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Matching Patients with Their Providers: Lessons on Attribution and Enrollment from Four Multi-Payer Patient-Centered Medical Home Initiatives

Within multi-payer medical home initiatives, it is critical to develop and implement attribution and/or enrollment methodologies that assign participating patients to the practice most responsible for managing their care for two important reasons: the numbers of patients assigned to each practice influences the amount of supplemental PCMH payments paid to practices and which patients are assigned to the practice may affect the practice’s performance on specific cost, quality, and utilization metrics.
This brief, supported by The Commonwealth Fund, presents key considerations for states when developing assignment models: determining the degree of alignment across payers; establishing a means to collect and distribute patient assignment data; assessing the accuracy of the model; and ensuring sustainability. Key considerations presented in this brief were gleaned from challenges and lessons learned from multi-payer initiatives in Maryland, Massachusetts, Michigan, and Rhode Island.

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Creating the Perfect Storm for Community-Based Prevention

April 18, 2014/in Policy Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Population Health /by NASHP

by Jill Rosenthal and Manel Kappagoda of ChangeLab Solutions
April 2014

The United States ranked 15th among affluent countries in life expectancy in 1980. By 2009, it had dropped to 27th place. Our fragmented health care delivery and public health systems, and the lack of coordination between the two, has resulted in an imbalance of high health spending and poor health outcomes.
A recent report by the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, confirms what we already know: dramatically changing these statistics requires a combined approach that comprises investment in health care delivery and expanding “our focus to address how to stay healthy in the first place.”
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Financing Prevention: How States are Balancing Delivery System & Public Health Roles

April 14, 2014/in Policy Reports Accountable Health, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Quality and Measurement, Safety Net Providers and Rural Health, Social Determinants of Health, Value-Based Purchasing /by Carla Plaza, Abigail Arons, Jill Rosenthal and Felicia Heider

This report, developed by the National Academy for State Health Policy and produced by ChangeLab Solutions, highlights leading states’ approaches to support community-based prevention initiatives by bridging the health care delivery and public health systems. It examines various mechanisms – both previously existing and created through health reform – that states can leverage to implement sustainable community-based prevention programs. They include Medicaid waivers, federal grants, accountable care and medical home models, pooled funding, and new federal requirements for nonprofit hospitals. The report includes opportunities and lessons from featured states (California, Maryland, Massachusetts, Minnesota, North Carolina, Oregon, Texas, and Vermont).

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Maryland – Medical Homes

April 1, 2014/in Policy Maryland /by Medical Homes

In April 2010 Maryland enacted SB 855/HB 929. This legislation requires the Maryland Health Care Commission (MHCC) to establish a Maryland Patient Centered Medical Home (PCMH) multi-payer program. All payers with premium revenues of over $90 million are required to participate.
MHCC released a request for proposals (RFP) in December 2010, and selected 53 practices, employing 339 providers (including about 60 nurse practitioners and physician assistants). The selected practices are geographically dispersed throughout the state. Further information is available here. In January 2013, the Maryland Health Care Commission reported that 250,000 patients were attributed to participating medical homes.
The Maryland initiative is unique in that:

Explicit allowance is made for single-carrier PCMH programs (distinct from the multi-payer program), with authorization from the MHCC.
A unique payment methodology has been developed that makes special accommodation for small practices.
Shared savings payments are being calculated separately for each practice.

For more information, please see the Maryland Health Quality and Cost Council’s PCMH Workgroup website and the state PCMH website. The practice participation agreement is also available online.
In January 2012, Maryland was selected to join the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community. As a part of this Learning Community, Maryland was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Maryland’s participation in the IMPaCT project enhanced the state’s ability to provide support to primary care practices and share practice data for quality improvement through a number of strategies, including assisting practices in achieving PCMH transformation and adopting EHRs.<
Last Updated: April 2014

Federal Support:

On September 27, 2013, CMS approved a Section 2703 health home state plan amendment, creating health homes for Medicaid enrollees with opioid substance use disorder. The SPA became effective as of October 1, 2013. Maryland was a recipient of a planning grant from CMS to develop its state plan amendment. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.

