Connecticut Medicaid Managed Care Council Legislative Office Building Room 3000

Connecticut
Medicaid Managed Care Council
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-0023
www.cga.ct.gov/ph/medicaid

Meeting Summary: April 8, 2005

Present: Sen. Toni Harp (Chair), Rep. David McCluskey, David Parrella & Rose Ciarcia (DSS), Thomas Deasy (Comptroller Office), Barbara Parks Wolf (OPM), Jeffrey Walter, Ellen Andrews Janice Perkins & Linda Pierce (MCO reps), Robyn Hoffman, Dr. Edward Kamens, Dr. Alex Geertsma, Sharon Langer for Mary Alice Lee.

Also Present: Dr. Mark Schaefer (DSS), Mary Eberle, Margaret Dickinson & Linda Thompson (Mercer), Deb Poerio (SBHC), Sylvia Kelly (CHNCT), Paula Smyth (Anthem BCFP), David Smith (PONE), M. McCourt (Council staff).

Medical Homes for HUSKY Children with Special Needs: MMCC ad hoc Work Group Report: Rep. Mary Eberle (please see attached report)

Rep. Mary Eberle reviewed the background of the Department of Public Health’s initiatives for Primary Care Medical Homes for children with special health care needs (CSHCN) and the Medicaid Council Chair’s charge to the ad work group. Senator Harp asked the group to:

1) Clarify the definition of the target population entitled to care coordination under the Balanced Budget Act of 1997,

2) Differentiate between the case management and care coordination already provided by the MCOs and care coordination provided by primary care physicians under the Medical Home model of the American Academy of Pediatrics,

3) Identify mechanisms for supporting providers who implement the Medical Home model, including the use of extended visit billing codes,

4) Identify whether a special product should be developed for managing care for medically complex children and their families, and

5) Consider funding alternatives such as federal dollars in Title V, or obtaining a Medical Home waiver.

· Develop a standard definition of Children with Special Health Care Needs, to be used by all MCOs. The Work Group recommends using the Title V eligibility definition.

· Screen all children, with special attention to children on SSI or under state care, for eligibility as CSHCN, as part of EPSDT.

· Reimburse primary care physicians for care coordination services performed for identified CSHCN.

· Develop uniform standards for MCO case management eligibility, covered CSHCN care coordination services, and PCP care coordination billing and reimbursement procedures for all MCOs.

· Consider using Program Improvement Plan funds, or other grant funding, to train pediatric primary care practices in the Medical Home model of care coordination

· Evaluate current DPH Medical Home pilots for costs/benefits of providing Medical Home care coordination services to Husky children.

ü Is there support for this Medical Home (MH) model in public schools and School-based Health Centers (SBHC)? Rep. Eberle stated the MH model involves managed care and primary care providers; however the model promotes the primary care provider’s (PCP) coordination of care with the schools, including the school nurse and SBHC for those children with chronic health conditions. Dr. Geertsma, head of one of the MH pilots at St. Mary’s Hospital, noted that he has received positive feedback from Waterbury schools and SBHCs. The model helped them become more effective and efficient in managing CSHCN in the schools and improved collaboration between the school/SBHC and the PCP.

ü PCP care coordination, while beneficial to families with CSHCN and potentially cost effective in reducing use of higher cost services, involves currently non-reimbursed staff coordination services, including indirect patient activities. The Academy of Pediatrics (AAP) and the Centers for Medicare & Medicaid (CMS) are developing codes for indirect PCP services that can be added to the codebook. According to DSS, if the CMS code changes pertain to EPSDT, the state would pass those on to the HUSKY MCOs.

ü What are the numbers of CSHCN that would receive PCP care coordination? According to DSS, reimbursed PCP care coordination for CSHCN and especially those outside the Balance Budget Act categories both represent new costs in the HUSKY program. While the DSS is looking at broader CSHCN definition and numbers, the work group had proposed using nationally accepted screening and severity of need indicator tools to identify those children (within the BBA definitions and outside these categories) most in need of PCP care coordination.

ü Office of Policy & Management (OPM) asked 1) why the evaluation of PCP care coordination is not done up front and 2) is provider care coordination not currently reimbursed in HUSKY?

1) Rep. Eberle responded that often the same CSHCN child is served through DPH Title V, the Maternal Child Health grants and Mental Health system. Sen. Harp had asked the work group to reconcile this. The DPH CSHCN medical home pilots can be used to this end. However, initially established standards are needed for screening children in Medicaid for special needs and intensity of need (see above), which contributes to identifying PCP care coordination eligibility and reimbursement.

