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Chapter 224 of the Acts of 2012, signed in August 2012, includes a number of provisions specific to promoting the adoption of patient-centered medical homes (PCMHs) in Massachusetts. This legislation requires a newly formed Health Policy Commission to develop certification standards, a training program, and a model payment system for PCMHs by January 2014. Chapter 224 ensures that existing medical home initiatives, such as the PCMH Initiative described below, may proceed as planned.
 
In June 2009, the Massachusetts Executive Office of Health and Human Services (EOHHS) convened a state Patient-Centered Medical Home Initiative (PCMHI), when the state Secretary of Health and Human Services invited a wide range of stakeholders to participate in a PCMHI Council. The council developed the PCMHI model, and the state used a request for responses process to select practices to join the PCMHI. In December 2010, EOHHS announced that a diverse group of 46 practices throughout the state were selected to join the project. All 46 practices – which together employ about 500 providers – are receiving a package of technical assistance to support practice transformation. Of these, 32 are receiving enhanced payment in exchange for meeting medical home recognition standards within 18 months of project launch. Approximately 500,000 patients receive care from these practices. Participating practices are expected to master 12 core competencies.
 
The PCMHI is a step towards meeting the EOHHS goal of having all Massachusetts primary care practices functioning as medical homes by 2015. Massachusetts’s work with the Safety Net Medical Home Initiative, which launched in 2009 with the goal of helping 14 community health centers become medical homes, represents another step towards the EOHHS vision.
 
Primary Care Payment Reform Initiative (PCPRI)
Chapter 224 of the Acts of 2012 also requires MassHealth to pursue alternative payment methodologies for enrollees; one way the state is doing so is through the Primary Care Payment Reform Initiative (PCPRI), a three-year initiative which seeks to improve access to care, patient experience, and quality of care, and to increase efficiency through the medical home model and integrated behavioral health services. The PCPRI – a joint project between MassHealth’s primary care case management program, known as the Primary Care Clinician (PCC) Plan, and the state’s Medicaid managed care organizations – will serve MassHealth members.
 
In March 2013, EOHHS released an RFA to practices seeking participants for a three-year Primary Care Payment Reform Initiative. The program seeks to implement a new payment model which incorporates payment for medical home services and a quality incentive payment, as well as shared savings and, for some, shared risk.
 
While practices participating in Massachusetts’s Patient-Centered Medical Home Initiative (see above) were eligible to apply for PCPRI, any PCMHI practices selected to participate in PCPRI would no longer be eligible to participate in PCMHI or receive medical home payments through PCMHI.
 
Federal support:
  • Massachusetts is one of six states selected in February 2013 by the Centers for Medicare and Medicaid Innovation (CMMI) to receive a State Innovation Model (SIM) Model Testing Award. Massachusetts received $44 million to implement and test its State Health Care Innovation Plan, which builds on the state’s work to advance patient-centered medical homes as well as accountable care organizations, profiled on the Massachusetts page of NASHP's State Accountable Care Activity Map.
  • The federal government provides federal financial participation (FFP) for the enhanced reimbursements that Medicaid/CHIP and Medicaid managed care organizations pay to participating providers.
  • Massachusetts has also received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.” 
Last Updated: November 2013
 
Massachusetts Patient-Centered Medical Home Initiative: The Massachusetts Patient-Centered Medical Home Initiative (PCMHI) Council includes representatives of:
  • state primary care provider professional associations
  • payers, including state employees
  • hospitals
  • key state agencies
  • philanthropy
  • consumers
  • advocates
  • community health centers
For more information, please see the PCMHI Council webpage.
Defining & Recognizing a Medical Home
Definition:
Chapter 224 of the Acts of 2012 defines a medical home as: “a model of health care delivery designed to provide a patient with a single point of coordination for all their health care, including primary, specialty, post-acute and chronic care, which is (i) patient-centered; (ii) comprehensive, integrated and continuous; and (iii) delivered by a team of health care professionals to manage a patient’s care, reduce fragmentation and improve patient outcomes.”
  
