Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. D. Program Financing and Contracting

01/01/2014

The central Blueprint payment reforms--payments to incentivize quality (rather than volume) and enhance capacity through core CHT members--are financed through payments made to practices from the state's public and private insurers. Practices receive these payments on top of payments for health care provision.

Quality incentive payments for PCMHs. All large private insurers (Blue Cross Blue Shield of Vermont, MVP Health Care, and Cigna Health Care), as well as Medicaid and Medicare, contribute toward PCMHs' quality payments at the same PMPM rate, based on the number of active patients enrolled in their insurance plan (that is, those seen by the practice in the last 24 months). Quality payments range from $1.40 to $2.50 per patient, depending on the PCMH's NCQA score. For example, if a PCMH enrolled in Blueprint achieved the highest NCQA score and saw 1,000 Medicaid patients in the past 24 months, Medicaid would pay the provider $2,500 on top of contracted health care payments for a given month, or $30,000 over a year. Payments are disbursed from insurers directly to providers on a monthly or quarterly basis. Practices are rescored every three years using up-to-date NCQA standards. Patients are attributed to a practice and insurer through an all-payer claims database (DVHA 2013c; personal communication with state Blueprint staff June 3, 2013).

TABLE VI.1. Funding Sources for Blueprint Initiatives
Blueprint Initiative Funding Source(s) Target Population/Purpose
"Functional" CHT members No distinct funding stream; functional members are employed by other state initiatives, such as VCCI, or local public or private organizations; they collaborate with core CHT members. Any patient whose needs cannot be met through routine primary care encounters.
Support and Services at Home (SASH) program Medicare Medicare beneficiaries who need support to age at home.
Hub and Spoke health homes Medicaid and the state Division of Alcohol and Drug Abuse Program, which funds methadone. Individuals with opioid addictiona.
Self-management workshops Medicaid and SGFs, plus some funds from tobacco legal settlements for the smoking cessation workshop. Depending on the workshop, individuals with chronic illness, anxiety, or depression, or individuals who smokea.
Vermont Chronic Care Initiativeb (VCCI) Medicaid-funded state employees (employed with the DVHA, the state's Medicaid entity). High-cost Medicaid patients with 1 or more chronic conditions.
Evaluation Quality Improvement Program (EQuiP) facilitators Medicaid Primary care practices transitioning to PCMHs.
Blueprint Sprint teams Medicaid and state funds for HITc. PCMHs seeking improved transmission and quality of data.
Central clinical registry Medicaid and state funds for HITc. Data system for PCMHs and CHTs.
SOURCES: DVHA 2013b; discussions with state staff.
NOTES:
  1. Minors under age 18 are eligible for Hub and Spoke health homes and for self-management workshops; however, these programs are primarily geared toward adults.
  2. VCCI is a separate state initiative that overlaps with Blueprint.
  3. The state's HIT funds derive at least in part from a fee attached to health care billing transactions, funding from the American Recovery and Reinvestment Act, and various CMS programs to support HIT and VHIE.

Cost for Core CHT members. All insurers also share the costs for "core" CHT members. Core members are those who work directly with PCMHs. A local multidisciplinary group of medical, behavioral health, and non-medical stakeholders determines the composition of the team, and an existing administrative entity (such as a hospital or FQHC) in each community hires the team members in order to avoid establishing a new administrative layer (DVHA 2010). Core CHT members cost $70,000 (for one full-time equivalent worker) per 4,000 patients (DVHA 2013b). Four of the insurers each contribute approximately 22 percent of the total core CHT costs, and the fifth insurer, which is smaller, contributes about 11 percent.

As shown in Table VI.1, Medicaid, Medicare, and other Vermont state agencies have made additional investments to extend services to targeted populations and to facilitate implementation of Blueprint practices. In addition, synergies between Blueprint initiatives, complementary state efforts--such as the Vermont Chronic Care Initiative (VCCI) and the Vermont Health Information Exchange (VHIE), described below--and local social service providers defray the costs attributable to Blueprint alone.

Financing mechanisms. According to Blueprint staff, the state exercised multiple mechanisms to enable Medicaid and Medicare to contribute funds. Vermont's 1115(a) waiver (known as the Global Commitment to Health) authorizes the use of Medicaid funding for Blueprint services. In addition, Vermont has a pending SPA to exercise the Medicaid Health Home option under the ACA, which establishes the Hub and Spoke model (described below) for those with opioid addiction and which in the future may be used to establish health homes for other populations. Vermont's participation in CMS's Multipayer Advanced Primary Care Practice Demonstration authorizes the use of Medicare funds for Blueprint.

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