Hopefully the New York State Medicaid program's recent plan for "health homes" is not a template for what will be rolled out for the rest of us under health reform if the Affordable Care Act is neither struck down by the Supreme Court nor repealed by Congress. The health home program seems to be little more than a bunch of bureaucratic jargon with a whole lot of blanks still to be filled in, though it is being rolled out despite those missing details.
The basic idea sounds sensible: People with chronic conditions are covered by Medicaid through health homes that coordinate their care. Many such individuals are currently covered by sometimes-uncoordinated programs administered through the AIDS Institute, the state Office of Mental Health and Office of Alcoholism and Substance Abuse Services, and regular community Medicaid services for physicians, etc.
The state Department of Health recently issued a special edition of its monthly Medicaid Update to try to explain what health homes are and how they will work. Frankly, the document seemed to be written by bureaucratic systems analysts without any particular substantive provisions that would lead one to believe it will actually improve care.
The newsletter tries, for example, to explain the difference between a new health home and a "patient-centered medical home" provided by physician-led practices. The health home will be a partnership involving health care providers, health plans and community organizations, or so says the state. Apparently this is different from the medical home model largely because of its expanded linkages to other community and social supports.
What will this mean in the real world? It is hard to know. Particularly troubling are the many provisions set forth in the Medicaid Update which merely say that some protocol or form will be developed soon. Guidance for retroactive claiming (since health homes started Jan. 1 in some areas) is to be posted on a website "as developed." Guidance from several of the state agencies about conversion/billing is said to be "forthcoming." "At a date yet to be determined, claims back to January 1, 2012, will be automatically reprocessed," and "more specific guidance on retroactive billing is being developed."
For the long-term care population there are two components "still under development," including the seemingly critical building of a network of nursing homes.
For the developmentally disabled, the newsletter says cryptically that they "will most likely convert to health homes after work is completed on a Medicaid waiver, the People First waiver, being developed for this population." Will that happen or not? If so when? Even vaguer is the statement that "A separate health home for children is also under discussion." Is this grand new scheme being rolled out without many important components actually being operational?
Even necessary forms are not necessarily ready. Two are said to be "available soon." The information necessary for making a referral and to complete the health home file for referred clients apparently is not ready; the update says it "will be forthcoming."
How will this plan coordinate with the traditional eligibility processes administered by local social services districts? The update simply says that "eventual amendments to state eligibility and payment systems" will allow providers to see a member's health home assignment. Given the high degree of turnover in the Medicaid program and churning in eligibility cases, just seeing an assignment to a health home will not be a solution. How about instead fixing the eligibility system so people don't cycle off and back on Medicaid every few months?
Health homes are supposed to improve quality. Guess what? Guidance from the federal government for the health home core quality metrics is "expected" this summer? Why weren't these established before the program began? How will any improvements in quality be determined if the protocols do not exist to begin the measurements when the program starts, rather than six or nine months later?
As a health lawyer, I suppose I should salivate over the legal disputes that inevitably will arise from the statement that payments to Medicaid managed care plans "should be shared commensurate with the health home services being delivered." The newsletter is silent on who will develop those criteria for sharing payments or what they might look like. Payment rates will be adjusted, "and initially will change monthly," while "eventually" being calculated and paid at a member-specific level. When might "eventually" be? Since rates also will be adjusted based on functional status, the update merely promises that this will occur "when functional status data becomes available." Certainly the providers deserve more certainty than this.
A seemingly massive undertaking like this cannot be rushed. Launching it with this many unknowns will not serve either patients or providers well.
Rene Reixach is an attorney with Woods Oviatt Gilman LLP, where he concentrates his practice on health law. He formerly was executive director of the Finger Lakes Health Systems Agency.5/18/12 (c) 2012 Rochester Business Journal. To obtain permission to reprint this article, call 585-546-8303 or email firstname.lastname@example.org.