2) Rose Ciarcia (DSS) stated only BH providers are reimbursed for provider case management for complex needs children. The HUSKY MCOs are responsible for other case management within the HUSKY program.

Rep. McCluskey suggested DPH provide the Medicaid Council with an update on the medical homes pilot projects at the next Medicaid Council meeting as part of a continued discussion of the recommendations.

Department of Social Services Report

· The MCOs have received 4% rate increase in SFY05. Mr. Parrella noted that while commercial insurers receive double digit premium increases from employers, the state’s single digit rate increases to MCOs is inadequate in the face of straining provider network capacity and reduction of service responsibility and per member per month MCO capitation rates proposed in the carve-out BH services. The question is will there be adequate dollars left in the capitation system for medical services?

· The DSS and DPH have memorandum of understandings (MOUs) for matching DPH 1) lead data and 2) birth data with HUSKY enrollees. The most recent available lead match is for FFY 02 (10/1/01-9/30/02) with the FFY 04 match in process. The two agencies will revise their MOU for birth data in April to provide this information in 6-month cycles rather than annually as requested by the Council.

· The department has had two meetings related to the growing numbers of uninsured served by SBHC. It is unclear the proportion of uninsured that are HUSKY eligible and those that are ineligible (undocumented immigrants or legally here after 1996). The agencies (DPH & DSS), SBHCs, Covering Kids grant and Rep. Nardello will continue to work on an approach to answer the questions of who are the SBHC uninsured and how can eligible students be reached.

There was a broader discussion of the increasing immigrant population in Connecticut and policy issues related to health care access for this population.

· Rep. McCluskey asked which state agencies address this area. The DSS noted that the agency has some involvement because of Medicaid; however the issue is not just Medicaid issues. Rep. McCluskey stated ideas to address this would be welcomed (i.e. establishment of a legislative task force) before the end of the 2005 session.

· The RWJ Covering Kids grant has involved HUSKY outreach in 9 towns and offered to present what they have learned at the May Medicaid Council meeting.

The DSS external quality review (EQR) contractor Mercer was asked to elaborate on their findings in the HUSKY 2004 baseline quality review (click to open meeting handouts, which were posted on the MMCC web site following the 4/8 meeting).

The Department outlined the various components of Quality Assurance program monitoring that include

The summary chart of performance measures (pg 7 of handout doc) compared each MCO measure with comparison national /state benchmark data. Methodologies have been refined for measuring provider network adequacy in the future reports.

The individual health plan Performance Improvement Projects (PIPS) provide some outcomes indicators. The audit identified the strengths and improvement areas for each MCO, highlighted individual MCO best practices in different areas and targeted the need for all MCOs to develop processes to proactively share with other MCOs the results of member’s special health care needs assessments and evidence of coordination of services during a member’s transition to another health plan.

ü Will the Mercer “mystery shopper” access to care study in 2006 include behavioral health services? Mark Schaefer (DSS) stated that while this study would be in the BH ASO contract, there is also consideration for this to be done in an external study by Mercer.

ü Dr. Kamens observed that there is little emphasis on the impact of health care services in HUSKY. Outcomes need to be defined and measured. Mercer noted that CMS & NCQA accept process measures as part of quality review, though future focus on measurable outcomes can be encouraged.

The health plans are in the process of developing PIPs in the same clinical areas, identifying individual plan interventions and assessing the effect of the intervention.

In June 2004, Senator Toni Harp, chair of the Medicaid Managed Care Council, convened a working group of agency representatives, managed care organizations (MCO), pediatricians, and children’s advocates to discuss the development of care coordination and “medical home” services for children with special health care needs (CSHCN) who are served by Connecticut’s Medicaid Managed Care plans (HUSKY). A list of the membership of the working group is attached to this report. Senator Harp asked the group to:

1) clarify the definition of the target population entitled to care coordination under the Balanced Budget Act of 1997;

2) differentiate between the case management and care coordination already provided by the MCOs and care coordination provided by primary care physicians under the Medical Home model of the American Academy of Pediatrics;

3) identify mechanisms for supporting providers who implement the Medical Home model, including the use of extended visit billing codes;

4) identify whether a special product should be developed for managing care for medically complex children and their families; and

5) consider funding alternatives such as federal dollars in Title V, or obtaining a Medical Home waiver.

