Goldberg: Cuomo Administration Looking To Revamp Health Home Program

NYAPRS Note: Politico NY health reporter Dan Goldberg provides an analysis of New York’s Health Home program this morning that concludes that this care management model for Medicaid beneficiaries with the highest degree of needs has had some success in reducing costs during its first five years but that “the program is working for some and not others” and that strategies have been or are being developed to address “misaligned payment incentives, communication problems, technology issues and enrollment struggles.”
Following are some of the article’s key points.

NY’s health home program was developed to improve coordination and health and cost outcomes for a large group of Medicaid beneficiaries, many of whom experience extensive and ongoing mental health, substance use and/or medical needs, partly because “working through the insurance companies wouldn’t suffice.” Health homes, which can be a hospital or health and human services agency, assemble a network of providers that are expected to work closely together to better manage healthcare for this group.

Engagement Challenges
Dan’s piece underscores that “the patient population is often transient. They can be poorly educated or unemployed, hungry or homeless. That makes them hard to find”, and enrolling the population proved harder than anticipated, especially since the original lists of eligible enrollees often came with inaccurate address or contact information. Many health
While the program was expected to enroll about 231,000 individuals, there are 163,000 people currently enrolled in 35 health homes across the state, with a 1/3 of the homes serving fewer than 2,500 patients enrolled. 
As a result, the state is taking several steps, 
· Reimbursement changes: the state is awaiting CMS approval to cut engagement time from 3 to 2 months if there’s a face to face contact and the monthly rate from $130 to $110.
· Requiring hospitals to make direct referrals, resulting in a 10% enrollment hike for one prominent health home.

Bureaucratic Challenges
“Some front-line staff also feel the program is too bureaucratic. The Department of Health needs providers to update care plans for patients because that's part of the agreement with the federal government. But providers get reimbursed for completing progress notes, a similar but separate process. That means to get paid and fulfill the state requirements, the work has to be done twice, and because care plans aren't linked to payments, sometimes they aren't done at all.” The state has simplified and streamlined some of the assessment and reporting requirements; many believe more is needed here.

Data Sharing
While the capability to share timely and reliable information is critical to effectively serve a group with such a high degree of instability and transience, current and emerging data systems continue to struggle. 
The state is hoping that the rising use of electronic record systems that can talk to each other and that are connected through broader data sharing systems like the Regional Health Information Organizations (RHIOs) will make a big dent in this issue.

Increasing Overall Program Investments
According to Goldberg, “the new rates, which also must be approved by the federal government, have not been publicly announced, but the low end is expected to be $250 per member per month. The mid-range payment, which would include most people in a HARP, would increase to the $400 range, and the highest level, for those who, for example, have a serious mental illness or HIV but are not virally suppressed, would increase to $800 per member per month.”
Health homes and care management agencies hope the rate hikes will allow them to lower caseloads and, in turn, slow the rapid turnover by case managers who often have had caseloads of as high as 150 members.

Program Outcomes to Date
The state provided the following information to this piece, detailing: 
· a 5% drop in ER use and a 1% hike in primary care utilization from the third quarter of 2015 to the first quarter of 2016.
· a 17% drop in preventable readmissions between 2014 and 2015 and a 17% increase in colorectal cancer screening.
· a drop in monthly per member inpatient costs by $39
DOH also saw a 23% rise in primary care costs and a 12% hike in pharmacy costs that the state believes will ultimately drive down avoidable inpatient and ER use and costs. One health home saw an 11% decline in emergency room visits and inpatient admissions.

Impact on Social Determinants
“It is also true that analysis of health home spending does not take into account important social costs. If patients are enrolled in a care management program, they are less likely to end up abusing drugs or be involved with the criminal justice system, and more likely to remain employed. These all have positive budget implications that aren't typically calculated in the cost-benefit analysis of the program.”

The article concludes with a quote from health home Alliance for Positive Change’s Sharon Duke: "If we could address the technology and fix the rates, I think we'd be in a really strong position to help people improve the way they access their care. Then everybody wins."