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Patient Centered Medical Home Multipayer Reimbursement Pilot: Authority for Washington State’s Patient Centered Medical Home (PCMH) Multipayer Reimbursement Pilot came in 2009 through Substitute Senate Bill 5891. This legislation directed the Washington State Health Care Authority (HCA) and the Washington State Department of Social and Health Services (DSHS) to develop, launch, and evaluate at least one medical home multipayer pilot. The legislation provided antitrust protection, and instructed HCA and DSHS to select sites, identify performance measures, and coordinate with related projects. Having secured the participation of payers and purchasers, the pilot launched on May 1, 2011, with eight practices (12 sites) serving about 25,000 patients. These sites were selected through an application process, and were judged on the basis of their readiness to function as medical homes. Participation in the Department of Health (DOH) medical home learning collaborative (see below) was viewed as a positive factor in site selection.
The Pilot is set to run for 32 months. For that period of time, participating practices will receive per member per month (PMPM) payments and will be eligible for shared savings payment if they reduce avoidable acute care utilization. If practices do not achieve savings greater than or equal to the total amount of the total PMPM payments, they may have to pay back up to half of the PMPM payments. Further information on the PCMH Multipayer Reimbursement Pilot is available here.
- Patient Centered Medical Homes Collaborative: In partnership with the Washington Academy of Family Physicians, the Washington State Department of Health (DOH) has led a Patient Centered Medical Home (PCMH) Collaborative. The Collaborative has been established as per Second Substitute House Bill 2549, which was unanimously passed in 2008. Citing the needs to, “improve the health and well-being of the people in the state of Washington; enhance the recruitment, retention, performance, and satisfaction of primary providers; and control costs,” the state provided funding for the PCMH Collaborative. The Collaborative has focused on providing practice transformation support. Support has been delivered through practice coaching, in-person learning sessions, and a series of webinars. Thirty-two teams have participated in the Collaborative. These teams represent about 700 providers, who together care for nearly 650,000 patients. Further information on the PCMH Collaborative is available here.
| Forming Partnerships |
A wide range of stakeholders have been involved in designing the Washington State Patient Centered Medical Home (PCMH) Multipayer Reimbursement Pilot, including:
For more information, please see Appendix K here.
The PCMH Collaborative has been developed as a partnership between the Washington Academy of Family Physicians and the Department of Health (DOH). Many of the stakeholder types referenced above – including providers, professional associations, and payers – have helped guide the Collaborative’s work. For more information, please see page 75 here. |
| Defining & Recoginizng a Medical Home |
Definition: According to Washington State’s 2008 Second Substitute House Bill 2549, a medical home is, “a place where health care is accessible and compassionate. It is built on evidence-based strategies with a team approach. Each patient receives medically necessary acute, chronic, prevention, and wellness services, as well as other medically appropriate dental and behavioral services, and community support services, all which are tailored to the individual needs of the patient.”
Recognition: Under the Patient Centered Medical Home (PCMH) Multipayer Reimbursement Pilot, practices are not required to maintain formal PCMH recognition. However, practices that had achieved National Committee for Quality Assurance (NCQA) recognition (or otherwise demonstrated their readiness to operate as medical homes) were favored in the selection process.
Practices participating in the PCMH Collaborative are not required to obtain formal recognition. Rather, they are assessed using the Medical Home Index to gauge change over time and identify areas for improvement. |
| Aligning Reimbursement & Purchasing |
Payer participation in Washington State’s Patient Centered Medical Home (PCMH) Multipayer Reimbursement Pilot is voluntary. The following payers have joined the program on behalf of their commercial, Medicaid managed care, Medicare Advantage, and Basic health lines of business:
For the duration of the Pilot, participating practices will receive per member per month (PMPM) payments and will be eligible for shared savings payment if they reduce avoidable acute care utilization. The amount of the PMPM payment is set at $2.50 initially; it will decrease to $2.00 PMPM after the first nine months. If practices do not achieve savings greater than or equal to the total amount of PMPM payments, they may have to pay back up to half of the PMPM payments. This will be accomplished by reducing the amount of future PMPM payments. Further information on the payment model is available here.
Under the Patient Centered Medical Home (PCMH) Collaborative, participating practices have received stipends of $6,400 per practice to attend eight days of learning sessions. |
| Supporting Practices |
Washington State Patient Centered Medical Home (PCMH) Multipayer Reimbursement Pilot has not provided for participating practices to receive supports other than enhanced payment.
The PCMH Collaborative has provided a range of supports to participating practices, including practice coaching, in-person learning sessions, and a series of webinars. Many webinar archives are available online, as are materials from the in-person learning sessions.
The Washington State Department of Health (DOH) and the Washington State medical Home Leadership Network also maintain a website devoted to helping providers and others better serve children and youth with special health needs through the medical home model. |
| Measuring Results |
The Washington State Patient Centered Medical Home (PCMH) Multipayer Reimbursement Pilot has planned for the University of Washington School of Public Health to conduct a comprehensive evaluation of their project. The evaluation will focus on the impact of the payment method on utilization, cost, outcomes, and experience. The evaluation team will draw on qualitative data (experience surveys, key informant interviews) and quantitative data (claims data, clinical quality measures). The evaluation will continue for a year after the pilot ends, in order to study changes following the conclusion of the program. Further information is available on pages 34-35 here.
The PCMH Collaborative has released a preliminary summary of evaluation results for participating practices. The summary provides information on:
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