNet) to existing primary care clinics and mental health centers that operate as health homes, separate from usual fee-for-service or managed care payments for direct care. (As described in the Context section below, Missouri launched an integrated health home model in 2005 but did not provide significant additional funding to the health homes, thus limiting the effectiveness of the program.) The amendments call for the payments to cover the costs of additional staff required at mental health and primary care health homes to ensure their ability to provide the six key functions of a health home: care management, care coordination, care transitions, health promotion, individual and family support, and referral to community services.
    • Payments to mental health centers: On October 20, 2011, Missouri received approval from the Centers for Medicare & Medicaid Services (CMS) to amend the State plan to implement Section 2703 ("Health Homes") of the Affordable Care Act for Medicaid beneficiaries with chronic conditions. The amendment allows community mental health centers to receive a PMPM payment (initially $78.74) to fund the services of a nurse care manager, primary care physician consultant, health home director, and staff who provide administrative support. As of March 2014, this payment had increased to $81.92 PMPM. 
    • Payments to primary care clinics: On December 22, 2011, CMS approved a second plan amendment that allows primary care clinics, including federally qualified health centers (FQHCs), rural health centers, and hospital-based primary care clinics, to receive a PMPM payment (initially $58.87) to fund nurse care managers, behavioral health consultants, and care coordination and administrative support staff. As of March 2014, this payment had increased to $61.25 PMPM. 
  • Eligible population: Medicaid beneficiaries can enroll in a health home if they have at least one of the following medical conditions: diabetes, chronic obstructive pulmonary disease (COPD), asthma, cardiovascular disease, developmental disability, obesity (defined as a body mass index above 25), or tobacco use, and they fall into one of the following categories: (1) they have a serious and persistent mental illness; (2) they have a mental health condition and substance abuse disorder; or (3) they have a mental health condition/substance abuse disorder. 
  • Enrollment: To date, approximately 19,000 individuals have enrolled to receive services from 28 community mental health centers that act as medical homes, and another l6,000 have enrolled at 22 primary care health homes (18 FQHCs and 6 public hospitals that collectively have 22 primary care and 14 rural health clinics). Approximately 20 to 25 percent of enrollees are dually eligible for Medicaid and Medicare. Using claims data, MO HealthNet identifies eligible beneficiaries who had prior-year costs of $10,000 or more and no terminal conditions. These individuals are automatically enrolled in integrated care. Those who received service in more than one primary care or mental health clinic designated under the program as a medical home are matched to the health home where they received the most episodes of care. These individuals receive notification of their enrollment along with an opportunity to opt out or choose another health home.
  • Integrated staffing in health homes: The PMPM payment funds various staff positions that allow the primary care clinics and mental health centers to provide the six key elements of a health home listed above. To be eligible for the payments, these clinics and centers agree to the following minimum staffing levels:
    • Health home directors: Mental health centers operating as health homes must have at least 1 director per 500 enrollees, while primary care clinics must have at least 1 director per 2,500 enrollees. Clinics with enrollment below these thresholds may hire a part-time director. The director (usually a nurse) oversees the daily operation of the health home; tracks enrollments and eligible individuals who decline to participate; develops relationships with hospitals; and monitors hospital discharges for those enrolled.
    • Nurse care managers: Both the mental health and primary care health homes must have 1 nurse care manager for every 250 enrollees. These care managers are integrated into existing health teams. In the mental health center, this team includes psychiatrists, master’s-level mental health professionals, and community support specialists. In the primary care clinic, the team includes physicians and nurses. When serving individual enrollees, nurse care managers review medical records, participate in treatment planning, discuss health concerns and treatment goals with the enrollees, and coordinate their care with external providers. The care managers also work with other team members on population-based care management activities.
    • Behavioral health consultants: Primary care health homes must have 1 behavioral health consultant for every 750 enrollees. These consultants ensure that each enrollee receives appropriate mental health and substance abuse services, work with the team to address behavioral concerns related to medical conditions (e.g., behavioral changes associated with a diabetes diagnosis), and coordinate care with outside behavioral health providers. Behavioral health consultants also implement the Screening, Brief Intervention, and Referral to Treatment (SBIRT) program for risky alcohol and drug use.
    • Primary care physician consultants: Mental health centers that operate as health homes must contract with primary care physicians (PCPs) or nurse practitioners (NPs) to provide an hour of consultation per enrollee each year (equivalent to roughly one-quarter of a full-time equivalent for every 500 enrollees). These consultants ensure that medical care is consistent with appropriate medical standards; consult with enrollees’ psychiatrists regarding health and wellness; identify care gaps; consult with other providers regarding specific health concerns; and coordinate care with hospitals and community providers.
    • Clerical/care coordinators: Each health home must have 1 clerical/care coordinator for every 500 enrollees. These individuals provide administrative support related to the six health home functions. 
  • Fee paid to associations to cover training and other support: Each health home remits $3 PMPM to the appropriate trade association (the Coalition of Community Mental Health Centers or the Missouri Primary Care Association), which in turn uses the money to provide various types of support to the health homes. Support includes training about health home services and integrated staffing, technical assistance with implementation, and information technology (IT) services and support. To date, the associations have hired a full-time operations manager who supports health home activities, contracted with a university to provide training, and hired IT staff who work at MO HealthNet. The associations also sponsor multiple inperson and telephone-based training events to support health home activities, including having coaches who call or visit each health home site every few months to discuss performance on health indicators and share best practices. To aid this process, the health homes submit data to a centralized disease registry that MO HealthNet uses to assess performance on specified measures and set appropriate benchmarks. 

