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Since 1997, Alabama Medicaid enrollees—80 percent children—have been assured access to a basic medical home through Patient 1st, the Agency’s Primary Care Case Management (PCCM) program. The statewide program operates under the authority of a 1915(b) wavier.
Alabama is enhancing the Patient 1st program through four community networks that support primary medical providers (PMPs) in becoming medical homes and delivering key services to patients. Each serves patients and providers in a defined geographic area. The program began in August 2011.
Among other services and functions, the Patient Care Networks of Alabama help PMPs coordinate care and teach self-management skills. The objectives of the PCNA Care Management Program are to:
Develop and implement patient-centered holistic plans of care;
Improve quality of care and quality of life;
Improve health literacy, health outcomes and self management;
Improve utilization of information technology resources by participants and providers in PCNA as available;
Promote the effective use of the healthcare system and community resources;
Reduce the potential for risks of catastrophic or severe illness;
Prevent disease exacerbations and complications;
Integrate use of evidence-based clinical practice guidelines into PCNA practices to ensure the “right care at the right time;” and
Reduce inappropriate utilization and costs associated with Emergency Department and hospital inpatient services.
The networks provide population health management through:
Systematic data analysis to target recipients and providers for outreach, education, and intervention;
Monitoring system access to care, services, and treatment including linkage to a medical home;
Monitoring and building provider capacity;
Monitoring quality and effectiveness of interventions to the population;
Supporting the medical home through education and outreach to recipients and providers; and
Facilitating quality improvement activities that educate, support, and monitor providers regarding evidence based care for best practice/National Standards of Care.
Networks provide care management by:
Advocating for high risk, high acuity recipients to ensure that recipients receive appropriate evidence based care; and
Educating patients about disease states and self management.
Visit the Patient 1st Handbook to learn more about that program. Further information on PCNA is available on the PCNA homepage, as well as in the original request for proposals.
Regional Care Organizations (RCOs)
Legislation passed in 2013 will build on the four existing PCNAs to form risk-bearing Regional Care Organizations (RCOs) that will manage a continuum of health care services for Medicaid beneficiaries under a single capitated rate. The RCO strategy stems from recommendations finalized in January 2013 by a multi-stakeholder Medicaid Advisory Commission that was convened by the governor in October 2012. The Alabama Medicaid Agency submitted an 1115 Waiver Concept Paper in early 2013 and has plans to work with Centers for Medicare and Medicaid Services (CMS) regarding the development of an application for a Section 1115 Demonstration Waiver.
To learn more about accountable care activity in Alabama, including Alabama’s plans to implement RCOs, visit the Alabama page of NASHP’s State Accountable Care Activity Map.
On April 9, 2013, CMS approved a Section 2703 health home state plan amendment, creating health homes for Medicaid enrollees with a) two chronic health conditions; b) one chronic health condition and the risk of developing another; or c) one serious mental illness. Alabama’s health home program builds upon the state’s Patient 1st and Patient Care Networks of Alabama programs, and implementation is limited to the four PCNA service regions. The SPA became effective as of July 1, 2012. Alabama 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.
On May 31, 2011, the Centers for Medicare & Medicaid Services (CMS) provided the necessary 1915(b) waiver authority for the state to launch the Patient Care Networks of Alabama program in the second half of 2011.
Last Updated: August 2013
Patient 1st and Patient Care Networks of Alabama (PCNA): The Alabama Medicaid Agency has established working relationships for this project with the state physician associations (including the Alabama chapters of the American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP)), the Alabama Primary Health Care Association (representing federally qualified health centers (FQHCs) in the state), the Department of Public Health (Children’s Health Insurance Program (CHIP) administrator), and the Department of Rehabilitation, among others. In addition, a reengaged and expanded Patient 1st Advisory Council that includes Family Voices and several physicians is guiding the Agency’s work. Alabama held town hall-style meetings with provider around the state to discuss the Patient Care Networks of Alabama (PCNA) program.