The group reviewed two sets of documents. The first was a report issued in December 2002 by the Children’s Health Council (CHC), entitled “Independent Assessment of Connecticut’s Husky Program: Access and Quality of Care for Children with Special Health Care Needs” (Report). The performance of this evaluation was a condition of the HCFA waiver allowing Connecticut to require children enrolled in Medicaid to enroll in its managed care program. According to the Report, Connecticut was required under the terms and conditions of its Medicaid Managed Care Waiver to develop and implement means for identifying enrolled children with special health care needs, to provide for assessment of their needs, and to ensure implementation of appropriate treatment programs for them.

The second set of documents the group reviewed dealt with the effort at the Department of Public Health to develop the Connecticut Medical Home System of Care for Children & Youth with Special Health Care Needs. In response to the urging of the Health Resources and Services Administration in the federal Department of Health and Human Services, DPH is working to develop a medical home support infrastructure in Connecticut for pediatric practices who serve CSHCN. Building on a previous small pilot program with three pediatric practices in 2003, DPH has established the Medical Home Learning Collaborative, to help pediatric practices become medical homes for the CSHCN served under its Title V program. DPH is implementing an expanded pilot of eight additional sites and a network of 5 regional medical home centers to support the care coordination efforts of the medical home pilot practices. DPH is providing training in medical home practices to the pilot practices and is also providing them with Doc-site software for tracking medical home care coordination services. Part of the charge to the Work Group was to determine how these two efforts relate to each other, and to recommend a unified course of action for the Medicaid Managed Care population.

The American Academy of Pediatrics issued two policy statements on Medical Home, one in 1992 and a second one in 2002. The 2002 Medical Home statement is attached to this report. These policies are focused on developing community-based systems of care for CSHCN that are:

§ Continuous (child has same provider through childhood and gets assistance with transition to adult care)

§ Comprehensive (care and consultation are available 24 hours/day, 7 days/week; preventive care is included; all needs are identified and addressed)

§ Coordinated (PCP develops care plan for child, refers to and coordinates with specialty providers, keeps child’s central medical record, provides links to support groups and other family resources, interprets reports and recommendations of specialty providers for family, is involved in hospital discharge planning for child and coordinates with educational and other community organizations)

§ Compassionate (PCP has concern for child and family well-being, empathy with individual circumstances)

§ Culturally Competent (cultural background of child and family is understood and

respected, effort is made to ensure family’s and child’s understanding of care plan and medical results, language barriers are adequately addressed)

The AAP policy statement says that such care should be delivered or directed by well-trained physicians who provide primary care and who help to manage and facilitate essentially all aspects of pediatric care. The physician should be known to the child and family and should be able to develop a partnership of mutual responsibility and trust with them. (AAP 2002 Medical Home Policy Statement). A Medical Home starts with early and continuous screening for health problems and identification of special health care needs, and includes the establishment and maintenance of a central comprehensive medical record. Active coordination with specialty providers, hospitals, schools, agencies and others involved in the care of the child is a key component of the Medical Home.

The development of Medical Homes for CSHCN has been included in the goals of the Maternal and Child Health Bureau (MCHB) by the Department of Health and Human Services in its Healthy People 2010 objectives.

According to the CHC’s Report, Connecticut’s Medicaid Managed Care Waiver defines CSHCN by reference to the four categories contained in the Balanced Budget Act of 1997 (BBA). These categories are:

4) Children receiving services under the state’s Title V program for children with special health care needs.

The CHC report recommends that Connecticut develop a definition of CSHCN for its Medicaid Managed Care plans that is more precise and reflects those children who need ongoing specialty care, therapy and care coordination. Indeed, CMS, in its revised Federal review criteria for CSHCN who are mandatorily enrolled in Medicaid managed care programs, recognizes that the BBA categories are a minimum and do not include all children who may have special health care needs. In its letter to State Medicaid Directors of January 19, 2001, CMS recommends consideration of the definition of CSHCN used by the American Academy of Pediatrics and the Association of Maternal & Child Health Programs. This is the same definition of CSHCN used by DPH for eligibility for Title V services.