Context of the Innovation

Part of the Missouri Division of Social Services, MO HealthNet serves as the State Medicaid authority, covering approximately 800,000 individuals. The impetus for the new PMPM payments goes back to 2005, when Missouri launched a health home model that encouraged primary care clinics and mental health centers to adopt integrated staffing. However, limited funding prevented optimal implementation of the model, causing MO HealthNet leaders to push for State plan amendments to better support the model in both types of health homes.

Did It Work?

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Results

Since implementation of the PMPM payments, the health homes have provided the vast majority of enrollees with access to needed medications, improved performance on various process and outcomes measures related to management of chronic conditions, and reduced utilization and costs.
  • Broad access to needed medications: Roughly 84 percent of enrollees who have been continuously enrolled in a health home since February 2012 and prescribed antipsychotic, antidepressant, or mood stabilizer medications have a medication possession ratio or MPR (a measure of the proportion of time an individual is in possession of a prescribed medication) of 0.80 or higher. The vast majority of those prescribed medications for chronic medical conditions also have MPRs of 0.80 or higher, including those prescribed cardiovascular and blood pressure medications (82 percent) and asthma and COPD medications (80 percent). More than 90 percent of adults and more than 85 percent of children and youth with asthma who have been continuously enrolled in a health home have been receiving a corticosteroid since the beginning of the initiative.
  • Better performance on process measures: The health homes have increased the provision of services that are known to be effective in serving at-risk enrollees, as outlined below:
    • More metabolic screening: Between February 2012 and June 2013, the percentage of adults who had a complete metabolic screening (used to diagnose and monitor diabetes, hypertension, and cardiovascular disease) increased from 12 to 61 percent. Among children and youth, the proportion receiving such screening rose from 9 to 56 percent.
    • More postdischarge followup and medication reconciliation: Between January 2012 and May 2013, the percentage of hospitalized individuals who received a followup contact after discharge increased from 32 to 68 percent. The percentage of all hospitalized individuals receiving medication reconciliation after discharge increased from 27 to 60 percent; 90 percent of those reached through followup calls received this service. 
  • Better chronic disease outcomes: The health homes have improved performance on various outcome measures related to management of chronic diseases, as outlined below:
    • Better diabetes control: Between February 2012 and June 2013, the proportion of diabetes patients meeting goals for low-density lipoprotein (LDL) cholesterol rose from 22 to 47 percent. Similar increases occurred among diabetes patients for blood pressure control (27 to 59 percent) and blood glucose control (18 to 53 percent).
    • Better blood pressure control: Between February 2012 and June 2013, the percentage of hypertensive patients who achieved adequate blood pressure control increased from 24 to 55 percent.
    • Greater likelihood of reaching cholesterol target: Between February 2012 and June 2013, the proportion of cardiovascular patients who reached target LDL levels increased from 21 to 49 percent.
  • Lower utilization and costs: An analysis of Medicaid expenditures for health home enrollees found a 12.8-percent decline in hospital admissions and an 8.2-percent drop in emergency department (ED) use in the year after enrollment (compared with the year before). These reductions translate into estimated savings of roughly $21 million a year for MO HealthNet.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on access to medications and pre- and post-implementation comparisons of performance on various process and outcome measures and hospital and emergency department utilization.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Setting up development team: MO HealthNet organized a team that included members of its own staff along with representatives from the Coalition of Community Mental Health Centers, the Missouri Primary Care Association, and providers from several existing health homes.
  • Designing State plan amendments: The team designed the State plan amendments to support the integrated staffing model.
  • Building IT tools: An IT vendor built data analytics tools, including one focused on care coordination and another that facilitated aggregate reporting.
  • Hiring and training staff: The practices hired nurse care managers, health home directors, clinical/care coordinators, and practice coaches, while MO HealthNet hired approximately eight individuals to run the project centrally. The University of Missouri’s Missouri Institute of Mental Health developed training resources for the health homes under a contract with MO HealthNet, including webinars, learning collaborative meetings, and coaching.

