§2703 Health Homes and Whole Person Care Pilots
One of the best questions at last year’s ITUP conference involved the differences and overlap between Section 2703 Health Homes and the new Section 1115 waiver for whole person care pilots. Both address the same fundamental challenge in the American health system – the lack of important connectivity among its excellent but disparate parts. This is particularly problematic in Medi-Cal due to the behavioral health/physical health divide. Both initiatives address the same populations of severely ill patients who are high users of emergency rooms, many of whom have severe co-occurring physical and behavioral health conditions, and a significant number are homeless individuals.
There are very important differences that we should all understand as we focus on better outcomes for severely ill individuals in these populations using these new tools. The §2703 health homes are a ramped up community clinic that can provide a full complement of integrated services to this population that will keep them out of the ER. The services covered are the connective tissue among primary, behavioral and specialty care for the severely ill. The key players are the local managed care plans and the clinics. Clinics could also be a private doctors’ offices, county clinics or hospital outpatient clinic.
The whole person care pilots are a way for county mental health, public health, housing and law enforcement to work better together – for example, to get a homeless individual housed, treated for behavioral illnesses, and ideally employed.
Who’s eligible for what services?
Section 2703 is an entitlement, a pmpm payment to a local Medi-Cal managed care plan that in turn contracts with a clinic or clinics to provide the services to the covered population. It is targeted to the top 3-5% of the high cost users where there is potential to improve the patients’ health outcomes and save money for the plans and state and federal governments. Examples include patients with major mental illnesses like schizophrenia, hypertension with heart disease, chronic liver disease, dementia, or substance use disorders. The patient’s risk score must be quite high, or the patient has to have used the ER frequently or been hospitalized in the past year. The clinic must offer care management, care coordination, comprehensive transitional care, patient and family supports referrals to social and community services and an IT system that links and tracks these services.
Whole person care pilots are not an entitlement, not reimbursement for services, but rather payments to increase local coordination and integration. They as well are intended for those few patients who are high cost, high users of multiple systems. They are for individuals with repeated avoidable use of ERs, hospital admissions and nursing facilities. They are for people with two or more chronic conditions, people with serious behavioral conditions, people who are homeless or at risk of homelessness. They can pay for supportive housing services to end homelessness, but not for the housing itself. They must be able to demonstrate improved outcomes and reduced use of emergency rooms and hospitals for avoidable services. The local health plans appear to be able (at their option) to use the savings generated by these pilots to invest in county housing pools.
The whole person care pilots are funded by the local intergovernmental match and the attendant federal waiver match. The pilots do not last more than the five year duration of the waiver. The pilots must meet their target metrics or lose their federal match.
The §2703 health homes have a 90/10 match for two start up years, and The California Endowment made a $25 million contribution for the start up match. After two years, the match reverts to a 50/50 match, and the project must show state General Fund savings equal to or exceeding the state cost in order for the program to continue.
In October the state will reveal the successful bidders for the whole person care pilots, which begin shortly thereafter. The state of California has already listed the implementation schedule for the §2703 health homes beginning with Group 1 on January 1, 2017.
Why I care?
Let me tell you a few patient stories with which I’m familiar. Patient A was in declining health fell multiple times during her last year of life, breaking bones and ending up in three separate emergency rooms where the same tests were run and the ER physicians were unable or unwilling to 1) call her primary care doctor or 2) access the results of the same tests done in a different hospital’s emergency department via electronic health records. Patient A was hospitalized multiple times and sent to nursing home rehabilitation centers several times. All were avoidable and preventable, but the prevention needed to occur at the site of the independent living center and with her primary care physician team. Patient Z suffered from serious mental illness and substance use disorder for decades; he was repeatedly on the knife-edge of homelessness, frequently beaten and robbed, multiple encounters with local law enforcement. He was hospitalized multiple times for long stretches for mental illness, and physical illnesses, broken bones, deep cuts and heart infections.
Do you think these patients can navigate the health and social service systems on their own? I don’t. Do you think the health system treats them holistically? I don't. And wouldn’t it make a huge difference if they were? I think so.
California Department of Health Care Services, Comparison of California’s Health Home Program, Whole Person Care Pilot, Public Hospital Redesign and Incentives in Medi-Cal Program, and Coordinated Care Initiative (March 16, 2016) at http://www.dhcs.ca.gov/services/Pages/WholePersonCarePilots.aspx
Health Homes for Patients with Complex Needs California Concept Paper – Final (March 31, 2016)
Prepared by: Lucien Wulsin