Ben Steffen, MA, Center Director, Maryland Health Care Commission, gives an update on the Maryland Multi‐payer PCMH Program (MMPP) at the New Tactics for Building Medical Homes in State Medicaid and CHIP Programs webinar.
2. Maryland MMPP Operational Goals
Phase 1 – Pilot Program
– 50 practices
– 200 providers
– At least 200,000 patients
– 5 largest commercial payers ‐‐ Build multi‐payer into program’s DNA.
All major commercial payers will participate and as many public
payers as are willing to join
• Participation goals have been exceeded
– Web‐based application process
– First step in selection is automated application scoring
• A current challenge ‐‐ expand initiative to self‐insured
– Maryland welcomes opportunities to work with other states in
devising strategies to engage self‐insured employers
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3. Maryland PCMH Requirements
• To receive enhanced PCMH payment in the Maryland
program, practices must:
– Sign participation agreement
– Participate in learning collaborative
– Demonstrate compliance with the NCQA PCMH
recognition standards (including the Maryland required
elements)
• Level 1+ by Dec. 31, 2011
• Level 2+ by Dec. 31, 2012
– Practices must also report on a set of performance
measures aligned with the federal HIT “meaningful use”
requirements
– Meet utilization measures.
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4. PCMH Financial Model
} Savings Opportunity
Total Cost of Care
Total Cost of Care
• In the medical home, primary care services
and pharmacy utilization will likely increase.
• Better patient management and outcomes
will reduce emergency room (ER) visits and
hospitalizations, producing net savings
• A portion of the expected savings are used
to fund fixed payments to the medical home
• The medical home also receives a share of
actual savings (incentive payment)
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5. Payment Model
Fee‐For‐Service
Primary care practices will continue to be reimbursed under their existing fee‐
for‐service payment arrangements with health plans.
+
Fixed Payment (Care Coordination Fee)
Primary care practices will receive a fixed, per patient per month fee (paid
semi‐annually). The purpose of this fee is to defray the costs of providing
enhanced primary care services, including care coordination.
+
Incentive Payment (Shared Savings)
Primary care practices will receive a share of any savings generated by
improved patient outcomes. Savings calculations will be performed using the
MHCC’s all‐payer claims database.
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6. PCMH Fixed Payment
• Adjusted for:
– Payer Type (commercial, Medicaid, Medicare)
– Practice Size
– NCQA Recognition Level
• Fixed payment ranges:
– Commercial: $3.51 to $6.01 per person per month
(PPPM)
– Medicaid: $4.08 to $7.00 PPPM
– Medicare Advantage: $9.62 PPPM
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8. Wrapping Up – Challenges We Need To Address
• Are we using the appropriate baseline for calculating saving?
– In a 3 year program a practice‐specific versus a normative baseline is
easier to implement.
• Are projected savings reasonable?
– Savings based on analysis of 6 conditions, it is likely that practices could
achieve additional savings through improved care beyond what we
estimated from the 6 conditions.
– Other pilots have reported savings in the range of 10 percent.
• Are the fixed payments (25% of projected saving) too low/high?
– Practices with large numbers high risk patients will need greater fixed
payments – argues for risk adjusting the fixed payment.
– If fixed payments are too high, practices will learn that they have no
chance for producing incentives and will stop trying.
• Program financial incentives will likely require adjustment during the initial
the 3 year program. That is a benefit of starting small.
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