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Pennsylvania’s Chronic Care Initiative (CCI) began as a project of the state’s Chronic Care Commission, which former Governor Ed Rendell created by Executive Order in 2007. The CCI has been staged in seven regional rollouts. The first regional rollout in Southeast Pennsylvania launched with a learning session in May 2008. Six payers participated in the Southeast rollout, and practices were encouraged to focus on diabetes and pediatric asthma. Subsequent rollouts in other regions of the state followed similar models. However, the state refined the programs on the basis of lessons learned, and added components, such as shared savings. Four of the seven rollouts then featured ongoing enhanced reimbursement from multiple payers. Three offered more limited assistance, without ongoing payment for medical home expenses. This portion of the CCI – referred to as Phase I – concludes in 2011.
 
Phase II of the CCI begins January 2012. Approximately 150 practices from three of the previous CCI rollout regions (Southeast, Southcentral, and Northeast) will be participating in Phase II.  In conjunction with a change in administration, oversight of the program has moved to the Pennsylvania Department of Health. 
 
Federal support: Medicare is joining as a participating payer in Phase II of the CCI through the Medicare Advanced Primary Care Practice (MAPCP) Initiative. Also, the federal government provides federal financial participation (FFP) for the enhanced reimbursements that Medicaid managed care organizations and Medicaid fee-for-service pay to participating practices.
 
Last Updated: October 2011

 

Forming Partnerships
The Chronic Care Commission, which developed the Chronic Care Initiative (CCI), included representatives from the following groups:
  • providers, including primary care physicians, registered nurses, nurse practitioners, physician assistants, pharmacists, and specialists;
  • health insurance carriers;
  • hospitals;
  • home health care;
  • philanthropy; and
  • consumers.
Defining & Recognizing a Medical Home
Definition:
Pennsylvania has adopted the Joint Principles of the Patient Centered Medical Home as the state’s medical home definition.
 
Recognition:

The Chronic Care Initiative (CCI) uses a National Committee for Quality Assurance (NCQA) plus approach to practice recognition: in addition to achieving at least NCQA Level 1 recognition, practices are expected to achieve certain otherwise optional standards at specified levels of performance.  As practices’ current NCQA 2008 recognitions expire, practices will be required to achieve obtain recognition under the NCQA 2011 standards.
Aligning Reimbursement & Purchasing
Under Phase I, different rollouts of the Chronic Care Initiative (CCI) in Pennsylvania tested different payment models, including lump sum payments to practices to cover start-up infrastructure costs, per member per month payments, and shared savings. Enhanced payments were stratified by practice recognition, with higher level practices receiving greater enhanced payment than lower level practices. Since 2009, the state’s contracts with Medicaid managed care organizations (MCOs) have required MCOs to participate in the CCI. Medicaid fee-for-service – which is a payer only in the Northeast region – did not provide enhanced payments to practices under Phase I.
 
Under Phase II, practices will receive per member per month (PMPM) payments from participating payers, including Medicare, Medicaid MCOs, and Medicaid fee-for-service.  The amounts of these PMPM payments will vary by initiative year and patient age. Payers are making two PMPM payments to practices.
 
  1. All practices are receiving “Physician Coordinated Care Oversight Services” PMPMs. The amounts are as follows:
  • Year 1: $1.50
  • Year 2: $1.28
  • Year 3: $1.08
  1. Practices are receiving “Coordinated Care Fees” that vary by patient age. These PMPMs are intended to provide funding for care coordinators.
  • The amounts are as follows for those age 18 or younger:

Year 1: $0.60
Year 2: $0.51
Year 3: $0.43

  • The amounts are as follows for those age 19-64:

Year 1: $1.50
Year 2: $1.28
Year 3: $1.08

  • The amounts are as follows for those age 65-74:

Year 1: $5.00
Year 2: $4.25
Year 3: $3.61

  • The amounts are as follows for those age 75 or older:

Year 1: $7.00
Year 2: $5.95
Year 3: $5.06

 

Practices will be eligible for shared savings payments that will take into consideration practice performance on key quality and cost metrics. As the PMPM amounts decrease from year 1 to year 3, practices will be eligible for greater shares of any savings.
Supporting Practices

The Chronic Care Initiative (CCI) rollouts have provided for learning collaboratives, including revenue to cover time lost when providers and practice staff were out-of-office. The CCI has also provided web-based patient registries and practice coaching. Under Phase II, the Department of Health is leading the learning collaboratives, holding monthly group calls for all practices, and overseeing practice coaching. Practices are asked to regularly submit clinical data to the practice coach for quality improvement purposes. Priorities for further practice transformation have also been identified.
Measuring Results The Commonwealth Fund is paying for researchers at RAND and Harvard School of Public Health to conduct an evaluation of Phase I of the Chronic Care Initiative (CCI). The Centers for Medicare & Medicaid Services (CMS) is evaluating the impact of the Phase II CCI on outcomes for Medicare patients through a contract with RTI International. NASHP and the Urban Institute are subcontractors to RTI. Final evaluation results are not yet available, but the state has seen promising improvements in process measures as determined by Pennsylvania’s Improving Performance in Practice (IPIP) program.