The State of State Medical Home Initiatives July 13, 2010 Lee Partridge, Senior Health Policy Advisor National Partnership for Women & Families

State Interest in Adopting Medical Home Model Growing Today more than half the states have some type of medical home program in place or under development; many involve incorporation into publicly funded health programs like Medicaid This discussion will focus on those initiatives that have some public program involvement

The Goal of the Patient-centered Medical Home Model ~To reorient the primary care system to be patient and family centered - Care is comprehensive, coordinated, personalized and planned - Patients, caregivers, and providers are partners, making informed, shared decisions - Transitions between settings of care are smooth, safe, effective and efficient - Patients can get care when and where they need it - Quality of care is routinely assessed and improved

The State’s Objectives for Adopting the Model Better health care outcomes for patients Reduce, or at least limit growth, in health care costs – some short term savings, but also longer term impact on population’s health status Enhance coordination of care and effective use of community resources (patient education, social services networks, public health initiatives) Greater patient and provider satisfaction

The Evolution of the PCMH Model Three distinct stages in evolution: - “plain vanilla” Primary Care Case Management, pairing patients with primary care providers who agree to be principal source of care and coordinate care for modest monthly payment per patient - an enhanced PCCM structure, requiring more of provider (24/7 access, adoption of more HIT, reporting on selected clinical quality measures, etc.) and incorporating more financial incentives - today, significantly enhanced PCCM, with rigorous participation standards, range of financial incentives, and often operating in partnership with private payors

Changes in Participation Standards Original PCCMs had minimal special requirements Next generation imposed more via state-provider program participation agreements NCQA began recognizing primary care practices as a PCMH in 2006; private and state purchasers began to adopt as certification requirements for participation in PCMH programs

The NCQA standards – 2011 draft Six major categories: - Access and practice organization - Identifying and managing patient population - Planning and managing care - Supporting patient/family self-management of care - Tracking and coordinating care - Performance measurement and quality improvement, including obtaining feedback from patients/families

NCQA standards (cont’d) 2011 draft standards being refined following public comment New PCMH patient experience of care survey also being developed Still gives practices great latitude in selection of quality measures used to evaluate and no reporting requirements Some states will probably continue to use own standards or modified NCQA

Supporting practice transition Practices find need help to transform into PCMH States have provided through various mechanisms - funding learning collaboratives (can include patients) - funding staff training - providing grants or other resources for acquisition of health information technology and incorporating it into practice - training practices to link with community services

Supporting care coordination State found practices, especially small, need assistance to provide effective care coordination Some techniques to address are – - referrals to disease management programs (Illinois) - funding community support teams (Vt.) or networks (NC) - some Medicaid HMOs testing funding of nurse coordinators co-located with the practice - funding HIT enhancements to track labs, tests, share results w/ other providers and patients

The Payment Mosaic Great variation in payment policies states are using PMPM amounts can be stratified - by age, gender, or complexity of care needs - by level of recognition achieved on NCQA recognition - by adopting certain HIT capability Savings in health care service costs, like reduced ER or inpatient utilization, shared with providers Bonus offered to practices that meet certain quality improvement targets during year

Partnering with Private Payers Collaboration among payers offers promise of lower cost per payer for support for PCMH model and more widespread transformation of health care system Recent NASHP state scan found at least 12 states involved in multi-payer initiatives: CO, IA, ME, MD, Mass., Minn., NH, NY, PA, RI, VT, WVa. Some states (NY, MD) waived state anti-trust laws to permit multiple payers to adopt same payment policies States very interested in bring Medicare into these partnerships as another payer, especially in practices serving many older adults

Some recent state decisions of special interest… Minnesota - at end of first year, to be re-certified, practice must document it has been effective in helping patients take an active role in managing their care. - PCMH must also establish a Quality Improvement team that includes patient representatives as equal team members. - state will make pay for care coordination using a CMS-approved 4-tier rate schedule stratified by complexity of care, and offer, in addition, a 15% increase in the rate for each tier for patients who have a primary language other than English or a serious and persistent mental illness

Recent state decisions (cont’d) Maryland - New law requires all major insurance plans operating in state to participate in state’s PCMH pilot - Patient participation will be voluntary (enrollment with opt-out) except for Medicaid will be mandatory - Practice size will be a factor in determination of PCMH payment rate, with smaller practices (under 4) to be paid highest rate due to higher fixed cost of practice transformation

Recent state decisions (cont’d) Oklahoma - practices qualify for higher payment if practice uses mental health and substance abuse screening and referral tool - provides after-visit follow up for medical home patients - developed model patient/practice medical home agreement North Carolina is opening its PCMH program to Medicare

Summing up…. State PCMH policies continue to evolve Early evidence of increased provider satisfaction and cost savings from use of model; need to collect more evidence on patient experience and clinical outcomes Growing recognition of the need to emphasize patient- centeredness of care and care coordination in both standards and payment policies Consumers can, and should, have a voice in these policy decisions

thank you Lee Partridge