Medical
Home Reimbursement Models: Funding Patient-Centered Care
with Multi-Stakeholder Collaborations
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There's
no question that the healthcare community has embraced the
patient-centered medical home (PCMH) model of care. To date, there are
22 multi-stakeholder pilots in 16 states, with eight state Medicare
pilots scheduled for 2009. The joint principles of the PCMH have been
endorsed by the AMA, AAFP, AAP, ACP and the AOA.
However,
with the cost of transforming a physician practice into a medical home
estimated at 30 percent over current fee-for-service reimbursement
levels, acceptable funding formulas are still needed to cover
construction and maintenance of medical homes.
Medical
Home Reimbursement Models: Funding Patient-Centered Care with
Multi-Stakeholder Collaborations presents three ongoing
medical home pilots built on a variety of reimbursement models. This
39-page special report provides an opportunity to evaluate three PCMH
financial models and benefit from the experiences of multi-stakeholder
collaborations. These case studies reflect early collaborations by
Colorado, Ohio and New Hampshire providers, employers and public and
private payors to build reimbursement structures that reward providers
for care coordination and preventive efforts without adversely
impacting healthcare costs.
Colorado
is deeply involved in medical home initiatives at the state and
national levels. In the first case study, Lesley Reeder, R.N., B.S.N.,
quality improvement specialist for the Colorado Department of
Health Care Policy and Financing, shares details on the
Colorado Children’s Healthcare Access Program (CCHAP), which
provides medical homes for Medicaid and SCHIP beneficiaries. CCHAP
offers enhanced reimbursement for preventive care for 59 providers who
care for 10,000 children. A physician champion and a supportive
governor figure largely in the success of this small pilot, which is a
stepping stone to larger medical home pilots in the state.
Colorado
also participates in the Multi-Stakeholder Patient-Centered
Medical Home Pilot, described in this book by Julie Schilz,
co-chair of the Center for Multi-stakeholder Demonstrations
and IPIP manager for the Colorado Clinical Guidelines Collaborative. In
this multi-state pilot, Colorado is partnering with Ohio and a mix of
employers and public and private payors to fund medical homes. Schilz
provides details on its three-tiered reimbursement model (an approach
recommended by the Patient-Centered Primary Care Collaborative) and
describes other considerations, including sensitivity toward antitrust
regulations.
Thirdly,
from New Hampshire comes details on a payor-provider medical home pilot
from Barbara Walters, M.D., senior medical director of
Dartmouth-Hitchcock Medical Center. Seasoned from its participation in
the CMS Group Physician Practice demonstration project
for Medicare beneficiaries, Dartmouth-Hitchcock partnered with Cigna to
create a medical home pilot whose reimbursement structure starts with
quality, not cost. This collaboration with a commercial payor allowed
Dartmouth-Hitchcock to apply lessons learned from the CMS demo as well
as the clinical model it had developed.
Dr.
Walters also shares details on the separate New Hampshire
Citizens Health Initiative, which is readying a multi-site
multi-stakeholder medical home pilot similar to Colorado's. Colorado
even advised New Hampshire during pilot development. The New Hampshire
initiative will launch in 2009 and will provide infrastructure and
practice support for participating practices who have not yet
clinically designed themselves in a medical home model.
This
report also provides details on the following:
- Building
community and legislative support for medical home initiatives;
- What
public and private payors can learn by participating in
multi-stakeholder collaborations;
- Avoiding
the unintended consequences of pay-for-performance models;
- Benefits
of process changes and staff satisfaction that result from medical home
implementation;
- Identifying
early "gets" and long-term gains;
- Value-added
services that a public payor/collaborator can provide;
- The
importance of reviewing antitrust regulations;
- Why
it helps to have physicians at the negotiating table;
- Building
a pilot that stands up to evaluation;
- Importance
of ICD-9 coding in risk-adjusted models;
and
much more.
Table
of Contents
- Reimbursement
Models for Medical Homes: From Pilot to Practice
- Gauging Your Success
- Evolution of the Colorado Pilot
- Enlisting the Physician Champion
- Challenges and Collaborations
- Identifying Early “Gets”
- Alternate Models for Consideration
- Multi-Stakeholder
Collaboration in Medical Home Reimbursement
- Payment Methodologies and Structure
- Payments that Support Care Delivery
- Reimbursement Models That Adjust for Risk
- Avoiding Anti-trust Violations
- Physician-Friendly
Reimbursements: Lessons from a Payor-Provider Partnership
- Learning from Participation in CMS Physician
Group Practice Demo
- Applying
the Medical Home to Commercial Populations
- New Hampshire Citizens Health Initiative
- Q&A:
Ask the Experts
- Establishing Care Management Fees
- Primary Care Practice Transitions
- Template for Financial Model
- Culture Change from Pilot to Practice
- Implications for Medical Malpractice
- Rewards for Preventive Care
- Supporting the Medical Home in Smaller
Practices
- Role of the Nurse/Coach
- Investing in Patient Registries
- Tying Payments to Outcomes and Cost Reduction
- Responding to Public Payor Resistance
- Public Payors
- Pair Provider Partnership Success
- Coding & PCMH Funding
- Already Overloaded PCPs
- Establishing Fee Structures
- Rewarding Participating Physicians
- Patient Communication
- Collaborations in Care Coordination
- Glossary
- For
More Information
- About
the Authors
Publication Date:
November 2008
Number of Pages: 39
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