States take these five actions to advance medical homes
States take these five actions to advance medical homes
Here are five ways that states are working to advance their medical home programs, according to research conducted by the State Consortium to Advance Medical Homes for Medicaid and Children's Health Insurance Program Beneficiaries:
1. Forming key partnerships.
In a new development, states are partnering with private purchasers, consumers, and providers. "States are interested in building on partnerships. Everybody can get farther if you are headed in the same direction," says Neva Kaye, the project's principal investigator and senior program director for the Portland, ME-based National Academy for State Health Policy. "There is a great opportunity there for partnership. The newer initiatives are very much designed with the input of the people that are going to function within it."
2. Defining a high-functioning medical home.
"This is really important, because not every practice is a high-functioning medical home," says Ms. Kaye. "If you are going to tie payment to performance, you need to define how practices are going to function and what they are going to achieve. You need to make sure those you are paying and supporting really are doing what patients need."
While Minnesota and Oklahoma developed their own standards, many others have adopted the National Committee for Quality Assurance's Physician Practice Connections-Patient-Centered Medical Home model. "I view the existence of that and other tools as fostering state interest at this point. You can really tell which practices are high-performing medical homes, and you need that piece," says Ms. Kaye.
Jeff Schiff, MD, medical director of Minnesota Health Care Programs and division director at the Minnesota Department of Human Services, says "what a medical home really offers for our clients and the agency is an opportunity for improved care, so patients with chronic illnesses can have their care coordinated and improved."
In 2004, the state received a grant for children with special health needs. "We developed a very robust medical home model through that, which ended up serving 25 practices and about 7,000 kids," says Dr. Schiff. "From that model, we got momentum for a lot of the things that have appeared in our criteria. We had that experience to build on, which gave us an advantage."
Since Minnesota's providers started out with different levels of understanding about what a medical home is, a lot of time was spent over the past two years coming up with a common definition.
"That groundwork has taken some time, but I think it has been very beneficial," says Dr. Schiff. Minnesota's criteria emphasize patient and family-centered care and quality improvement at the practice level, as opposed to implementation of electronic health records (EHRs).
"In contrast to some of the other states, we have de-emphasized EHRs. It's not that we don't want everyone to have EHRs. As medical homes develop, they will probably need EHRs to do the job well and be cost-effective. But we see it as a tool, not as a criteria for being a medical home," says Dr. Schiff.
A paper verification process for medical homes is currently used, but going forward, the department of health will have a verification process that includes some site visits and technical support. "Our program is a little different than some other states," says Dr. Schiff. "We are working on the program in collaboration with the department of public health, and we are developing a model that can be used both by the public sector and private sector."
3. Developing a methodology for reimbursement to support the medical home.
Ms. Kaye says states seem to be falling into two major categories for how they are going to reimburse providers for being a high-performing medical home. The first group structures payment like a primary care case management (PCCM) program, with a fee-for-service payment for all the care that the practice directly provides, and also a per-member, per-month fee.
"In the old PCCM programs, those fees were often two or three dollars a month, but some of these programs are getting into fees of $40 or $50 a month. So, it's a quite significant payment to recognize significant administrative costs, in terms of care coordination and outreach, for performing as a medical home," says Ms. Kaye.
However, states also are tying specific requirements to payments, to create an incentive to do things that support a high-functioning medical home. For instance, Rhode Island will pay more to a practice with a nurse on staff to perform care coordination.
"North Carolina is an excellent example of that, and Oklahoma has shifted to that as well," says Ms. Kaye. "In both instances, additional payments are provided. Alabama is sharing some savings with participating providers. So, there is often an element of a payment that is tied to performance."
The second category that states are falling into is payment of enhanced fees, which arises in part from the desire to use existing billing and claims procedures. For example, when a primary care provider performs a Medicaid Early & Periodic Screening & Diagnostic Treatment Benefit on one of its medical home patients, it receives an enhanced payment of $36 over the regular screening fee.
"The idea is they are trying to create an incentive to not just recognize the administrative costs of being a medical home, but also for the provider to get the kid in the door. Those well-child evaluation visits are such a key piece of serving as a medical home," says Ms. Kaye. "So, they want to be sure the payment also incents that."
