Iowa – Medical Homes

IowaCare

Iowa’s 2008 Health Care Reform Act (House File 2539) charged the Iowa Department of Public Health with convening a Medical Home System Advisory Council to craft recommendations for implementing a statewide patient-centered medical home (PCMH) system. The stated purpose of a patient-centered medical home is to provide for the, “coordination and integration of care, focused on prevention, wellness, and chronic care management, using a whole person orientation through a provider-directed medical practice.” The Advisory Council has also convened a Multipayer Collaborative Workgroup to explore the potential for a multi-payer medical home project in the state.

The Council has guided the state in re-launching IowaCare as a medical home program for a select group of low-income adults. IowaCare operates under the authority of an 1115(a) waiver. Previously, IowaCare included a limited benefit package and only offered two providers. In accordance with Senate File 2356, beneficiaries are now assigned to one of eight recognized geographically dispersed medical homes. (The program launched with two federally qualified health centers (FQHCs) in October 2010, and has incrementally increased the number of medical homes since then.) All but two of the medical homes are FQHCs. As per the special terms and conditions of the 1115(a) waiver, the goals of the program are as follows: IowaCare member satisfaction with health care.

  1. Improve statewide access of IowaCare members to quality health care.
  2. Reduce duplication of services.
  3. Enhance communication among providers, family, and community partners.
  4. Improve the quality of health care to IowaCare members through the patient-centered medical home model.
  5. Promote and support a plan for meaningful use of health information exchange (HIE) in accordance with the Federal Register requirement.
Since inception, IowaCare has served over 144,000 Iowans (as of SFY2012); the program currently covers over 68,000 adults. For more information on IowaCare, visit the IowaCare homepage, or the following resources available online: a 2012 fact sheet or a 2011 white paper on the IowaCare model. Information on “lessons learned” is available on the final slides of this presentation.
IowaCare is slated to end in October 2013; the authorizing waiver expires December 31, 2013. At that time, if Iowa chooses to pursue a Medicaid expansion, most members should be eligible for either standard Medicaid coverage or subsidies to purchase coverage on the exchange. The 1115(a) waiver requires Iowa to prepare a plan outlining how IowaCare beneficiaries will be assisted in transitioning to new coverage options.
Federal support:
  • On June 8, 2012, CMS approved a Section 2703 health home state plan amendment for Medicaid enrollees with chronic conditions, which became effective July 1, 2012. To be eligible, patients must have two qualifying chronic conditions, or one qualifying chronic condition and risk for a second. A second health home state plan amendment for adults with serious mental illness and children with a serious emotional disturbance was approved on June 18, 2013. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
Last Updated: September 2013

 

