For Mentally Ill, Home Is Where the Health Home Pilot Is

Little Rhode Island’s health department is getting a lot of attention this week.

While 13 states shared in $220 million in CMS grants on Tuesday, the Ocean State was alone in receiving a Stage 2 award — worth nearly $58 million over two years — for its health insurance exchange efforts.

But a smaller, path-breaking reward escaped many health wonks’ notice: $12.7 million in federal matching funds for Rhode Island to become the nation’s second state to establish a “health home.”

What is a Health Home?

You may have heard of a “medical home” — an emerging model to provide team-based, patient-centered care, as evidenced by Healthy San Francisco.

A health home goes a step further, at least when defined by CMS in Section 2703 of the Affordable Care Act.

Specifically, the homes must integrate physical and mental health services, partly by requiring care providers to collaborate with community organizations and in-the-market resources.

Another key wrinkle: health homes are intended for high-risk Medicaid beneficiaries — those with chronic health conditions and others with “serious and persistent” mental health conditions.

These aren’t easy goals to accomplish, but CMS included a carrot to spur adoption: State programs named as health homes receive a 90% enhanced federal match rate to provide care for the first eight fiscal quarters after implementing the model.

Some state officials say that funding could be transformative — and is desperately needed.

Mentally Ill Patients Can Be Lost in Shuffle

In recent years, states have significantly pared funding for mental health services. The National Alliance on Mental Illness recently reported that states have reduced their mental health budgets by a combined $1.7 billion since fiscal year 2009; California alone has made $764.8 million in cuts.

Such cuts are fraying the safety net and leaving patients’ lives in the balance, advocates warn. About one in five adults in California suffer from a mental disorder and one in 25 have a serious mental illness. But between a population with disparate needs and the stigma of mental illness, it’s hard to rally a political constituency to fight cuts to mental health care.

And as Felice Freyer writes in the Providence Journal, the nation’s mental health crisis is about more than, well, mental health. Afflicted patients have many physical health care issues, too.

“People with mental illness tend to die 25 years sooner than people without mental illness,” partly because of chronic conditions like heart disease and diabetes, Rhode Island health official Craig Stenning told Freyer.

Rhode Island To Experiment on Care Delivery

As director of Rhode Island’s Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, Stenning will lead a three-pronged approach to address mental health patients’ chronic conditions and lack of access to providers.

Under the new program, some of Rhode Island’s 5,400 mentally ill adults will be steered toward medical clinics at community health centers, while others will receive care at stand-alone clinics or from private physicians. State officials will monitor the outcomes to see if the care is thorough, effective and ultimately cost-saving by avoiding trips to the emergency department.

Meanwhile, the first state to be named a health home — Missouri — is aiming for a Jan. 1 launch for its own initiative. Under the program, Missouri’s 27 community mental health centers will coordinate care for roughly 15,000 eligible adults, serving as the hub to connect behavioral health professionals and area physicians.

Golden State Also Weighs Participating

More than 30 states have expressed interest in the Section 2703 option, and a handful — including Iowa and North Carolina — have submitted draft state plan amendments. New York in August issued a broad call for providers to participate in its health home program, although CMS has yet to approve the state’s application.

So the pertinent question for California Healthline readers: Will California apply for the program, too?

State health officials are currently assessing the model and its fiscal and operational viability, DHCS spokesperson Anthony Cava told California Healthline. That initial assessment should be completed within the next month or so.

While DHCS is “very interested” in improving coordination of care for vulnerable patients, it’s crucial to determine if the CMS program will be cost-effective, Cava specified. Key considerations for cash-strapped California include whether the state can shoulder any supplemental costs and whether providers are ready to absorb the new slate of health home responsibilities, he added.

California’s Approach to Mental Health

Rhode Island has served as a reform pace car before; the state enacted a Medicaid waiver in 2008, two years before California’s own Bridge to Reform.

But California has a history of being a leader, not a laggard on mental health care, having passed a mental-health parity law nearly a decade before Congress enacted a similar requirement. Proposition 63 — approved by voters in 2004 — also has provided crucial funding to bulwark services in the face of cuts.

And California’s county-focused health system has allowed for regional experimentation, NAMI’s Bettie Reinhardt told California Healthline. For example, Reinhardt cited how San Diego-area mental health providers “are actively talking about health homes” after spending several years working toward integrated care.