Children with special health care needs are those who have, or are at risk of having, a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

Extrapolating from national estimates, there are approximately 120,000 children in Connecticut who have special health care needs under this definition. DPH estimates that there are between 8,000 and 16,000 CSHCN who could benefit from Medical Home services. However, Connecticut’s Title V program currently serves only 1,300 children. DPH therefore finds that there are underserved CSHCN in Connecticut. It is unclear how many of these underserved CSHCN are currently covered by HUSKY A, and how many are covered by private health insurance or managed care plans. Using the BBA definition, DSS’s Quality Review contractor, Mercer, submitted a report to the group indicating that CSHCN in HUSKY A totaled 12,641 out of a total enrollment of 229,243 (5.44%), as of December 10, 2004.

The Work Group recommends that, at least initially, all children enrolled in HUSKY who meet the minimum criteria of the BBA’97 (SSI or in state care or state supported adoption) and those who meet the Title V definition of eligibility for CSHCN services (as opposed to those actually receiving Title V services) be screened for intensity of need for medical services and care coordination services. Those that meet the Title V definition of chronic illness coupled with higher than average use of health and related services would qualify for “medical home” care coordination by the primary care provider (PCP). Health and related services beyond that required of children in general should be measured by one of the following methods:

· the high utilization codes listed in the Chart Book, published by the Institute for Child Health Policy at the University of Florida, or

· one of the instruments mentioned in the CMS Review Criteria for Certain Children with Special Health Care Needs dated December 2000 and its successors.

Each of the four managed care organizations (MCOs) that participate in the CT Medicaid Manage Care program is required to provide early and periodic screening, diagnosis and treatment (EPSDT). In addition, they are required by contract to provide case management for children with high intensity health care needs. The plans have provided the work group with descriptions of their case management services and their payment of CPT extended visit billing codes. The plans differ in which CPT extended visit codes and/or modifiers they pay and in the case management services they offer. In the case of at least two plans, case management services are provided by the MCOs and not necessarily by the PCP. In addition, the work group was provided with a chart that summarized the four plans’ Case Management provider reimbursement practices for children with complex behavioral health needs (attached to this report). The plans are not consistent in their definition of children who are eligible for behavioral health case management, what providers are authorized to provide behavioral health case management services, the level of care required before behavioral health case management will be authorized or their definitions of reimbursable events. The plans also vary in their criteria for authorization for provider behavioral health case management services and in their definitions of reimbursable events of service.

Medical Home care coordination services, by contrast, are performed by the primary care provider. All CSHCN, regardless of whether they are at risk for out-of-home placement, would receive these services under the Medical Home model. Telephone as well as face-face meetings with the family, agencies, other treatment providers, ancillary service providers, schools and others involved in the care/treatment of the child (such as day care providers) are included in Medical Home services. Medical Home services do not necessarily replace the case management services of the MCOs, but would allow the PCPs to work in collaboration with the MCO case managers to ensure that families understand the care plans for their children and have the supports they need to implement and comply with them. One of the key elements of a Medical Home is that it is local and easily accessible to the child and the family, which the MCO case managers may not be. Other key elements are that the Medical Home is both compassionate and culturally competent as regards the individual child and family, which enables the PCP to support the family in their efforts to care for their child. All the elements of the Medical Home are designed to assist the family in understanding their child’s illness, in implementing the child’s care plan and in complying with the care plan over the long term. Children with special health care needs need this assistance from their primary care providers, with whom they and their families have built a trusting and cooperative relationship. Standards for these services should be uniform among the plans.

The Work Group recommends that, at a minimum, DSS develop a uniform definition of CSHCN for all MCOs to use; uniform methods for identifying enrolled children who meet the definition of CSHCN; uniform standards of eligibility and services for MCO case management services, and uniform PCP billing and reimbursement standards for Medical Home care coordination services. In addition, the Work Group recommends that DSS evaluate the DPH Medical Home pilot for efficacy and outcomes for HUSKY CSHCN.

There are a number of resources already available to primary care practices who want to develop into Medical Homes. The Department of Public Health is developing a Medical Home program that will include training for the primary care provider and staff at the DPH pilot sites, provision of software to these primary care providers for tracking and billing for care coordination and the development of regional resource centers on medical home for them. The Medical Home model of primary care that is recommended by the American Academy of Pediatrics is the basis for the DPH program.

