Partnering with FQHCs and Applying the Medical Home Model to Improve Access to and Quality of Care for IowaCare Members

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Partnering with FQHCs and Applying the Medical
Home Model to Improve Access to and Quality of
Care for IowaCare Members

• Jennifer Vermeer, Iowa Medicaid Director
• Iowa Medicaid Enterprise

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Objectives

• The presentation will provide an overview of
  Iowas strategy to strengthen, build upon, and
  align Federally Qualified Health Centers with
  IowaCare, an 1115 demonstration waiver, in order
  to create a health system better able to meet the
  states and national health care goals. 
• The presentation will include information about
• IowaCare
• Iowas FQHCs
• IowaCare Medical Home Model

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IowaCare
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IowaCare History

• IowaCare Act (House File 841) passed FY2005
• IowaCare is a 1115 demonstration waiver
• Goals of IowaCare are to
• Expand access to health care coverage for
  low-income, uninsured adults who are not eligible
  for Medicaid
• Provide financial stability for safety net
  hospitals who have high amounts of uncompensated
  care
• Experiment with health care innovations
• IowaCare has provided necessary health care for
  over 72,000 Iowans from FY2005-2010.

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IowaCare Members

• IowaCare covers single adults and childless
  couples ages 19-64, up to 200 FPL, who do not
  qualify for Medicaid or other insurance
• More than 80 of IowaCare members have income
  below 100FLP
• Members are required to pay a monthly sliding
  scale premium if above 150 FPL

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IowaCare Provider Network

• From SFY 2005 2010, the provider network
  included
• University of Iowa Hospitals and Clinics (UIHC)
• Located in Iowa City (serves population
  Statewide)
• Broadlawns Medical Center
• Located in Des Moines (serves Polk County
  residents only)
• 39,000 enrolled as of August 2010

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IowaCare Services

• IowaCare services include
• Inpatient and outpatient hospital services
• Physician and advanced registered nurse
  practitioner services, including annual
  preventive physicals
• Limited dental services
• Smoking cessation
•  
• IowaCare providers donate prescription drugs and
  some durable medical and equipment with their own
  funds.

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Problems

• Access - Long travel distance to access care at
  UIHC
• High incidence of unmanaged chronic disease
• 25 have never had health insurance 66 have not
  had insurance for more than 2 years
• 80 of patients have one or more chronic
  conditions (diabetes, chest pain, coronary artery
  disease, cancer, high blood pressure, pain)
• IowaCare patients self report poorer health
  status than the general Medicaid population
• Long wait times to access physician services at
  UIHC due to lack of reimbursement for UIHC
  physician services
• Unreimbursed emergency care at non-IowaCare
  hospitals
• Unmet needs due to program/funding limitations
  i.e. no mental health, no drugs, no podiatry, etc.

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IowaCare Expansion Goals

• Improve geographic access of IowaCare members to
  quality healthcare
• Reduce duplication of services
• Enhance communication among providers/family and
  community partners
• Improve the quality of healthcare to IowaCare
  members through the patient-centered medical home
  model.
• Promote and support a plan for meaningful use of
  health information exchange (HIE) in accordance
  with the Federal Register requirement
• Expansion enacted in SF 2356 to begin in 2010.

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Expansion Specifics (SF 2356)

• Local Access
• Adds 13 FQHCs to IowaCare provider network
• Primary care services expansion will be phased in
  through the network of Federally Qualified Health
  Centers in Iowa
• Sioux City and Waterloo first two sites for
  expansion, October 1, 2010
• Improved access to UIHC
• Adds partial reimbursement for UIHC physicians to
  reduce wait times for appointments
• Medical home model to improve care delivery for
  chronic disease
• Capped 2M reimbursement for emergency services
  at non-IowaCare hospitals (associated with
  inpatient stay)

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IowaCare Phase Out

• Program will transition to Medicaid Expansion
  under the Affordable Care Act January 1, 2014
  when Medicaid will cover all persons 133 FPL and
  below
• Vast majority of the IowaCare population is below
  100 of FPL
• The expansion of IowaCare serves as transition
  period and an opportunity to pilot the medical
  home model in Medicaid with the goal of
  replication.

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Federally Qualified Health Centers
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Why Expand IowaCare in FQHCs?

