Jennifer Vermeer, Iowa Medicaid DirectorIowa Medicaid Enterprise

ObjectivesThe presentation will provide an overview of

Iowa’s 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 state’s and national health care goals. 

The presentation will include information about:IowaCareIowa’s FQHCsIowaCare Medical Home Model

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IowaCare HistoryIowaCare 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 MembersIowaCare 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 100%FLP

Members are required to pay a monthly sliding scale premium if above 150% FPL

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IowaCare Provider NetworkFrom 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 ServicesIowaCare services include:

Inpatient and outpatient hospital servicesPhysician and advanced registered nurse

practitioner services, including annual preventive physicals

Limited dental servicesSmoking cessation 

IowaCare providers donate prescription drugs and some durable medical and equipment with their own funds.

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ProblemsAccess - Long travel distance to access care at UIHCHigh 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 hospitalsUnmet needs due to program/funding limitations – i.e. no

mental health, no drugs, no podiatry, etc.

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IowaCare Expansion GoalsImprove geographic access of IowaCare

members to quality healthcareReduce duplication of servicesEnhance 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 IowaSioux City and Waterloo first two sites for expansion, October

1, 2010Improved 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 OutProgram will transition to Medicaid

Expansion under the Affordable Care Act January 1, 2014 when Medicaid will cover all persons 133% FPL and belowVast 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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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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Iowa’s 14 FQHCs

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IowaCare Medical HomeSF2356 mandates that providers in the network

(UIHC, Broadlawns, FQHCs) comply with certification requirements of a Medical HomeMust meet equivalent of NCQA Level 1 certification by

the end of the year (September 30, 2011)Providers complete self-assessment toolTransition to state designated certification process

when available

IME specified minimum standards include:Provide Provider Directed Care Coordination ServicesDesignate a Care Management/Care Coordination staff

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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/Ye

ar

Monthly Care Coordination

PMPM

Performance Based

Reimbursement

Possible Total Reimbursement

PMPMYear 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 MeasuresAll of the IowaCare providers will qualify for

HITECH Medicaid EHR incentive paymentsSelected measures that align with coming

meaningful use standardsSelected 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 CoverageCurrent IowaCare enrollment is approximately

38,000 adultsFirst phase of Medical Home will have 4 sitesOver half of enrolled (23,456) will be in medical

home as of October 1, 2010:11,740 – Broadlawns7,740 – UIHC533 – 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 ScheduleFY2011

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 RequirementsMembers 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 UIHCFQHCs 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 – telemedicineEstablished referral protocols between providers

to reduce duplication of testing and evaluation, streamline process for members

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Questions?

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