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Medicaid programs making headway with medical homes
Over the past year, eight states Alabama, Iowa, Kansas, Maryland, Montana, Nebraska, Texas, and Virginia have been working with the National Academy for State Health Policy (NASHP) to develop medical home programs in their Medicaid and Children's Health Insurance Programs.
"This period of technical assistance that we provided to states came at a very challenging time for them," reports Mary Takach, MPH, RN, the lead researcher on NASHP's Medical Homes II Consortium project. "All were struggling with budget constraints, and many had to cut their Medicaid programs."
States worked on forming partnerships, defining and recognizing medical homes, reforming payment, supporting practices, and measuring progress, says Ms. Takach. While budget constraints did slow progress in some states, she says, things continued to move forward.
"It didn't stop their efforts. States still seemed very committed to pushing ahead," says Ms. Takach. "Many are extremely hopeful that the funding for medical homes in the PPACA [Patient Protection and Affordable Care Act] will help push things along at a faster pace."
Ms. Takach holds up Nebraska as one example of a state that had a modest budget to launch its medical home program, and had to scale plans back substantially. "It is very modest. They are starting out with two practices," she says. "The interesting thing is that they are thinking ahead."
Nebraska has a state plan amendment in place for the Centers for Medicare & Medicaid Services to review, which includes the fundamental developments in its pilot program, so that the state can take this to scale when new funding becomes available, explains Ms. Takach.
"A state like Maryland, which has a very tough budget situation, got legislation passed in a very short amount of time to get a multipayer effort going," adds Ms. Takach. "They were very innovative in the way they used community resources. They exploited some resources in their own backyard to get their medical home program going."
Despite not having a lot of state funding, she says, they were able to obtain support from commercial plans to help fund the medical home pilot.
Ms. Takach says that in fact, dire budget situations may be helping the growth of medical homes. "It really kind of forced states to look at ways to slow the growth cost in their Medicaid programs," she says. "I think that the budget situation has made medical homes rise to a level of high interest in legislatures and [with] governors."
Ms. Takach says that she was surprised to see New Jersey, a state that is facing significant budget constraints, pass legislation last year requiring Medicaid to start a medical home pilot. Part of the motivation for efforts like this, she says, is that states clearly see that what they are currently doing is not effective.
"The outcomes have been pretty flat in Medicaid programs, and costs are spiraling," Ms. Takach says. "They have been encouraged at results seen in other states with flattening the cost growth, increasing patient and provider satisfactions, and actually providing some quality outcomes in their Medicaid populations."
Programs are still new
Ms. Takach says that while there are a couple of states with robust medical home programs where the project is not convened by the state, for the most part, it is the state leadership that is key. "That is needed to galvanize the community stakeholders to really do the hard work that is needed to achieve those delivery system changes," she says.
There are very few states so far that have had the opportunity to scale up on a statewide basis, says Anne Gauthier, MS, a senior program director at NASHP. "The states that have done so are generally small states such as Vermont," she adds. "North Carolina has its program statewide, but as they add enhancements, they start in only a subset of counties and areas. It takes time to figure out how to implement innovations across the state."
Ms. Takach notes that the oldest medical home pilot is only two or three years old, and states are just beginning to think about making the transition to statewide.
In a new round of technical assistance, says Ms. Takach, NASHP will be working with states to find viable sources of funding to sustain medical homes beyond the pilot stage, add more payers, expand it to additional populations, and use resources available in the PPACA.
While states that already have medical homes in place have opportunities to bring in other payers, says Ms. Gauthier, states that aren't as far along still have the chance to take advantage of opportunities in the PPACA.
"The window doesn't shut; that's the good news," says Ms. Gauthier. "There will be funding when they are ready to move ahead."
Some states are waiting for the evaluation of the pilot that is under way to be completed, Ms. Gauthier explains, which will provide some impetus for them to begin their own programs.
Ms. Takach notes that the PPACA includes a new state option to provide health homes for the chronically ill, and this is available to states when they are ready to apply. In fact, she says, it may be easier for states to take advantage of this particular funding if they haven't gotten medical homes in place yet.
"It might be more challenging for states that already have programs going to retrofit their programs to take advantage of the funding," explains Ms. Takach. "For states that just haven't been able to mobilize around health homes yet, this is a perfect opportunity to test the waters."
Outcomes are encouraging
The medical home pilot projects were successful in preventing inappropriate utilization of services, such as decreases in ED utilization and readmissions, reports Ms. Takach. "Outcomes from patients are encouraging, too," she says. "Patients are getting more preventive services and screenings. There is good data around that."
Consumer satisfaction was extremely high with Oklahoma's medical home program, with complaints to the Medicaid department regarding the ability to access care dropping from thousands to a mere handful, notes Ms. Takach.
"They have been extremely pleased with seeing that kind of satisfaction among their Medicaid beneficiaries," she says.
Another positive development involved dramatic increases in provider participation rates in Oklahoma and Colorado, Ms. Takach says, which have very broad-based Medicaid medical home programs.
"You are asking Medicaid providers to do more. To become certified as a medical home is an extra hoop to jump through, and the payment incentive to do that is modest," says Ms. Takach. "It's not a lot of money, but providers like these programs and this new attention to quality."