• Presence in and knowledge of their communities
• Experience working with current member and
  potential new member population mission to
  serve this population and willingness to provide
  subsidies, i.e. prescription drugs
• Provide comprehensive primary care services
  (medical, oral, and behavioral health) as
  required by federal grant
• Provide high quality of care made evident through
  national performance and outcome reporting
  requirements
• Implemented a Population Patient Health
  Management System/Registry in 2007
• Implementing a comprehensive electronic medical
  record
• Progressing towards becoming a patient-centered
  medical home

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Iowas 14 FQHCs
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IowaCare Medical Home
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IowaCare Medical Home

• SF2356 mandates that providers in the network
  (UIHC, Broadlawns, FQHCs) comply with
  certification requirements of a Medical Home
• Must meet equivalent of NCQA Level 1
  certification by the end of the year (September
  30, 2011)
• Providers complete self-assessment tool
• Transition to state designated certification
  process when available
• IME specified minimum standards include
• Provide Provider Directed Care Coordination
  Services
• Designate a Care Management/Care Coordination
  staff person

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IowaCare Medical Home, cont.

• Implement a Disease Management Program
• Diabetes Disease Management is required during
  the first year. Subsequent studies will be added
  based on disease burden.
• Implement a Wellness/Disease Prevention Program
  with quarterly reporting on quantities and
  activities
• Demonstrate evidence of acquisition, installation
  and adoption of an electronic health record (EHR)
  system
• Establish a plan for meaningful use of health
  information exchange (HIE) in accordance with the
  Federal Register requirement
• Electronic system must include a Registry
  Function/Immunization Registry

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IowaCare Medical Home Payment System Methodology
Level of Certification/Year Monthly Care Coordination PMPM Performance Based Reimbursement Possible Total Reimbursement PMPM
Year 1 3.00 1.00 4.00
Year 2 Level 1 1.50 1.50 3.00
Level 2 2.50 1.50 4.00
Level 3 3.50 1.50 5.00
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Selection of Performance Measures

• All of the IowaCare providers will qualify for
  HITECH Medicaid EHR incentive payments
• Selected measures that align with coming
  meaningful use standards
• Selected measures that are used by largest
  commercial payor in their quality measurement
  program to align data collection for the provider
• Combination of measures than can be collected
  from claims data and clinical measures providers
  will need to collect from their EHR

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IowaCare Medical Home Designations
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Medical Home Coverage

• Current IowaCare enrollment is approximately
  38,000 adults
• First phase of Medical Home will have 4 sites
• Over half of enrolled (23,456) will be in medical
  home as of October 1, 2010
• 11,740 Broadlawns
• 7,740 UIHC
• 533 Siouxland FQHC (Sioux City, NW Iowa)
• 3,476 Waterloo FQHC (Northeast/North Central
  Iowa)
• We expect enrollment to grow significantly in the
  regions of the state where FQHCs are added

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Phase-in Schedule

• FY2011
• October 1, 2010 Sioux City, Siouxland Community
  Health Clinic Waterloo, Peoples Community Health
  Clinic
• January 1, 2011 Fort Dodge, Fort Dodge CHC
  Ottumwa, River Hills CHC
• May 1, 2011 Council Bluffs, Council Bluffs CHC
  Storm Lake, United CHC
• FY 2012 Dates not specified
• Phase 1 Burlington, Southern Iowa CHC Primary
  Health Care, Inc. (for outside Polk County only)
• Phase 2 Dubuque, Crescent CHC Marshalltown,
  Primary Health Care, Inc.
• Phase 3 Davenport, Community Health Care Cedar
  Rapids, Linn Community Care

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Medical Home Requirements

• Members will be assigned to the Medical Home
  based on county of residence
• Members will have to access care through their
  medical home referral required to access UIHC
  specialists
• Prescription drugs will be covered by the Medical
  Home through their own funds, so provider sets
  requirements
• All of the providers have 340B drug programs

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Integration with UIHC

• FQHCs do not have specialty or hospital care
  that care still provided by UIHC
• Model is to deliver as much care as possible in
  local setting (Medical Home) to avoid travel to
  UIHC
• New role for UIHC and the other providers need
  to create a network
• Necessary for close coordination between medical
  home and UIHC specialists/hospital

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Strategies

• Strategies to support coordination (in addition
  to care coordination)
• Electronic exchange of information between
  IowaCare providers test case for HIE
  development
• Specialist support of primary care provider -
  Reimbursement for peer to peer consultation (to
  encourage collaboration among UIHC and medical
  home
• Future telemedicine
• Established referral protocols between providers
  to reduce duplication of testing and evaluation,
  streamline process for members

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Questions?