Each Patient Care Networks of Alabama network is organized as a 501(c)(3) corporation. At least one half of the board of directors for each network must be comprised of primary care physicians, and in addition the board must also include at least one representative from an FQHC, a hospital, the health department, a Regional Public Mental Health Authority, and a community pharmacist. This composition encompasses representatives from across the community to support practice transformation.
|Defining & Recognizing a Medical Home||
Patient 1st and Patient Care Networks of Alabama (PCNA): Expectations for Patient 1st primary medical providers (PMPs) can be found in the Patient 1st Handbook. No formal recognition standards are being used at this time. Alabama’s definition of a medical home includes the following components:
ACA Section 2703 Health Homes: Alabama’s health homes program aligns with the Patient 1st and Patient Care Networks of Alabama programs; health home providers must meet the participation requirements described above.
|Aligning Reimbursement & Purchasing||
Patient Care Networks of Alabama (PCNA): Medicaid pays the networks $3.00 per member per month (PMPM) for each assigned enrollee who is not aged, blind, or disabled (ABD). The fee is $5.00 PMPM for each assigned ABD enrollee. Networks are also eligible for up to $50,000 in reimbursement for start-up costs.
Patient 1st primary medical providers (PMPs): PMPs who have agreed to partner with their area networks are receiving a $1.60-$2.10 PMPM care management payment. This is in addition to the $1.00 Patient 1st care management PMPM that has traditionally been paid to all Patient 1st PMPs. Medicaid varies the additional network provider payment based on the average acuity level of each PMP’s panel.
Since 2004, Patient 1st PMPs have been eligible to receive shared savings payments that vary in accordance with performance on certain quality benchmarks. As of late 2011, PMPs outside of PCNA network areas are still receiving these incentive payments. Further information, including shared savings methodology, is available online here.
ACA Section 2703 Health Homes: Alabama will pay health homes through separate per-member per-month payments made to the participating providers and Patient Care Networks of Alabama.
The Patient Care Networks of Alabama will receive $9.50 per member per month for each health home patient.
Patient 1st, Patient Care Networks of Alabama (PCNA), and ACA Section 2703 Health Homes: Alabama has launched four patient care networks run by Patient Care Networks of Alabama (PCNA) in select counties to support primary medical providers (PMPs), with services including:
The networks are each developing initiatives around topics that have already been identified (high cost/high co-morbidity patients, asthma, diabetes, etc.) and topics that will be defined through mutual agreement. One of the state’s strategies to support and sustain provider change is through information technology. With a Medicaid Transformation Grant in 2007, Alabama Medicaid is working with PMPs to help them use the QTool, the Agency’s electronic health record and clinical support tool. Additionally, PMPs have access to in-home monitoring program data that allows patients to record certain vital signs and/or test results at home and transmit the data to a central repository. Patient 1st PMPs receive a quarterly physician report card, known as the Profiler, which contains summary information on a PMP's panel for 12-month period. The Profiler contains information on how a particular PMP compares with his or her peers on certain key quality and cost measures. Alabama has begun work to create a system to reimburse and integrate community pharmacists/pharmacies for their cognitive and professional services.
Patient 1st and Patient Care Networks of Alabama (PCNA): Alabama is planning to have an outside entity perform Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys for a baseline and post-implementation evaluation of change in patient experience within each community network pilot. Additionally, the state will perform a pre- and post-financial analysis. Key outcomes of interest for the community network pilots will include improved clinical outcomes, improved patient satisfaction, and Medicaid cost containment. Specific measures that will be used include CAHPS survey results, emergency department utilization for asthmatics, HbA1C measures for diabetics, inpatient hospitalization, immunization rates, and average number of office visits. The University of Southern Alabama is assisting with evaluation design. The Alabama Healthcare Improvement and Quality Alliance Workgroup—a public/private effort—is working to collectively establish measures predicated on national standards that can be used to assess progress on all programs throughout the state.
ACA Section 2703 Health Homes: Alabama has identified seven specific goals for the program:
Alabama will primarily use Medicaid claims and eligibility data to track the state’s performance specific to these goals.