Maryland’s Multi-payer Patients Centered Medical Home Program

As the result of legislation, insurance carriers required to participate are the following Aetna, CareFirst, BlueCross, BlueShield, CIGNA, United Healthcare, and Coventry. Carriers who gross more than 90 billion are required participators

The Centers for Medicare and Medicaid Services announced a pilot project so that any state-sponsored programs may participate.

The program requires that all participating practices apply for NCQA’s recognition program for level 1+ or higher within 6 months. By December 2011 and level 2+ within 18 months of implementation. The practices must pass categories within each of the nine NCQA domains. The elements are strongly linked to potential cost savings to purchasers, and patients. 

  

Selection criteria including primary care physicians, and nurse practitioners. Geographic diversity, practice size, and ownership type are a part of the criteria selection too.

According to the NCQA recognition requirement nurse practitioners are not recognized however, NCQA will review applications and forward the details to the MHCC, if they meet level 1+ and level 2+ requirements. The caveat is they will not be recognized by NCQA.

Practices may participate in Maryland’s MHCC program and single payer programs, such as CareFirst if the program is site specific, using NCQA requirements; CareFirst is enrolling practices at the organization level. Participation with both programs requires following patient participation rules, payment methodologies, and quality reporting according to both programs. In other words not combining information into one report if variances between the reporting requirements differ.  CareFirst may supplement MHCC payment system consistent with Care First’s for the practice using both payment systems. Other practice locations not in the MMPP will follow the CareFirst conventions.

In order for cost-effectiveness for the practice, the practice needs to participate with 2-5 of the required carriers.

Patient participation includes an op-out option. The payment for those patients opting out who opt-out are excluded from the payment and quality measures.

Every six months patients joining and leaving the practice will be added to the payment program. The quality measure includes providing a list of patients and their insurer to MHCC. The information is matched against enrollment records and claims histories. The patient according to where most primary services received using E&M codes for the prior two years are matched to the primary provider. If the patient has not received services within the window, the patients are evaluated with pharmacy claims. Those patients who have changed carriers within the window are in the process of determining verification.

Do I want the government knowing what I am being treated for and how is that information used? What other entities have access to the information.

It is irrelevant the number of locations within the practice, all locations is included in the payment system.

Practices performance measures for monitoring are at least one disease including diabetes, heart/stroke management, and asthma control. These measures align with Medicare and Medicaid’s EHR meaningful use definition for bonus payments and Medicare’s PQRI standards. Incentive payment guidelines including meeting thresholds in reduction.

The payment structure is different from managed care capitation. PCMH offers a fixed and incentive payment in addition to the fee-for-service payment. The fixed and incentive payments differ for treatment services.

Payment includes two types of reimbursement. Practices will receive per patient monthly payment for those patients participating with the program. This is to cover the cost related to the program. This payment is semiannual. Adjustments include the number of patients, payer category, and NCQA recognition standards. Practices that decrease emergency department visits and hospital utilization are included in payment as well. Fixed payments begin April 1, 2011. The semiannual payment is retrospective and depends upon meeting quality thresholds.

How much is per patient, is the carrier required to report this information to MHCC? How does it benefit the carriers who pay the fixed payment?  If the practice receives bonuses for decreasing hospital services and ER services then how is that a savings for the state? What is the projected savings with and without using this incentive?

  

If the practice receives subsidy from a private carrier for house bill 706 and participate in the program the subsidy payment will be a countable cost in shared savings computation.  The example provided is if a practice location receives $15,000.00 in HER subsidies in 2011, those payments will be counted as expenses to the practice when the shared savings are calculated. The treatment of the subsidy is identical to the fixed payments are considered in the share savings computation.

Reducing Readmission Rates Part III

            Starting October 2012 Medicare begins penalties for facilities for readmissions within 30 days of discharge. Late last year Dartmouth Institute for Health Policy and Clinical Practice and Robert Wood Johnson Foundation announced little progress was made during a study from 2003-2009. The report found 1 in 6 Medicare patients were readmitted within 1 month of discharge. A staggering 60% Medicare patients did not follow-up after discharge as a factor.

            Hospitals have until October to make systemic changes to coordinate care across the health care continuum. Systemic changes will include ancillary service coordination. 

Medicare will start a 1% reduction in payments to facilities not reducing the readmission rate for patients with specific diagnoses including pneumonia, heart attack, or heart failure.

The National Committee for Quality Assurance implemented 9 practice standards that align with the Joint Principles of Patient Centered Medical Home including Access and Communication, Patient Tracking and Registry Functions, Care Management, Patient Self-Management Support, Electronic Prescribing, Test Tracking, Referral Tracking,

Performance Reporting and Improvement, and Advanced Electronic Communications.

             Group Health Cooperative published a study after one year of using the model emergency room visits saw a 29% reduction rate. Hospitalizations decreased 11%. The medical home visits decreased 6%. The caveat is the model administrative cost increased $ 53 per patient. The emergency room savings saw a decrease of $ 54 per patient.

           CMS Partnership for Patients initiatives is to improve the quality, safety, and affordability of health care not exclusive for the Medicare population, rather for all. The partnership has nine core areas to improve hospital readmission rates by 20% by 2013. The elements include adverse drug events, catheter-associated Urinary Tract Infection, Central Line-associated bloodstream infection, Injuries from Falls, and Immobility, Obstetrical adverse events, pressure ulcers, surgical site infections, Venous thromboembolism, Ventilator-associated Pneumonia, preventable readmissions.

            Higher Volume of Post-acute Care Patients Associated With a Lower Rehospitalizations Rate in Skilled Nursing Facilities by Li Y (at el,) says yes. The study found a 15% reduction in readmission rates within 30 days of discharge. Patients that transfer to step down care requiring skilled nursing care supports the need for improved care coordination.