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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.
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Update on theMaryland Multi‐payer PCMH Program (MMPP)
National Academy for State Health Policy
December 16, 2010
Ben Steffen
Maryland Health Care Commission
1
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
2
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.
3
Total Cost o
f Care
PCMH Financial Model
• 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)
Total Cost o
f Care
} Savings Opportunity
4
Payment Model
Fee‐For‐ServicePrimary 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.
+
+
5
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
6
PCMH Incentive Payment
• Incentive payments are based on shared savings
• Practices are eligible for incentive payments if they:
– Meet performance and measurement criteria
– Achieve savings relative to their own baseline
• Calculations to be performed by MHCC, which may adjust for case mix or outliers
• Achieve savings, report on quality, reduce utilization
7
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.
8