Nebraska – Medical Homes

Nebraska Medicaid Patient-Centered Medical Home Pilot

The Nebraska Department of Health and Human Services (DHHS), guided by a governor-appointed physician Medicaid Medical Home Advisory Council, launched a two-year medical home pilot. The program operated under the authority of a 1932(a) state plan amendment, approved by CMS in January 2011. This pilot was limited to two practices selected through a Request for Information process in February 2011; the pilot launched in February 2011 and ran through February 2013.

Nebraska began its process in 2009 with a statutory definition of the medical home and a legislative mandate to implement a pilot. The state then:

  • Engaged several key stakeholders;
  • Conducted an RFI selection process to determine the practices to participate in the pilot;
  • Developed the payment structure;
  • Developed pilot outcomes and measures; and
  • Contracted with TransforMED to provide technical assistance to the pilot practices.

Agendas and meeting minutes for Nebraska’s Medicaid Medical Home Advisory Council are available online here.

It should be noted that Nebraska has implemented managed care in regions of the state that were previously fee-for-service. DHHS requires each Medicaid managed care plan to develop and support at least two practices in becoming medical homes annually.

Multi-Payer Patient-Centered Medical Home Pilot
In January 2014, Nebraska’s major commercial insurers and Medicaid managed care plans voluntarily launched a two-year multi-payer medical home pilot. The pilot aims to align participation requirements and measures across participating payers and practices, and requires payers to contract with an average of ten practices per pilot year. The pilot participation agreement describes expectations for participating payers and practices.

Stakeholders were convened by the Nebraska Legislature, which also supported the planning process. An archive of documents and press information is available online here. Nebraska also received support for this initiative as a member of NASHP’s Multi-Payer Medical Home Learning Collaborative.

Last updated: April 2014

Forming Partnerships
Nebraska Medicaid Patient-Centered Medical Home Pilot: The Nebraska Medicaid Medical Home Advisory Council consists of one hospital administrator, six primary care providers (representing family, internal, and pediatric medicine), and one ex-officio legislator, each appointed by the governor. The Council began meeting in October 2009 and continues to meet regularly.
The Nebraska Department of Health and Human Services (DHHS) has also worked to engage a variety other stakeholders, including BlueCross Blue Shield of Nebraska and the Dietetic Association.
The Medical Home Advisory Council is supported by DHHS staff. A job description for the DHHS Medicaid Medical Home Program Coordinator is available here.
Multi-Payer Patient-Centered Medical Home Pilot: Representatives of the following individuals and groups signed the pilot participation agreement:
  • Nebraska State Senators Mike Gloor and John Wightman
  • Blue Cross Blue Shield of Nebraska
  • Nebraska Academy of Family Physicians
  • Coventry Health Care of Nebraska
  • Nebraska Medical Association
  • Arbor Health Plan
  • Nebraska Chapter of the American Academy of Pediatrics
  • CoOportunity Health
  • UnitedHealthcare
Defining & Recognizing a Medical Home
Definition: 
Nebraska Medicaid Patient-Centered Medical Home Pilot and Multi-Payer Patient-Centered Medical Home Pilot: In Nebraska, a medical home is defined as a health care delivery model in which a patient establishes an ongoing relationship with a physician in a physician-directed team, to provide comprehensive, accessible, and continuous evidence-based primary and preventive care, and to coordinate the patient’s health care needs across the health care system in order to improve quality, safety, access, and health outcomes in a cost effective manner. For further information, see the Medical Home Pilot Program Act (LB 396).
 
Recognition: 
Nebraska Medicaid Patient-Centered Medical Home Pilot: The Nebraska developed two tiers of recognition. Tier 1 practices were required to meet 29 standards in five “core competencies,” with eight additional standards required to meet Tier 2 recognition standards.
Multi-Payer Patient-Centered Medical Home Pilot: Payers participating in the pilot are not required to use certification or recognition standards. The pilot participation agreement specifies that if participating insurers do require practices be certified or recognized as medical homes, they will accept NCQA PCMH recognition, Joint Commission PCMH certification, URAC achievement, or Nebraska Medicaid PCMH Pilot Program standards.
Aligning Reimbursement & Purchasing
Nebraska Medicaid Patient-Centered Medical Home Pilot: Nebraska developed a unique payment structure to support medical homes through the Nebraska Medicaid Patient-Centered Medical Home Pilot, a two-year pilot which launched in February 2011 and ran through February 2013. Upon signing a participation agreement with the Nebraska Department of Health and Human Services (DHHS), practices were paid $2.00 per member per month (PMPM). This PMPM rate increased to $4.00 upon achievement of Tier 1 recognition. Practices that chose to continue medical home transformation to meet the more advanced Tier 2 standards received 105% of standard rates for select evaluation and management and preventive codes.
Authority for Nebraska’s payment methodology came in January 2011 with the approval of a 1932(a) state plan amendment.
Multi-Payer Patient-Centered Medical Home Pilot: The participation agreement for Nebraska’s multi-payer medical home pilot does not require payers and practices to use a specific payment methodology. Instead, it puts forward broad requirements for payment agreements between participating payers and practices:
  • Payments must be value-based and go beyond the fee-for-service system.
  • Payments should be linked to practice performance (clinical, financial, and/or patient satisfaction).
  • Payments should not be limited to patients with a specific condition or set of conditions; instead, practices should be paid on behalf of their full panel of covered patients.
Supporting Practices
Nebraska Medicaid Patient-Centered Medical Home Pilot: The Nebraska Department of Health and Human Services (DHHS) provided each practice with:
  • Technical assistance for transforming into a medical home through a contract with TransforMED;
  • Funding for a care coordinator staff position;
  • Funding for a patient registry;
  • Access to claims data; and
  • Regular performance reports throughout participation in the pilot;
In addition, the state conducted an orientation and provided two day-long learning collaboratives for physicians, nurses, and key office staff.
Measuring Results
Nebraska Medicaid Patient-Centered Medical Home Pilot: Nebraska identified five outcomes of interest for the Medicaid Patient-Centered Medical Home Pilot, which launched in February 2011 and ran through February 2013:
  • Improved health care access;
  • Improved health outcomes for patients;
  • Medicaid cost containment;
  • Patient satisfaction; and
  • Provider satisfaction.
A list of measures for each outcome of interest is available here.
In addition, TransforMED collected metrics on the progress of the transformation of the practices through the Patient Experience Assessment Tool (PEAT) and provider/staff surveys.
The evaluation for the two-year pilot, competed in November 2013, used analysis of claims data, provider records, and surveys to measure pilot impact on the identified outcomes of interest. Highlights from the evaluation findings include:
  • A statistically significant decrease in the rate of overall emergency department visits per 1,000 patients;
  • A statistically significant decrease in the number of prescriptions written per 1,000 patients and in spending for prescriptions per 1,000 patients;
  • A significant decrease in the percentage of total visits to specialists, and in the rate of visits to specialists per 1,000 patients;
  • Improvement in clinical process measures preventive care and chronic disease management, including cancer screenings, tobacco use screenings, body mass index tracking, diabetes control, cholesterol control, and high blood pressure control; and
  • Increased patient satisfaction.
Multi-Payer Patient-Centered Medical Home Pilot: The participation agreement for Nebraska’s multi-payer medical home pilot requires participating payers select measures for practice reporting from a mutually agreed-upon list. The lists of adult quality measures and pediatric quality measures are available online.