Primary Care and Behavioral Health

2/4/2011CIBHA

Promising Provisions

• Affordable Care Act– Prevention and Public Health Trust FUND--PCBHI– Section 2703 Health Homes for Individuals with

Chronic Conditions– Medicare Accountable Care Organizations Shared

Savings Program– Dual Eligible Demonstration Projects

Health Homes

• States can currently amend Medicaid State Plan

• 90% match for 8 quarters for following health homes services:– Comprehensive Care Management– Care Coordination and Health Promotion– Patient and Family Support– Comprehensive Transitional Care– Referral to Community and Social Support Services

SAMHSA’S PCBHI PROGRAM

• Focus on coordination between primary care and specialty care:– Significant enhancements to primary care• Workforce enhancements• Increased funding to SAMHSA, HRSA and IHS• Bi-directional

– MH/SUD in primary care– Primary care in MH/SUD settings– Services and technical assistance– Pharmacy opportunities through partnering (340b program)

SAMHSA’S PCHBI PROGRAM

• 2009—Grant award to 9 sites• 2010—Expanded to another 44 sites• 2010—Developed the Training and Technical

Assistance Center in cooperation with HRSA• Worked with ASPE to develop specific

outcome measures for participants

Health Homes

• For Medicaid enrollees with– two or more chronic conditions,– one condition and the risk of developing another, or– at least one serious and persistent mental health condition

• Conditions include: – a mental health condition, – a substance use disorder, – asthma, diabetes, – heart disease, and – being overweight*

*as evidenced by a body mass index over 25.

Health Homes

• Providers:– Team of health care professionals

• physicians • nurse care coordinator• nutritionist,• social worker, • behavioral health professional

– Can operate in a variety of settings• Free standing teams, • Virtual teams• Hospital-based• Community health center• Community behavioral health centers• Rural clinics• Group practice• Academic health center

Health Homes

• Flexibility in defining the service• Flexibility in reimbursement strategies• Outcomes are defined by state:

Medicare ACOs

• Organizations that may become an ACO– Physicians and other professionals in group

practices– Physicians and other professionals in networks of

practices– Partnerships or joint venture arrangements

between hospitals and physicians/professionals– Hospitals employing physicians/professionals– Other approved by Secty.

Medicare ACOs

• Requirements of ACOs– Have a formal legal structure to receive and distribute shared savings– Have a sufficient number of primary care professionals for the number

of assigned beneficiaries (to be 5,000 at a minimum)– Agree to participate in the program for not less than a 3-year period– Can match physicians and patients– Have a leadership and management structure– Have defined processes to

• (a) promote evidenced-based medicine, • (b) report the necessary data to evaluate quality and cost measures • (c) coordinate care

– Demonstrate it meets patient-centeredness criteria, as determined by the Secretary

Dual Eligibles

• Why focus on dual eligibles?– Approaching $300 B in expenditures in 2010– Most have 2-5 chronic conditions– More likely to be institutionalized/hospitalized– States have incentives, but no plausible strategies

to connect information or payment– 60% of all duals have a ID/BH condition

Dual Eligible Demos

• Two Current Initiatives:– Sharing Medicare Part A, B and D data with states

—get a composite look at what persons gets/gaps– $15 million in design grants to States (2/1). • Goal—identify and validate service delivery and

payment integration models • Models can be rapidly tested• Spread to other states