Still, the CMS program is a “great opportunity,” according to DHCS’ Cava. “Road to Reform” will be watching to see if California seizes it.

Here’s what else is happening around the nation.

Challenges to Reform

  • Lobbyists are expected to spend millions of dollars over the next few months in an attempt to influence the U.S. Supreme Court‘s forthcoming decision on the constitutionality of the federal health reform law. Observers say their efforts are expected to include ideological appeals, arguments about the law’s popularity among U.S. residents and campaigns that certain justices recuse themselves from the case (Pecquet, “Healthwatch,” The Hill, 11/27).
  • In letters to U.S. Attorney General Eric Holder and White House Counsel Kathryn Ruemmler last week, House Judiciary Committee Chair Lamar Smith (R-Texas) asked the Obama administration to produce documentation and internal communication regarding U.S. Supreme Court Justice Elena Kagan‘s relationship to the federal health reform law, bolstering calls for her recusal from a case against the overhaul. Republicans argue that Kagan should recuse herself from the case because she was solicitor general in the Obama administration when the law was passed, creating a potential conflict of interest. The administration has said that Kagan did not participate in discussions on the law (Haberkorn, Politico, 11/22).
  • A U.S. Supreme Court order list issued on Monday did not indicate whether the court will hear arguments in Virginia’s challenge to the federal health reform law. Last week, justices met in a private conference to discuss the roster of hearings in the coming months. The lawsuit — which was filed by Virginia Attorney General Ken Cuccinelli (R) and dismissed by the 4th U.S. Circuit Court of Appeals — reportedly was on the high court’s list of petitions under consideration. Meanwhile, the justices have not discussed in conference whether to hear a separate Virginia-based challenge, which was filed by Liberty University and also dismissed by the 4th Circuit court (CQ HealthBeat, 11/28).

In the States

  • On Monday, HHS rejected requests from Indiana and Louisiana for waivers on the medical-loss ratio rule under the federal health reform law. Under the rule, private insurers must spend at least 80% in the individual market or 85% in the group market of their premium dollars on direct medical costs. HHS found that health plans in the two states can meet the MLR threshold and that plan members will get a better value with the current rules, according to CMS officials. HHS already has granted MLR waivers to seven states and denied requests from Delaware and North Dakota (Pecquet, “Healthwatch,” The Hill, 11/28).
  • Several states are considering whether to wait to implement the health insurance exchanges under the federal health reform law until after the U.S. Supreme Court has ruled on the constitutionality of the overhaul. The governors of Kansas and Nebraska have said their states will not implement an exchange until a high court ruling, but both states are continuing to plan in case the court upholds the overhaul. CMS Center for Consumer Information and Insurance Oversight Director Steve Larsen said he believes states will be cautious ahead of the Supreme Court’s decision but they will not want to fall too far behind schedule in case the court rules in favor of the law (Millman, Politico, 11/28).
  • Despite their opposition to the federal health reform law, Georgia lawmakers are developing a plan to launch a state-based health insurance exchange in accordance with the overhaul’s requirements. If the law is not overturned by the U.S. Supreme Court, states will have to implement their own insurance exchanges or cede developmental control to the federal government. Georgia is participating in the multistate lawsuit that the high court will review in 2012, but officials continue to develop the exchange in an effort to avoid federal control if the law is upheld (Gugliotta, Kaiser Health News/Washington Post, 11/21).

Public Opinion on Reform

  • A recent Quinnipiac University poll found that 48% of U.S. residents support the high court striking down the reform law and 40% say the court should uphold it. The survey showed that 70% of Democrats said the court should uphold the law, while 86% of Republicans want the court to rule the overhaul unconstitutional (Baker, “Healthwatch,” The Hill, 11/23).

Effects of Reform

  • The coverage gap in Medicare Part D will shrink by about 40% for beneficiaries who land in the “doughnut hole” this year because of provisions in the federal health reform law, according to data provided by CMS’ Office of the Actuary. Without provisions in the federal health reform law, the average beneficiary who reached the coverage gap would have spent $1,504 this year on prescription drugs. However, provisions in the overhaul reduced that figure to $901 (Alonso-Zaldivar, AP/San Diego Union-Tribune, 11/27).

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