Forming Partnerships	The Governor’s Council created the Patient Centered Medical Home (PCMH) Workgroup in 2009 to work toward creating an all-payer medical home pilot. Three subgroups—focusing on foundations, practice transformation, and purchaser/consumer education—of workgroup members and other stakeholders were formed. The subgroups were instrumental in selecting the program participation criteria, transformation activities, quality performance measures, and payment strategies. Project staff has met with a wide range of stakeholders, including: The state medical society; Professional family practice and pediatric associations; The hospital association; Federally qualified health centers (FQHCS); Nurse practitioners; Private payers and managed care organizations (MCOs); Local health departments; The Department of Health and Mental Hygiene (DHMH) Office of Minority Health & Health Disparities; and Private, academic, and hospital based practices. The Maryland Health Care Commission (MHCC) has also created a web PCMH portal for providers and hosted seven regional symposia to introduce the initiative to providers. Maryland participated in the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community, where it was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Through participation in this project, Maryland strengthened partnerships between state government and universities, among hospitals, and between practices and external partners such as provider associations and non-profits.
Defining & Recognizing a Medical Home	Definition: SB 855/HB 929 defined a patient centered medical home (PCMH) as: “a primary care practice organized to provide a first, coordinated, ongoing, and comprehensive source of care to patients to: Foster a partnership with a qualifying individual; Coordinate health care services for a qualifying individual; and Exchange medical information with carriers, other providers, and qualifying individuals.” Recognition: National Committee for Quality Assurance (NCQA) medical home recognition, with additional expectations. Practices without NCQA recognition or with recognition expiring after March 2011 must meet the NCQA 2011 standards; others may meet the NCQA 2008 standards. The additional expectations are specified on page 25/B-3 of the practice participation agreement, and include capabilities around 24/7 access, registry use, medication reconciliation, e-prescribing and more. Practices show that they have these additional capabilities by achieving certain NCQA elements that are optional under the standard NCQA system. Practices were required to achieve Level 1+ recognition no later than March 31, 2012. The state announced that, as of April 2012, all pilot practices achieved this milestone. Practices were required to submit an application for Level 2+ recognition no later than September 30, 2012. Nurse practitioner-led practices are eligible for state recognition as medical homes.
Aligning Reimbursement & Purchasing	The five largest commercial payers in Maryland – Aetna, CareFirst BlueCross BlueShield, CIGNA, United Healthcare, and Coventry – are required to make payments to participating practices under SB 855/HB 929. Medicaid has budgeted $1.5 million for fiscal year 2012 and $2.89 million in fiscal year 2013 to provided fixed transformation payments. Further information on the methodology that these payers will use to attribute patients is available in the practice participation agreement. Participating providers are eligible for ongoing per member per month payments (PMPM) referred to in Maryland as “fixed transformation payments.” Fixed transformation payments, paid twice a year, facilitate practice-level infrastructure improvements. Practices may also be eligible for “shared savings payments” as described below. Fixed transformation payments are calculated as specified below. In general, smaller practices receive higher PMPM payments than larger practices all else being equal. Likewise, practices with higher recognition levels receive greater PMPMs. Federally qualified health centers (FQHCs) are not eligible for fixed transformation payments. The exact amounts of the fixed transformation payments are adjusted annually on the basis of the Medicare Economic Index. Commercial Population Practice sites with fewer than 10,000 patients: Level 1+: $4.68 PMPM Level 2+: $5.34 PMPM Level 3+: $6.01 PMPM Practice sites with 10,000-20,000 patients: Level 1+: $3.90 PMPM Level 2+: $4.45 PMPM Level 3+: $5.01 PMPM Practice sites with more than 20,000 patients: Level 1+: $3.51 PMPM Level 2+: $4.01 PMPM Level 3+: $4.51 PMPM Medicaid Population All practice sizes: Level 1+: $4.54 PMPM Level 2+: $5.19 PMPM Level 3+: $5.84 PMPM Medicare Advantage Population All practice sizes: Level 1+: $8.66 PMPM Level 2+: $9.62 PMPM Level 3+: $11.54 