Resources Used and Skills Needed

  • Staffing: The integrated staffing initiative has added approximately 200 net new staff positions to the health homes and the MO HealthNet office.
  • Costs: Upfront program development costs are unavailable. Ongoing costs total roughly $14.25 million a year, made up mostly of staffing.
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Funding Sources

Centers for Medicare and Medicaid Services; Missouri Foundation for Health; MO (Missouri) HealthNet
MO HealthNet pays 35 percent of the new PMPM payment, while CMS covers the remaining 65 percent. The Missouri Foundation for Health funds the coaches that assist the medical homes.end fs

Tools and Other Resources

Web-based tools based on the American Psychological Association’s book Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention are available at:
http://www.innovations.ahrq.gov/content.aspx?id=2919.

The Lexicon for Behavioral Health and Primary Care Integration, a set of concepts and definitions developed by the National Integration Academy Council and the University of Minnesota, is available at:
http://www.innovations.ahrq.gov/content.aspx?id=3948.

The Partners In Health: Mental Health, Primary Care And Substance Use Inter-Agency Collaboration Tool Kit (2nd Edition) is available at:
http://www.innovations.ahrq.gov/content.aspx?id=2924.

Information about SBIRT is available at: http://www.samhsa.gov/prevention/sbirt/.

Adoption Considerations

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Getting Started with This Innovation

  • Do not replace existing payment schemes: The PMPM payment should not replace any existing billing mechanisms, but rather be an add-on to fund new services related to care coordination, care transitions, and health promotion. Otherwise, providers will resent being asked to do more work for the same amount of money.
  • Automatically enroll eligible individuals: Beneficiaries should be automatically enrolled based on utilization data. Since individual practices are not likely to have such data available, identification of eligible individuals should occur at the State level. In addition, programs should only enroll patients for whom health home services can improve care, such as those with frequent ED visits, unnecessary hospital admissions, or poor medication adherence. Programs should not enroll those for whom health homes will not have much of an impact, such as those receiving hospice care or dialysis or those with terminal cancer. 
  • Invest in oversight, training, and IT: Adding new staff alone is not sufficient. Program sponsors must also invest in infrastructure to support staff in their work.

Sustaining This Innovation

  • Ask about and respond to health home needs: Programs should elicit feedback on a regular basis about the challenges facing the health homes and should also provide training, technical, and other support as necessary to help the health homes meet these challenges. 
  • Track and share performance data: Program sponsors should track data documenting the program's impact on health outcomes and costs and should share this information with key stakeholders. Such data can help practices identify and address opportunities for improvement and can convince key stakeholders, including government leaders, of the need to support the program on an ongoing basis. 

More Information

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Contact the Innovator

Joseph Parks, MD
State of Missouri
MO HealthNet Division
615 Howerton Court
P.O. Box 6500
Jefferson City, MO 65102-6500
(573) 751-6884
E-mail: joe.parks@dss.mo.gov

Innovator Disclosures

Dr. Parks reports that he receives a salary from the State of Missouri and has received consultancy fees from two organizations (Care Management Technologies and Health Management Associates); expert testimony and manuscript preparation fees from the National Council for Behavioral Health; grant/contract funding from the Agency for Healthcare Research and Quality, the Substance Abuse and Mental Health Services Administration, and Rutgers University; and speaker fees from the Center for Health Integration Strategies. Information on funders is available in the Funding Sources section.

References/Related Articles

National Academy for State Health Policy: Missouri [Web site]. Available at: http://www.nashp.org/med-home-states/missouri.

Progress report: Missouri CMHC HealthCare Homes. November 1, 2013. Provided by program developers.

Achievements of Missouri health homes [PowerPoint presentation]. Provided by program developers.

Parks, J. Health homes [unpublished manuscript]. Provided by program developers.

Learning from Missouri health home implementation [unpublished manuscript]. Provided by program developers.

Footnotes

1 Druss BG, Rosenheck RA, Desai MM, et al. Quality of preventive medical care for patients with mental disorders. Med Care. 2002;40(2):129-36. [PubMed]
2 Frayne SM, Halanych JH, Miller DR, et al. Disparities in diabetes care: impact of mental illness. Arch Intern Med. 2005;165(22):2631-8. [PubMed]
3 Katon WJ, Richardson L, Russo J, et al. Quality of mental health care for youth with asthma and comorbid anxiety and depression. Med Care. 2006;44(12):1064-72. [PubMed]
4 Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):A42. [PubMed]
5 Pan A, Lucas M, Sun Q, et al. Bidirectional association between depression and type 2 diabetes mellitus in women. Arch Intern Med. 2010;170(21):1884-91. [PubMed]
6 Jackson J, Passamonti M, Kroenke K. Outcome and impact of mental disorders in primary care at 5 years. Psychosom Med. 2007;69(3):270-6. [PubMed]
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Original publication: July 02, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 02, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.