Massachusetts Patient-Centered Medical Home Initiative: The Massachusetts Patient-Centered Medical Home Initiative (PCMHI) has identified 12 core competencies for participating practices:
  1. Patient/family-centeredness
  2. Multi-disciplinary team-based approach to care
  3. Planned visits and follow-up care
  4. Population-based tracking and analysis with patient-specific reminders
  5. Care coordination across settings, including referral and transition management:
  6. Integrated care management focused on high-risk patients
  7. Patient and family education
  8. Self-management support by all members of the practice team
  9. Involvement of the patient in goal setting, action planning, problem solving and follow-up
  10. Evidence-based care delivery, including stepped care protocols
  11. Integration of quality improvement strategies and techniques
  12. Enhanced access
Primary Care Payment Reform Initiative (PCPRI): The PCPRI has identified ten core competencies for participating practices, many of which overlap with the PCMHI core competencies listed above:
  1. Patient-centeredness
  2. Multi-disciplinary team-based approach to care
  3. Planned visits and follow-up care
  4. Population-based tracking and analysis with patient-specific reminders
  5. Care coordination across settings, including referral and transition management
  6. Clinical care management services focused on highest-risk panel enrollees
  7. Self-management support of panel enrollees by the multidisciplinary care team
  8. Integration of quality improvement strategies and techniques
  9. Enhanced access to services
  10. Clinic system integration
Recognition:
Chapter 224 of the Acts of 2012 requires a newly formed Health Policy Commission, with consultation from the Office of Medicaid, to develop and implement medical home certification standards by January 1, 2014. The legislation requires the commission to consider existing accreditation standards, including those developed by the National Committee for Quality Assurance (NCQA). The legislation requires the standards to include:
  • Enhanced access;
  • Expanded providers, including care coordinators and social workers;
  • Shared decision-making;
  • Care planning and risk assessment. 
Chapter 224 also requires certified medical homes to use adopt an electronic medical record by December 31, 2016.
 
Massachusetts Patient-Centered Medical Home Initiative: PCMHI practices are required to achieve at least National Committee for Quality Assurance (NCQA) Level 1 recognition. In addition, practices are expected to achieve three otherwise optional NCQA standards. Participating practices must achieve NCQA Level 1 “plus” recognition within 18 months of project launch.
 
Primary Care Payment Reform Initiative (PCPRI): PCPRI practices are required to achieve NCQA Level 1 recognition within 24 months of joining the program.
 
Participating practices must also have:
  • Achieved Stage 1 Meaningful Use standards, or to have received Medicaid Adopt/Implement/Upgrade incentives and attest that they plan to achieve Stage 1 Meaningful Use by October 1, 2014; pediatric practices or others ineligible for Meaningful Use due to low Medicaid volume are to provide evidence of this.
  • An electronic medical record (EMR) with patient registry to support chronic disease management, document treatment plans, and have the ability to assign a primary care provider to each patient.
  • 24/7 access by phone or in-person.
  • Hired or contracted with a clinical care manager to identify and serve high-risk patients (within 6 months).
  • Meet the ten core competencies listed above (within 18 months).
Participating practices are required to provide integrated primary care and behavioral health services, with coordination and information sharing between primary care and behavioral health providers. Participating practices must pursue one of three behavioral health integration strategies which align with the requirements listed below: non-co-located but coordinated; co-located; and clinically integrated.
 
Participating practices are assigned a Comprehensive Primary Care Payment (CPCP) Tier based on the level of behavioral health covered services provided by the practice (see Attachement K of the PCPRI RFA for a list of behavioral health covered services):
  • CPCP Tier 1: Practices do not provide behavioral health services as defined by the PCPRI.
  • CPCP Tier 2: Practices provide a minimum set of covered behavioral health services. In addition to the standards listed above, Tier 2 practices are required to provide a full-time behavioral health provider (master’s or doctoral level) on-site, with ability to schedule behavioral health appointments within 14 days of request.
  • CPCP Tier 3: Practices provide the maximumset of covered behavioral health services. In addition to Tier 2 requirements, Tier 3 practices must include an on-site psychiatrist as part of the multidisciplinary care team for at least .2 FTE; maintain 24/7 access for behavioral health services; and ensure providers have 24/7 access to a behavioral health record for each enrollee including diagnosis, medications, and acute safety issues.
For more information, see section 3 of the PCPRI RFA.
Aligning Reimbursement & Purchasing
Chapter 224 of the Acts of 2012 requires the newly formed Health Policy Commission to develop a model payment system for certified patient-centered medical homes by January 1, 2014. The commission is required to consider per-patient payments, payments adjusted on patient-complexity; payments for care coordination/clinical management, performance-based payments, and shared savings.
 
Massachusetts Patient-Centered Medical Home Initiative:
The following payers and purchasers are making enhanced payments through the Massachusetts Patient-Centered Medical Home Initiative (PCMHI):
  • MassHealth Primary Care Clinician (PCC) Plan
  • Health Safety Net
  • Blue Cross Blue Shield of Massachusetts
  • Boston Medical Center HealthNet Plan
  • CeltiCare
  • Fallon Community Health Plan
  • Harvard Pilgrim Health Care
  • Health New England
  • Neighborhood Health Plan
  • Network Health
  • Tufts Health Plan
  • Senior Whole Health
  • UniCare
  • The Health Connector Authority
  • Group Insurance Commission (state employees)
Payers have committed to making several types of payments to support medical homes:
  • Start-up payments to practices to support medical home infrastructure: these payments will range up to $15,000 in the first year of the PCMHI and $3,500 in the second year.
  • Ongoing payment for medical home activities: $1.50 per member per month (PMPM)
  • Ongoing support for clinical care management services: $0.60 PMPM for individuals under age 18, $1.50 PMPM for individuals age 18-64, $6.00 PMPM for individuals age 65 or older
  • Shared savings payments: the payers have agreed to share savings with the participating practices if they generate savings relative to a control group of practices. However, the methodology has not yet been announced.
It should be noted that Medicaid managed care plans are required to make PCMHI payments.
 