PMPM All participating practices—including FQHCs—are eligible for shared savings payments if they meet performance criteria. The performance criteria include measures around evidence-based practices and utilization reduction such as: Blood pressure measurement (also a Centers for Medicare & Medicaid Services (CMS) electronic health record (EHR) meaningful use core measure); Adult Weight Screening and Follow-Up (also a CMS EHR meaningful use core measure); Reduction in 30-day readmission rate; Reduction in number hospital days per 1,000; and Reduction in emergency room visits per 1,000. Practices that meet the performance criteria will then be entitled to payments of 30 percent to 50 percent of any savings generated by the practice. FQHCs will be able to share in 65 percent of savings for patients with Medicaid coverage. Savings will be calculated separately for the commercially insured, Medicaid, and Medicare Advantage populations. The calculations will entail comparing expected costs for a given practice’s population (as derived from baseline data) with actual costs for the practice population. Expected costs will be adjusted to include medical inflation. It should be noted that fixed transformation payments will be included in determining actual costs. Therefore, practices must generate savings beyond the amount of the fixed transformation payments in order to be eligible for incentive payments. (FQHCs are eligible for “first dollar” shared savings, as they are not receiving fixed transformation payments.) Provision is made for the Maryland Health Care Commission (MHCC) to adjust the incentive payment algorithm in recognition of changes in practice case mix or for outliers. The MHCC announced in October 2012 that 23 of the 52 participating pilot practices received shared savings payments from Aetna, CareFirst BlueCross BlueShield, CIGNA, United Healthcare, and Coventry. The total incentive payments, based on 2011 performance metrics and savings, were $815,669.62. Full details on the payment methodology are available online in the practice participation agreement.
Supporting Practices	According to the practice participation agreement, the Maryland Health Care Commission (MHCC) is responsible for establishing a learning collaborative with the support of the Community Health Resources Commission (CHRC). The objectives of the learning collaborative are to support practices in obtaining medical home recognition and effectively using a care manager. Practice staff are required to participate in the learning collaborative. A timeline of learning collaborative activities— which include webinars, in-person large group meetings, site visits, and regional meetings—is available here. The CHRC is also providing the MHCC with resources to hire “practice transformation coaches.” Coach responsibilities include: Providing registry support for practices without electronic medical records (EMRs); Developing practice-specific medical home implementation plans and timetables; and Providing support for achieving National Committee for Quality Assurance (NCQA) medical home standards. Practices will be expected to use an MHCC-provided registry unless they have an acceptable EMR. Maryland participated in the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community, where it was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Through participation in this project Maryland provided support to primary care practices. Mary supported all of the practices participating in the Maryland Multi-Payer Patient-Centered Medical Home Program (MMPP) in implementing an Electronic Health Record (EHR). Additionally, 65% of the practices now participate in the State-Designated Health Information Exchange. The Maryland Learning Collaborative (MLC) used an expert consultant to train Practice Transformation Coaches who provide logistical and educational support to primary care practices in transforming into PCMH. Additionally, the MLC secured a care manager responsible for implementing the changes necessary for practices to become PCMHs in each of the pilot practices.
Measuring Results	SB 855/HB 929 directs the Maryland Health Care Commission (MHCC) to adopt a, “uniform set of health care quality and performance measures that the participating patient centered medical home is to report to the commission and,” health plans. MHCC has contracted with Impaq International to conduct an evaluation of the program. The evaluation will draw on multiple data sources including: claims information, condition-specific quality measures, and patient/provider satisfaction surveys. MHCC expects to use a, “pre/post treatment with a quasi-experimental control group of similar practice.” As of August 2011, the evaluation was expected to be more expensive than had originally been estimated.