Minnesota also is using enhanced payments for very complex patients, which can amount to hundreds of dollars each year depending on the complexity of the patient's disease burden. "The idea is to create the incentive for an ongoing relationship," says Ms. Kaye. "Also, by using an enhanced payment, the regular billing procedures can be used, so it fits with the way the practices regularly bill. It makes it easier for the provider, because they don't have to do special billing things."
Minnesota already has established its payment methodology for its 2007 Provider Directed Care Coordination legislation, with a per-member, per-month fee averaging $50 paid to providers who care for patients with complex illnesses in its fee-for-service population. Currently, a payment methodology is being developed for the program's expansion to a much broader population. Minnesota passed legislation in 2008 requiring all its health plans to offer a medical home to patients with a chronic disease and to pay in a method that is consistent with the methodology developed by the Department of Human Services. A stratified pay structure is required, based on the patient's complexity.
"Rather than developing this method in secret, we are in the process of developing it collaboratively with our health plans," says Dr. Schiff. "We are being transparent with our health plans, so they can actually see what we are doing."
Enhanced payments for Minnesota's medical home patients can be billed by providers no more frequently than every six months. "Our legislature set out that the average cost would be about $50 a month to do the care coordination for these folks, so we set up three separate rates that average $50 a month," says Dr. Schiff. "We worked with the provider community, and we believe that the financial incentive for the practice is significant enough for them to provide this level of service."
Dr. Schiff says, "What we have always said is that we want real care coordination and real medical homes set up, and we expect real results. And we understand that it takes some capital to develop a system and also to run it."
4. Giving resources to support providers in becoming high-functioning medical homes.
"Change is hard, particularly if you are in a busy practice without a lot of time to spend," says Ms. Kaye. "Practices need to change the way they deliver care and to integrate being a medical home into their standard business."
For this reason, providing support for care coordination is important. In addition to this, some states are giving providers information about their performance, patient needs, and utilization.
Pennsylvania does this by offering providers access to health information technology and practice coaches, while Minnesota plans to hold learning collaboratives for physicians and practice teams. "In order to change the culture of primary care practices, we needed to create a social network to have that happen," says Dr. Schiff. "And as part of our patient-centeredness focus, we expect patients to be on the learning teams." New Hampshire has contracted with a local university to do a gap analysis, so practices seeking to become medical homes can identify where they will potentially fall short in meeting the criteria.
To be a high-performing medical home, care coordination clearly needs to happen within the practice. "That is one of the hallmarks of a medical home. But there are also other aspects of care coordination and outreach that can support the practices of a medical home," says Ms. Kaye. "For example, it's unrealistic to expect somebody in a medical practice to know all the community resources that can help an identified need. But a true medical home should be able to meet that identified need." For unique or very involved cases, it's important for the practice to have somewhere else to turn to.
5. Measuring results.
States are advancing medical homes because they want to achieve cost savings through better-quality care. However, proof that goal is being achieved may be difficult to come by.
"This is where I think that states are struggling the most," says Ms. Kaye. The first step is to identify measures on how the practice delivers care. For instance, do they have an electronic medical record or a nurse case manager on staff?
"But ultimately, what you really want to know is whether you are having the intended effect," she says. "Were hospitalizations avoided? Were unnecessary ED visits avoided? Those are the things you would ultimately expect to change."
If you are evaluating appropriate asthma care, for example, you'll want to see the practice billing for certain services. Also, you want to use measures that can change relatively quickly. "You can't wait five years to show results," says Ms. Kaye.
Ideally, you'll want to use measures that have been validated and accepted nationally, so when a measure changes for the better, indicating that better quality care has been provided, the measure itself is not questioned.
In addition to hospitalizations and ED visits, the other thing states are measuring is the patient experience. "I use that term instead of 'patient satisfaction' deliberately," says Ms. Kaye. "Of course, they want patients to be satisfied. But they also want to know if the experience was what it should have been, in terms of appropriate care."
Dr. Schiff says Minnesota's primary goal is to be sure there is a real improvement in how care is delivered. This means more utilization of preventive services, less utilization of hospitalizations and EDs, and better patient engagement and decision making.
"We expect patients and families to feel much more aware of and engaged in their health and their health care planning. We have a big list of outcomes we are looking for," says Dr. Schiff.
Here are five ways that states are working to advance their medical home programs, according to research conducted by the State Consortium to Advance Medical Homes for Medicaid and Children's Health Insurance Program Beneficiaries:Subscribe Now for Access
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