Supporting Primary Care through Networks, and Teams, and Pods

The support of care coordinators, nutritionists, social workers, and other professionals can help primary care providers keep their patients healthy and out of the hospital. While larger medical practices may be able to directly hire these sorts of professionals, smaller practices generally cannot afford additional staff on their own. State practice support systems are one solution to the dilemma. Under this approach, teams of health professionals support multiple primary care practices in better serving patients. Small practices may draw on these resources most heavily, but larger practices often benefit as well. North Carolina credits support networks with helping the Medicaid program save more than $382 million in fiscal year 2010, and Vermont’s program is also showing preliminary signs of success. Health reform provides states with new opportunities to develop, spread, and sustain these promising approaches.
Across the country, the state practice support systems are referred to as “networks,” “community health teams,” “community care teams,” or “pods.” These teams provide services that wrap around those offered by practice staff. Typical functions include: coordinating patient care, linking patients with community resources (such as local Meals on Wheels programs), supporting transitions in care, and much more. Most states with practice support systems like these—networks and teams that are based outside the practices they serve—are also enhancing practices’ “in-house” capabilities through medical home projects.
State Refor(u)m’s new “fast facts” matrix profiles state practice support systems in six states. As the matrix makes clear, practice support projects differ in some critical ways. This makes sense: no one model has been proven best, and it is wise for states to develop programs that build on their strengths, align with stakeholder preferences, and take into account local priorities. Here are three of the key design considerations that states are navigating as they develop these programs:

• Scope and payer participation: Community Care of North Carolina is the oldest of the profiled projects, and covers the most patients (1.2 million). The Community Care budget tops $100 million. The program serves nearly all Medicaid enrollees statewide, as well as privately insured individuals, state employees, and Medicare enrollees in select regions of the state. Initiatives in Maine, New York, and Vermont also feature multi-payer participation.  Vermont, in fact, enacted legislation requiring insurer participation. These multi-payer approaches facilitate whole-practice transformation for affiliated primary care providers and promote continuity of care when a patient’s coverage changes.

Other states have started smaller. Oklahoma, for instance, is piloting practice supports in Medicaid, establishing proof of concept, and will then consider expansion. The Oklahoma Health Access Networks cover about 53,000 Medicaid enrollees at a cost of $3.3 million.

• Structuring payment: Four of the six profiled states—Alabama, Maine, North Carolina, and Oklahoma—are making direct per member per month (PMPM) payments to practice support teams. Participating payers make these payments on behalf of all their members who have been attributed to a practice support team, even though only a subset of patients will actually receive special services. In the profiled states, PMPM amounts range from $0.30 (Maine, for privately insured patients) to $13.72 (North Carolina, for aged, blind, or disabled Medicaid patients).

New York (Adirondack Region) and Vermont have taken somewhat different approaches. In New York, practices contract with and pay pods directly. Program leaders feel this promotes accountability between the practice and the support team. In Vermont, community health team costs are shared equally by all participating payers with two exceptions (as explained in the matrix).

• Leveraging health reform resources: Several of the profiled states began their practice support projects prior to the enactment of the Affordable Care Act and are now seeking to integrate health reform resources in their programs. The Maine, New York (Adirondack), North Carolina, and Vermont programs all successfully applied to have Medicare join their projects through the Innovation Center’s Medicare Multi-payer Advanced Primary Care Demonstration.

New York is one of the first states to obtain federal approval for its Section 2703 state plan amendment to develop and pay health homes. Some of the enhanced care coordination fees paid under this plan on behalf of eligible Medicaid enrollees will support pod services. Alabama, Maine, and North Carolina are also pursuing similar plans that will align with their practice support systems.
Activity in this area goes beyond the six states profiled here. Minnesota is in the early stages of a community care team pilot, and Montana has developed a health improvement program thatallows practices to share health center-based care coordination services. Is your state developing a practice support program? If so, how is your state’s plan similar or different from those discussed here? We invite you to share your activities or offer reactions in a comment