Primary Care Payment Reform Initiative (PCPRI): Participating practices receive three types of payments:
  1. Comprehensive Primary Care Payment (CPCP): A risk adjusted per-member per-month (PMPM) payment for primary care services which can include payment for behavioral health services as well.
  2. Quality Incentive Payment: Participating practices receive incentive payments based on fulfilling PCPRI measurement and reporting requirements (“pay for reporting” or P4R); and for performance improvement and/or achieving high quality (“pay for quality performance” or P4Q). Practice performance for calendar year 2012 will serve as a baseline for P4Q.
  3. Shared Savings/Shared Risk Payment: Shared savings and shared risk payments are calculated based on the difference between each participating practice’s target spend – set by the Massachusetts Executive Office of Health and Human Services (EOHHS) – and their actual spend. Participating practices can choose to include long-term services and supports in target and actual spend calculations for the purpose of calculating shared savings and shared risk. Participating practices choose one of three risk tracks on which shared savings payments will be based:
    • Risk Track 1 (Upside/Downside Risk): Practices are eligible to share in savings or losses, and will receive or owe 60% of the difference between their target spend and their actual spend, up to 6% of target spend. Risk Track 1 practices must have at least 5,000 patients enrolled in a MassHealth MCO or the Primary Care Clinician (PCC) Plan, MassHealth’s Primary Care Case Management program.
    • Risk Track 2 (Transitioning to Downside Risk): In Year 1, practices are eligible for shared savings only, using the Risk Track 3 methodology for calculating savings and distributing payments (see below). In Year 2, practices are eligible to share in savings or losses, and will receive or owe 60% of the difference between their target spend and their actual spend, up to 6% of target spend for shared savings and up to 3% of target spend for shared losses. In Year 3, practices will transition fully shared savings and risk, using the Risk Track 1 methodology. Risk Track 2 practices must have at least 5,000 patients enrolled in a MassHealth MCO or the PCC Plan.
    • Risk Track 3 (Upside Risk Only): Practices are eligible to share in up to 50% of savings. The proportion of savings paid to practices varies based on the level of savings. Practices that produce greater savings (the difference between actual spend and target spend as a percentage of target spend) are eligible for a greater share of savings. Risk Track 3 practices must have at least 3,000 patients enrolled in a MassHealth MCO or the PCC Plan.
For more information on how the state plans to calculate CPCP, quality incentive, and shared savings/shared risk payments, including target spend and actual spend, see Attachement A of the PCPRI RFA.
 
Practice performance on 23 quality measures that will also impact P4R (all years), P4Q (Years 2-3), and SS (Year 3 only) payments. For more information on the selected measures, including impact on payment, see Attachement D of the PCPRI RFA.
Chapter 224 of the Acts of 2012 requires the newly formed Health Policy Commission to establish a patient-centered medical home training program; participation in the training program may be necessary for certification.
 
Massachusetts Patient-Centered Medical Home Initiative: Patient-Centered Medical Home Initiative (PCMHI) practices are receiving a variety of supports, including:
  • Access to a patient registry, if the practice lacks an electronic medical record (EMR) with registry functionality
  • Use of an online portal to see practice performance on key metrics over time and compared to other practices
  • Nine days of in-person learning collaborative meetings over February 2011 and January 2013
  • Monthly hour-long webinars or conference calls
  • The assistance of medical home facilitators
Primary Care Payment Reform Initiative (PCPRI): Massachusetts Executive Office of Health and Human Services (EOHHS) provides participating practices with a variety of supports through learning collaboratives and other means:
  • Claims-based data to guide care coordination and care management efforts, including a list of attributed enrollees and claims history, claims-based risk scores for all attributed enrollees, and per-member per-month utilization metrics for different types of services.
  • Targeted technical assistance on topics such as quality improvement and data analysis.
Massachusetts Patient-Centered Medical Home Initiative: The University of Massachusetts Medical School’s Department of Commonwealth Medicine will conduct an evaluation of the Patient-Centered Medical Home Initiative (PCMHI).
 
Primary Care Payment Reform Initiative (PCPRI): The PCPRI RFA identifies 23 quality measures that participating practices will be required to report across six domains:
  • Adult prevention and screening;
  • Behavioral health (adult and pediatric);
  • Pediatric health (excluding behavioral health measures)
  • Adult chronic conditions
  • Access (adult and pediatric)
  • Care coordination (adult and pediatric)
These measures will impact pay for reporting, pay for quality performance, and shared savings payments over the course of the three year initiative. For more information on the selected measures, including impact on payment, see Attachement D of the PCPRI RFA.
 

 

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