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Aligning Reimbursement & Purchasing

Supports and rewards practices which meet performance expectations.

Alabama

When Patient 1st began in 1997, primary medical providers (PMPs) were paid a flat case management fee of $3 PMPM. Since December 1, 2004, PMPs have the ability to “build” their case management fee based on agreed upon contract components, such as providing EPSDT screenings or immunizations, or for completing CME training on medical homes. In 2007, the Agency shared $5.7 million in savings with PMPs who – compared to their peers – worked with the agency to improve the quality of health care provided through its Patient 1st program while saving millions of dollars for taxpayers.  The state is considering options for adjusting its shared savings program to better reward advanced primary care.

Colorado

For children: enhanced reimbursement for EPSDT/well-child visits. Under consideration are:
• Using a pay for performance mechanism for enhanced reimbursement.
• Per member per month (PMPM) payment structure for health plans and primary care case.
• Supportive payment to health plans for CHP Plus.
For adults: multi-payer payment that includes:
• FFS plus PMPM care coordination payment.
• Pay for performance.

Florida

In general, the Medicaid Medical Home Task Force has suggested that increasing Medicaid fee-for-service (FFS) rates from the current average of approximately 58% of Medicare rates may be necessary to attract more providers to serving as Medicaid medical homes.  The Task Force did not suggest a specific financing mechanism to compensate providers for the added expenses of offering medical homes, but rather proposed giving “strong consideration” to enhanced fees, care management fees, and pay-for-performance systems.  Achieving a positive return on investment is a top priority, and the Task Force recommended studying financing mechanisms with this goal in mind.
 

Iowa

The reimbursement workgroup has discussed opportunities associated with funding for IowaCare.  IowaCare will have $6 million to invest in the program, and how to best use this funding to promote the medical home model is a topic of ongoing discussion.  The Council is interested in using reimbursement levers to incent remote provider peer consultation and regular adult screenings.

Louisiana

Waiver application includes a shared savings model or network ownership with providers, risk adjusted premiums with required disease management, and incentives for both providers and beneficiaries.

Maine

Prospective per member per month (PMPM) care coordination fee.

Maryland

SB 855/HB 929 grants the Maryland Health Care Commission (MHCC) discretion in developing a medical home payment methodology to be used by all participating payers.

Minnesota

Minnesota’s Primary Care Coordination (PCC) serves Medicaid patients with at least five or more persistent chronic conditions.  Generally, providers are eligible to receive care coordination payments every six months for the care coordination services they have performed over the preceding six months.  The care coordination payment range from of $235.32 to $458.52, varying greatly on the basis of the number of chronic conditions the patient has, and modestly on the basis of whether the practitioner offering care coordination services is a physician or nurse practitioner/physician assistant.  Claims for care coordination must be submitted in conjunction with a claim for an evaluation and management (E&M) visit.  For further information, please see: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION...

Minnesota’s Health Care Homes program will serve those with less complex needs than the PCC population.  That payment methodology has not yet been finalized.

Nebraska

A fee for service plus per member per month approach is being discussed.

New Hampshire

Prospective per member per month (PMPM) fee that increases with National Committee for Quality Assurance (NCQA) Recognition Level paid every six months. Existing pay for performance programs for improvements in quality and cost.  The Medicaid Medical Information System, to begin in 2010, will be capable of creating a medical home designation, patient assignment, and prospective and incentive payments.

New York

For fee-for-service Medicaid: plans to use enhanced payments for certain primary care services (select Evaluation and Management codes and Preventative Medicine codes).  Amount of enhanced payment will vary depending on level of National Committee for Quality Assurance (NCQA) recognition and whether the practitioner is office-based or operating in an Article 28 clinic.

For Medicaid managed care: new contracting language will require plans to pay a PMPM to providers.  The State will prospectively compensate managed care organizations (MCOs) for this expense.

North Carolina

Pays fee-for-service (FFS) at 95% Medicare. Pays a per member per month (PMPM) fee directly to practices for their Medicaid enrollees ($2.50 PMPM, $5.00 PMPM for Aged, Blind and Disabled). Pays a PMPM fee directly to the networks for aggregate enrollment of participating practices ($3.00 PMPM, $5.00 PMPM for ABD).

Oklahoma

Oklahoma Medicaid pays medical home providers a tiered per member per month (PMPM) payment for administrative costs through their primary care case management (PCCM) program that ranges from $3.03 to $8.69. In addition, this state paid providers a one-time payment to support their transition from the previous program to this new arrangement.

Oregon

Overall medical home reimbursement structure under consideration, especially in Medicaid.  The Oregon Health Fund Board recommends that payment reform should be designed to incentivize desired outcomes: quality, efficiency, health outcomes, and care coordination.

Pennsylvania

Payments vary per region/practice, shared proportionately by carriers:
 

  • Southeast PA: Approximately $21,170 infrastructure development payment per practice covering registry licensing fee, support for data entry to registry, cost of NCQA PPC-PCMH survey/application fee, and lost revenue time to attend learning collaboratives. In addition, enhanced payments to FFS/capitation. During the 1st  3 yrs, lump sum payments are aligned with stepwise achievement of 3 NCQA levels with a plan to transition to P4P.
  • Southcentral and Southwest PA: Up to $20,000 infrastructure development payment per practice for Year 1 learning collaborative, practice coaches, timely reporting, entering data into registry, etc. In addition, enhanced payments to FFS/capitation aligned with stepwise achievement of 3 NCQA levels. 1st tiered payment for NCQA certification not until month 18.
  • Northeast PA: Funds for practice management beginning Month 1; funds to hire on-site care coordinators beginning Month 4; additional funds from shared savings
Rhode Island

Connect Care Choice (primary care case management [PCCM] program) adjusts the monthly care coordination fee to account for the time needed to care for complex patients.  Practices that care for moderate to high risk Connect Care Choice members and have a nurse care manager integrated into their practice receive an additional $30 per person per month.

Rhode Island’s multi-payer medical home pilot requires payers to pay practices a per member per month (PMPM) care coordination fee and share in the salary and benefits costs of an on-site nurse care manager.

Texas

Pilot practices will receive cost-based reimbursement for expenses associated with becoming health homes.  Practices receiving payment under all payment models are eligible for participation in the pilot.

Vermont
  • Varies based on National Committee for Quality Assurance (NCQA) score. Up to $2.39 per member per month (PMPM).
  • Shared payer support for Community Care Teams (5 FTEs).
  • State subsidizes Medicare share of payment.
Washington

Multiple methods under consideration; may test several through pilots. Methods include:

  • Pay for primary care through capitation or global fee.
  • Pay for performance and other incentive-based mechanisms.
  • Diagnosis Related Groups (DRG) and case management fees.
  • Ambulatory Patient Groups (APG) and risk factor adjustments.
  • Base payment and incentives for quality.
  • Capitation and risk factor adjustment.