Quality Measurement to Support Value-Based Purchasing: Aligning Federal and State Efforts

February 21, 2014/in Policy Reports Cost, Payment, and Delivery Reform, Health Coverage and Access /by NASHP and Mike Stanek

Public payers are moving to implement payment strategies that reward value in the health care system by linking payment to quality. This report—the third in a series supported by The Commonwealth Fund to explore opportunities for improvement in federal and state policy— highlights quality measurement strategies underpinning value-based purchasing initiatives at the federal and state level. It also describes opportunities for federal-state alignment identified during a Commonwealth Fund-supported discourse among high-level state and federal officials hosted by NASHP.

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November 5, 2013/in Policy Maryland /by NASHP

In Maryland:

As of July 1, 2011, there were 986,304 beneficiaries enrolled in Maryland’s Medicaid program. Of these, 735,859 were enrolled in managed care. Most Medicaid enrollees, including children, are eligible to receive physical health services through the state’s mandatory managed care program, HealthChoice. Groups ineligible for managed care include enrollees in the state’s Model Waiver.
An administrative services organization (ASO), ValueOptions, administers a Public Mental Health System in Maryland. A separate ASO, DentaQuest, is responsible for administering the Medicaid oral health benefit for children, pregnant women, and certain adults in Maryland.
Home and Community-Based Services are aimed at children in Maryland through 1915(c) waivers:
- Autism Waiver, which provides a range of services therapeutic and support services to children ages 1-21 who have an Individualized Family Service Plan or Individualized Education Program and meet the Intermediate Care Facility for Persons with Mental Retardation Level of Care;
- Model Waiver for individuals under the age of 22 who, without care in the home, would be at risk of hospital admissions or institutional care

As of 2012, 643,569 individuals were eligible for Maryland’s Health Kids Program (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2012, Maryland achieved an EPSDT screening ratio of 94% and a participation ratio of 64%. 332,479 children received dental services of any kind, with 305,394 receiving preventive dental services.

Last updated February 2014.

Medical Necessity	Under the Code of Maryland Regulations, "Medically necessary" means that the service or benefit is: Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition; Consistent with current accepted standards of good medical practice; The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and Not primarily for the convenience of the consumer, the consumer’s family, or the provider.
Initiatives to Improve Access	Maryland’s Medical Assistance Program funds local health departments to provide assistance to families when children under 21 need to access follow-up treatment services resulting from a Healthy Kids preventive care screen. Local health departments are also responsible for assisting high-risk beneficiaries, including children, to access necessary health care services.
Reporting & Data Collection	The state issues report cards on Medicaid managed care organizations (MCOs) that compare MCOs on several metrics, including “Keeping Kids Healthy.” This domain includes measures of: Immunizations Well-child visits to physicians and dentists Lead testing
Behavioral Health	Service delivery Primary mental health services in Maryland are mental health services provided in the primary care office; the state allows primary care providers to treat mental health conditions if the treatment falls within the scope of the provider’s practice, training and expertise. Conditions that cannot be treated in primary care settings are referred to the state’s local public mental health system. The Specialty Mental Health System, frequently called the Public Mental Health System, provides a full range of mental health services. The Maryland Mental Hygiene Administration (MHA), along with local Core Service Agencies (CSAs), has oversight of the mental health authorities in each jurisdiction. Specialty mental health services are covered by Maryland Medicaid and available to all Medicaid recipients. Screening Maryland requires that general developmental screening be performed for all children at the 9-, 18-, and 24-30 month Healthy Kids preventive care visits, and whenever a concern is identified through developmental surveillance. If the child is not seen at these recommended ages, screening should be conducted at the next preventive care visit. Healthy Kids recommends the following standardized, validated developmental screening tools for use in general developmental screening at the intervals noted above: The Ages and Stages Questionnaire (ASQ) Pediatric Evaluation of Developmental Status (PEDS), www.pedstest.com The state also provides an additional list of approved standardized, validated general developmental screening tools. In addition to requiring general developmental screening, the MD Healthy Kids Program recommends autism-specific surveillance at all visits and requires structured autism-specific screening at 18 and 24-30 month well child visits. The Maryland Healthy Kids Program recommends the Modified Checklist for Autism in Toddlers (MCHAT) screening instrument. The Healthy Kids Program developed a series of age-specific Mental Health Questionnaires to help primary care providers identify behavioral and emotional problems. The state also allows providers to bill for substance abuse screening (using the 99408 and 99409 CPT codes) and recommends use of the CRAFFT substance abuse screening tool for adolescents.
Support to Providers and Families	Support to Families Maryland’s Health Kids Program provides funds to the local health departments to collaborate with the MCOs and provide support services such as outreach, appointment scheduling, transportation assistance, tracking and case management services to assist with treatment for identified problems and assure continuity of care. Support to Providers Healthy Kids Program Nurse Consultants work to certify primary care providers to participate in the program, train staff on program standards and procedures, assist providers with program billing and reporting, and educate providers about referral processes. The Department of Health and Mental Hygiene maintains an EPSDT website that contains resources for providers, including the provider manual, provider forms, and the state’s periodicity schedule.
Care Coordination	The state has produced the Maryland Uniform Consultation Referral Form to facilitate referrals and follow-up services when screens uncover health conditions in a child. Maryland has an Administrative Care Coordination/Ombudsman (ACCU) program that provides information and consultation for Medicaid and managed care recipients to enhance their access to Medicaid services. Local health departments provide linkages to care and care coordination services to “at risk” pregnant or postpartum women, and children to assist recipients with access and utilization of the managed care system and other health related services. Maryland also has a multi-payer medical home program in which Medicaid participates.
Oral Health	Since 2009, all dental-related customer services for Maryland Medicaid beneficiaries have been coordinated by DentaQuest. DentaQuest is contracted to assist Medicaid enrollees in the “Maryland Healthy Smiles” Program locate dental care within a reasonable distance from the enrollees’ residence to ensure adequate access to oral health care services. Additionally, DentaQuest provides verification of dental benefits and eligibility verification. The Maryland Healthy Smiles Dental Program is available for all Maryland Medicaid enrollees under 21 years of age as well as pregnant women. The program covers a variety of dental benefits for children, including fluoride treatment, cleanings, and fillings. Through the Maryland’s Mouths Matter Fluoride Varnish and Oral Health Screening Program for Kids program, Maryland Medicaid reimburses for the application of fluoride varnish to Medicaid-enrolled children ages 9 months – 36 months old in primary care provider offices. Reimbursement by Medicaid is limited to EPSDT certified primary care providers who have successfully completed a state approved oral health screening and fluoride varnish program training program.