Identification of CSHCN and billing appropriately for Medical Home services are major stumbling blocks in the development of Medical Home primary care practices. To address these and other issues, the AAP in cooperation with the MCHB established the National Center of Medical Home Initiatives for Children with Special Needs (National Center). This Center has developed materials and resources to assist pediatric primary care providers to develop medical home practices. These materials and links to other resources are found at www.medicalhomeinfo.org. One of the tools on this website is the Medical Home Crosswalk to Reimbursement. This tool lists CPT billing codes that can be used to bill for a wide variety of activities that could be included in the medical home model of care coordination. Various other tools are recommended in the May 2004 issue of Pediatrics, the journal of the AAP, which is devoted to articles on the Medical Home. These include methods of flagging CSHCN patient files, both in the PCP office and at the MCO, checklists of services provided that help PCP offices track and bill for all services provided, and suggestions for hiring non-medical personnel to provide some of the coordination services. In the work group, DSS discussed the possibility of using Medicaid Program Improvement Program funds to support the development and use of these tools in the DPH pilot offices for their HUSKY CSHCN patients.

The Work Group recommends that DSS explore with the MCOs the possibility of using Plan Improvement Program funds for training primary care practices in the Medical Home model and that DSS develop a standard list of CPT billing codes that the MCOs pay for Medical Home care coordination services

The Work Group devoted much of its time to discussing ways to determine what the provision of Medical Home-based care costs, both to the individual pediatric practice and to the managed care plans as a whole. The primary care provider who participated in the Work Group was the director of one of the original DPH small pilot sites. He said that the Medical Home model did work, and helped his practice streamline their treatment protocols for some very time-intensive diagnoses. However, he said that his program could not continue this level of care coordination services without reimbursement to cover the non-medical staff assigned to do much of the coordinating, and his program certainly could not consider expanding the Medical Home model beyond the randomly selected pilot subjects without additional reimbursement.

The premise of the Work Group’s discussions was that, if medical home care coordination services were a net additional expense for the plans, then it would be more difficult in the current budgetary circumstances to obtain additional dollars for the programs. However, it is possible that the provision of medical home care coordination services will lead to a net reduction in costs to the plans, if these services result in better patient and family understanding of and compliance with their treatment plans. (Palfrey, J. et al, The Pediatric Alliance for Coordinated Care: Evaluation of a Medical Home Model, PEDIATRICS vol 113, No. 5, May 2004, pp. 1507-1516.) The logical outcome of better compliance should be fewer urgent care visits to the primary care provider, fewer emergency room visits for crisis management, and fewer unplanned hospitalizations. These crisis services are generally more costly than care coordination services, and the plans may be able to reimburse PCPs for care coordination at no net additional cost to the MCOs. There are few studies documenting this outcome, however,

The Work Group recommends that DSS be funded to do an evaluation of these outcomes in the DPH pilot Medical Home sites to see if medical home care coordination actually has these results and that reimbursement be negotiated with the MCOs after all cost data have been analyzed. The University of Connecticut Center for Health Policy and Primary Care is currently discussing the design of such an evaluation with the Children’s Health and Development Institute, one of the Work Group members. The Work Group also recommends that DSS pursue grant funds to provide reimbursement for the CPT codes identified in the Crosswalk to Reimbursement to the primary care providers in the DPH pilot for HUSKY CSHCN for the evaluation period,

· Develop a standard definition of Children with Special Health Care Needs, to be used by all MCOs. The Work Group recommends using the Title V eligibility definition.

· Screen all children, with special attention to children on SSI or under state care, for eligibility as CSHCN, as part of EPSDT.

· Reimburse primary care physicians for care coordination services performed for identified CSHCN.

· Develop uniform standards for MCO case management eligibility, covered CSHCN care coordination services, and PCP care coordination billing and reimbursement procedures for all MCOs.

· Consider using Program Improvement Plan funds, or other grant funding, to train pediatric primary care practices in the Medical Home model of care coordination

· Evaluate current DPH Medical Home pilots for costs/benefits of providing Medical Home care coordination services to Husky children.

The Work Group generally felt that Medical Home services can provide real benefit to children with special health care needs and their families, and that there is an added benefit to having those services provided at the primary care level. Many of the components of Medical Homes are already provided under the CT Medicaid Managed Care program, but these are not provided or reimbursed in a systematic or consistent manner across the MCOs that provide services under the program, and are not always provided by the primary care provider. Many pediatric primary care providers in the program already have many of the attributes of a Medical Home, but again not in a conscious, systematic or consistent way. Establishing the Medical Home as the policy of CT’s Medicaid Managed Care program, developing consistent definitions and standards for eligibility, covered services, and PCP documentation, billing and reimbursement and providing training in Medical Home practices to the primary care providers will strengthen the Medicaid Managed Care program, be cost-effective and better serve Connecticut’s children.