Forming Partnerships
IowaCare: The Iowa Medical Home System Advisory Council (MHSAC) is made up of legislators and a variety of stakeholders including Medicaid, the state chapter of the American Academy of Family Physicians (AAFP), the state chapter of the American Academy of Pediatrics (AAP), the physician assistant association, the osteopathic society, the nursing association, the chiropractic society, the medical society, the dental association, consumers, private payers, and the primary care association (PCA). MHSAC is supported by 1.5 full-time staff at the Iowa Department of Public Health and has published two issue briefs to educate policymakers and stakeholders in Iowa about issues regarding the medical home model.
A full list of MHSAC members is available here.
Defining & Recognizing a Medical Home
Definition: 
IowaCare: According to Iowa’s 2008 Health Care Reform Act (House File 2539), a patient-centered medical home means an, “approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, and other health care professionals, and where appropriate, the patient’s family; utilizes the partnership to access all medical and nonmedical health-related services needed by the patient and the patient’s family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the characteristics specified in section 135.158.” Section 135.158 identifies the following characteristics:
  • Personal provider
  • Provider-directed medical practice
  • Whole person orientation
  • Coordination and integration of care
  • Quality and safety
  • Enhanced access to health care
  • Appropriate payment.
Recognition: 
IowaCare: Participating IowaCare medical homes are expected to obtain recognition from either the National Committee for Quality Assurance (NCQA) “or the equivalent, as determined by the” state. This is specified in the IowaCare 1115(a) waiver.  Iowa has agreed to accept the Joint Commission primary care medical home designation as an acceptable alternative to NCQA recognition.
In addition to medical home recognition (NCQA) or certification (Joint Commission) practices are expected to meet standards related to:
  • Development of continuity of care documents to aid in communication across care settings
  • Development of personal treatment plans
  • Comprehensive patient evaluations
  • 24-hour provider accessibility
  • Use of a protocol or standards for tracking patient referrals
  • Provision of same-day services when appropriate
  • Designation of a dedicated care coordinator
  • Establishment of a disease management program (practices must focus on diabetic patients in year one)
  • Establishment of a wellness/disease prevention program
  • Use of health information technology
  • Use of a system to remind patients about preventive services
  • Establishment of a system to share information with the University of Iowa Health Center for specialty care
Further details on the additional standards are available on pages 36-38 of the IowaCare 1115(a) waiver.
ACA Section 2703 Health Homes: Participating practices are required to achieve NCQA-PCMH recognition under the 2011 standards, as well as complete a self-assessment and submit the results to the state. Health homes are also required to meet additional standards, such as maintaining continuity of care documents for eligible patients; designating a dedicated care coordinator with responsibility for health home enrollees; adopting electronic health records; implementing a formal behavioral health screening process; and reporting annually to the state on process and outcome measures.
Aligning Reimbursement & Purchasing
IowaCare: The special terms and conditions of the IowaCare 1115(a) waiver waive certain requirement pertaining to the prospective payment system for the federally qualified health centers (FQHCs) serving as IowaCare medical homes. The special terms and conditions also provide for Iowa Medicaid to pay IowaCare sites using the physician fee-for-service methodology. In addition to fee-for-service reimbursement, IowaCare sites receive ongoing care management fees delivered as per member per month (PMPM) payments. The amount of these payments vary:
During first 18 months: $3.00 PMPM
Medical home recognition below highest level (i.e., National Committee for Quality Assurance (NCQA) Levels 1 or 2): $2.50 PMPM
Medical home recognition at highest level of recognition system: $3.50 PMPM
Practices without medical home recognition: $1.00 PMPM
Practices are also eligible for performance-based payments that are calculated on a PMPM basis but delivered annually. The amount of these potential PMPMs vary as well:
During first 18 months: $1.00 PMPM
Medical home recognition below highest level: $1.00 PMPM
Medical home recognition at highest level: $1.50 PMPM
Practices without medical home recognition: $1.50 PMPM
Practices are judged to be eligible for performance-based payments on the basis of criteria related to:
  • Colon and cervical cancer screenings
  • Documentation of patient body mass index
  • Use of culturally and linguistically appropriate educational materials
  • Tracking of patients referred to the hospital
  • Tracking of patient medications
  • Use of disease registry
  • Documentation of tobacco use
  • Immunization administration
  • Use of HbA1c tests for diabetic patients
Further detail on the performance measures is available on pages 42-43 of the IowaCare 1115(a) waiver.

 

In addition to these payments, the IowaCare waiver established reimbursement for peer-to-peer provider consultation. This allows remote hospital-based specialists to receive payment for consulting with IowaCare primary care providers.  The consultations are reimbursed at fees ranging from $20.30-$44.37 depending on the length and method of consultation (telephone, e-mail, or video conference). Further details are available on pages 40-41 of the waiver.
ACA Section 2703 Health Homes: Health homes receive a complexity-adjusted per-member-per-month (PMPM) on top of fee-for-service reimbursements for patients with chronic diseases based on a Patient Tier Assessment Tool:
  • Tier 1 (1-3 chronic conditions): $12.80 PMPM
  • Tier 2 (4-6 chronic conditions): $25.60 PMPM
  • Tier 3 (7-9 chronic conditions): $51.21 PMPM
  • Tier 4 (10+ chronic conditions): $76.81 PMPM
Supporting Practices
IowaCare: The Iowa Healthcare Collaborative, a non-profit organization dedicated to educating and equipping health care providers across Iowa, leads a Medical Home Learning Community. The leader of the Iowa Healthcare Collaborative is also chair of the Iowa Medical Home System Advisory Council (MHSAC).
The IowaCare 1115(a) waiver states, “The State must collaborate with the State’s HIE [health information exchange] designated entity to ensure that primary network providers are a high priority for connecting to the State’s HIE.”
ACA Section 2703 Health Homes: Iowa is in the process of implementing a statewide health information exchange which health home practices will be required to join.
Measuring Results
IowaCare: IowaCare will draw on clinical information from patient registries and provider records to evaluate progress in several key areas of interest, including:
  • Reduction in unjustified variation of utilization and expenditure
  • Improvement of safety, timeliness, effectiveness, and efficiency
  • Increased patient participation in decision making
  • Increased access to evidence-based care in underserved areas
  • Cost containment
A draft of the full evaluation design is available here.
ACA Section 2703 Health Homes: Iowa is working to measure success toward the state’s two goals for this state plan amendment:
  1. Change patient behavior to increase the use of preventative services and increase awareness of appropriate chronic condition management; and
  2. Transform provider practices by adopting the patient-centered medical home model to improve population health.
Specific measures, drawn from the National Quality Forum and CHIPRA core measure sets, include hospital admissions and readmissions, emergency department utilization, and skilled nursing facility visits.
The state is also tracking the program’s administrative costs, total cost savings, patient outcomes, and patient satisfaction, as well as gathering input from patients and providers on the implementation process and lessons learned.