Making an IMPaCT: State Models for Primary Care Transformation

October 23, 2013/in Policy Webinars Cost, Payment, and Delivery Reform /by NASHP

The national IMPaCT project supported North Carolina as one of four leading states in the field of practice transformation and primary care extension. Through IMPaCT, North Carolina partnered with four other states (Idaho, Maryland, Montana, West Virginia) to disseminate its primary care practice transformation strategies. Together these states formed the North Carolina IMPaCT Learning Community, and each state received individual and group technical assistance to help implement a practice transformation initiative. North Carolina, meanwhile, is completing its own IMPaCT project with a focus on further improvements to its primary care transformation model. Participants on this webinar will hear from the states in the Learning Community. Idaho will present on how it used the technical assistance offered through the project to devise a plan for primary care transformation that would become the basis of its State Innovation Model Design award. The other three states in the Learning Community will react to Idaho’s presentation and recount how the NC IMPaCT project promoted their development in key areas of data infrastructure, stakeholder engagement, and practice support. Participants will also hear from North Carolina on its IMPaCT practice support improvements. At the end of the webinar participants will have the opportunity to ask questions of the speakers about their experiences with primary care transformation.

Speakers:

Denise Chuckovich, Deputy Director, Idaho Department of Health and Welfare
Jonathan Griffin, MD, Family Physician, St. Peter’s Medical Group
Nancy Sullivan, Assistant to the Cabinet Secretary, West Virginia Department of Health and Human Resources
Niharika Khanna, MD, Associate Professor, University of Maryland School of Medicine
Darren DeWalt, MD, Associate Professor of Medicine, University of North Carolina – Chapel Hill

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Lessons in Primary Care Extension from Four States

October 3, 2013/in Policy Blogs Cost, Payment, and Delivery Reform /by NASHP

By Larry Hinkle
October 2013

Many states are testing primary care extension as a strategy for supporting continuous quality improvement in practice. Primary care extension is based on the model of the Agricultural Extension Service. In health care this model applies scientific research and new knowledge to practices through provider education – often led by other providers or specially trained practice facilitators.
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Lessons from the Field: State- and Practice-Level Policies to Foster High Performance in Cervical Cancer Screening in Federally Qualified Health Centers

August 29, 2013/in Policy Reports /by NASHP

States can make important strides in eradicating cervical cancer deaths. This report features promising state and federally qualified health center policies that support high performance in cervical cancer screening within the context of the medical home. Drawing from Colorado, Maine, Maryland, New York, Texas, Vermont, and Virginia, this report summarizes innovative programs, practices, and partnerships that facilitate improvement in cervical cancer screening. Experiences in these states offer examples for adoption by others to ensure high-quality preventive care for women. This publication was made possible through the support of the Health Resources and Services Administration.

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Federal and State Policy to Promote the Integration of Primary Care and Community Resources

August 7, 2013/in Policy Reports Cost, Payment, and Delivery Reform /by NASHP and Mike Stanek

Around the country, models are emerging to link primary care providers not only to other medical service providers but also to resources and services in the community. This report—the first in a series supported by The Commonwealth Fund to explore opportunities for improvement in federal and state policy–highlights relevant policy levers and federal and state initiatives to integrate these resources. It also discusses opportunities for policy improvement identified during a Commonwealth Fund-supported discourse among high-level state and federal officials hosted by NASHP.

Michael Stanek

August 2013

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