| THE “MEDICAL HOME” GETS UPDATED: IMPROVING OUTCOMES WHILE REDUCING COSTS
Volume 29, Issue 511 March 17, 2008 Anna C. Spencer These days, one of the newest concepts in health care is also one of the oldest: the patient-centered medical home. At the heart of the medical home is the primary-care provider (PCP) who assumes responsibility for coordinating care among all service providers for their patients. States have created such “homes” for Medicaid enrollees chiefly by enrolling them in managed care and by creating primary-care case management systems (under which a PCP receives a small per patient monthly fee for care coordination). Of the 42 million Medicaid beneficiaries, 6.5 million are enrolled in primary-care case management programs and 20 million are enrolled in capitated managed care. But the newest model of the medical home rewards providers both for managing patient care—and for meeting or exceeding quality and performance standards. Payment to medical home providers is tied to improving patient care through such methods as implementing electronic health records, e-prescribing, coordinating medication management with pharmacists, and tracking tests and referrals. “We’re not looking for extra compensation without improving outcomes,” said Dr. James King, president of the American Academy of Family Physicians (AAFP), which is helping to promote the new medical home model. By 2007, 10 states had incorporated the medical home model into their Medicaid and SCHIP programs, according to a study by the National Academy of State Health Policy and ERIC (the ERISA Industry Committee). Seven states operate Primary Care Case Management programs in which PCPs receive fee-for-service payments for all serves they provide to enrolled beneficiaries and additional payments to perform care coordination (a PCCM fee). Four states pay for primary care through capitation. Managed Care Organizations received a capitated rate per enrollee to provide a comprehensive set of benefits, including primary care. In some states, MCOs also receive financial incentives to achieve certain benchmark performances, such as telephone access after business hours and the percent of children who receive well-child visits. In Washington, the legislature approved HB 2549 in early March directing the state Health Care Authority to establish a pilot project to provide funding and technical assistance to primary care providers willing and able to adopt and maintain medical home models. The key tasks of the pilot project include developing common and minimal core components of a medical home, fostering standardized outcome measurements and promoting the adoption of techniques that support patient-centered care. The Health Care Authority will report back to the legislature in Jan. 2009 with recommendations on how to realign payment strategies for primary care providers, providing funding for the adoption of health information technology, the implementation of signing bonuses or other incentives to increase the number of and participation by primary care providers, and on a time-line for implementing payment and provider performance strategies for the medical home model. Alabama has employed this medical home concept since 2004. Patient 1st is a primary-care case management program that requires Medicaid beneficiaries to designate a “personal medical provider,” whose role it is to provide first contact and continuous, comprehensive care. Currently, more than 1,000 such providers and 420,000 Medicaid enrollees participate in the program. Patient 1st expands the traditional fee-for-service reimbursement model to compensate physicians for the care coordination they provide to their patients. The program also rewards physicians—with a check—for improving performance within their practice. State analysts estimate that primary-care case management saved the state $11.4 million in 2007. The fee structure includes: Fee-for-service payment for services provided by the personal medical provider to members. A per member/per month case management fee that is individually calculated for each provider based on nine characteristics of the practice: EPSDT participation; Vaccines for Children program participation; Medical Home CME completion; provision of around-the-clock coverage seven days a week; hospital admitting privileges; in-home monitoring (disease management); electronic notices; InfoSolutions (a program used to provide claims and pharmacy information to physicians electronically); and electronic educational materials. A shared savings program. In 2007, Medicaid distributed 50 percent of the documented savings ($5.7 million) to PMPs. For more about the payment calculations, visit http://www.medicaid.state.al.us/documents/ProgramPt1st/Shared_Savings/Pt1st_SOS_calculation_methodology.pdf In the coming year, Alabama hopes to expand Patient 1st in a number of ways. First, the program will increase in-home monitoring of non-compliant individuals with chronic conditions (Patient 1st currently does in-home monitoring for patients with diabetes only), as well as increase in-depth case management for high-risk individuals. In addition, program managers will examine ways to increase the use of electronic support tools “to better enable providers to treat Medicaid recipients,” said Carol Stekel, commissioner of the Alabama Medicaid Agency. Patient-centered case management is the “only way we see being able to provide better health care at lower cost.” More Bang for the Buck Research shows that in countries where patients are connected to a medical home—and primary care physicians are the foundation of that home—people live longer, populations are healthier, patients are more satisfied with their care and health care costs are lower. When PCPs are able to provide care beyond brief face-to-face encounters, they are able to perform more screenings and immunizations, provide better preventive care for chronic conditions, and their patients experience fewer complications and fewer hospitalizations for preventable conditions. With this kind of evidence, it’s no wonder that the private sector also is pursuing the concept. “No one is happy with the current status of health care in this country,” said Dr. Paul Grundy, IBM's Director for Health Care Technology and Strategic Initiatives. “Employers are paying for mediocre care, primary-care doctors can’t perform the functions they need to provide better care and consumers are dissatisfied,” he said. To that end, large employers, health plans and the four major primary-care physician organizations have joined together to promote the patient-centered medical home through the Patient Centered Primary Care Collaborative. “The desire is to move away from fragmented, episodic care and build on the patient-physician relationship,” says the AFFP’s Dr. King. Many consumers rebelled against the restrictions of tightly managed care, but King is quick to point out that the model is not about gate-keeping or restricting access to care, but instead making “primary-care doctors the gateway to better care.” © Copyright 2008, State Health Notes |