AAFP Calls for Changes in Proposed Medical Home Legislation

The AAFP has raised concerns about a bill that would provide a patient-centered medical home for some Medicaid recipients and others, saying that key provisions of the legislation should be changed.

Sens. Richard Durbin, D-Ill., and Richard Burr, R-N.C., recently introduced the legislation, S.B. 2376 (at the THOMAS Web site, type "S 2376" in the search box after selecting "Bill Number"), which would create a medical home demonstration program for certain beneficiaries enrolled in Medicaid and the State Children's Health Insurance Program, or SCHIP.

Under the legislation, Medicaid and SCHIP beneficiaries without a regular source of care would be assigned to medical homes with primary care physicians who would be responsible for managing and coordinating their care. The legislation also would create local medical management committees to establish standards and measures for patient-centered medical homes and, in addition, would pay each participating physician practice a minimum management fee of $2.50 per member per month for serving as a patient-centered medical home.

AAFP Board Chair Rick Kellerman, M.D., of Wichita, Kan., in a Nov. 14 letter (2-page PDF: About PDFs) to Durbin and Burr, praised the legislation's "emphasis on primary care as the principal site of the patient-centered medical home," noting that the bill "requires the medical home to be physician-directed."

"The evidence pointing to better health outcomes and reduced costs includes both factors," said Kellerman.

He pointed out, however, that the success of the medical home depends on how it is defined and "the tools available to implement the concept."

The Senate legislation is based, to a large extent, on the Community Care of North Carolina program, which employs physician-led networks and patient-centered medical homes to improve care and save costs. For example, the Durbin-Burr legislation sets a minimum care management fee of $2.50 per patient per month, which is the same amount paid to physicians under the North Carolina program.

"We appreciate the fact that the legislation is attempting to set a floor for this necessary payment for care management within the patient-centered medical home, but the bill does not provide the states or the CMS with guidance for determining how much this fee should be," wrote Kellerman. "As a result, states are likely to use this floor as the payment amount."

Each state, Kellerman said, should determine the fee based on a recommendation from a value-determination team comprised of a CMS representative and representatives from each of the primary care physician organizations in the state.

The legislation also seeks to localize the decision-making process in an attempt to emulate the success of the North Carolina program. It gives medical management committees the authority to define the patient-centered medical home, but does not require those committees to base the definition on any national standard, creating the possibility that differing definitions of the medical home could emerge. Such an eventuality could require physicians to respond to "multiple sets of different requirements," Kellerman wrote.

"The four organizations with primary care physicians (i.e., the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association) have been concerned about the emergence of differing definitions of a medical home, many prompted by specific disease management companies or insurance plans for purposes unrelated to improved health care," Kellerman said.

The AAFP and the three other organizations worked with the National Committee for Quality Assurance, or NCQA, to develop a single set of standards for the recognition of physician practices as patient-centered medical homes.

"We would suggest that the legislation at least require the local medical management committees to automatically deem a physician practice to be a qualified medical home if it has achieved recognition by NCQA or other national standard setting organization," said Kellerman. "Our preference would be to avoid having the medical management committees reinventing the wheel by simply making the NCQA standards the minimally acceptable standards for a patient-centered medical home designation."

Similarly, the legislation also should require the medical management committees to base their performance standards for the medical home on the list determined by the Physician Consortium for Performance Improvement, those endorsed by the National Quality Forum and those chosen for primary care implementation by the Ambulatory Care Quality Alliance.

"This process creates a single, reliable, evidence-based list of performance measures," Kellerman explained. Although "it is important to adapt the patient-centered medical home to local conditions, it is perhaps unrealistic and certainly unnecessary to ask the local medical management committees to undertake the expensive and time-consuming process of setting their own performance standards," he said.

The legislation also seeks to encourage the use of health information technology by providing a monthly state payment of $2.50 per targeted beneficiary to the steering committee for the purchase of health information technology, among other things.

"Given the significant barriers represented by the cost of installation and maintenance of electronic health records, this amount may be inadequate for the stated purpose," Kellerman said.

In addition, although the legislation's medical home program would be physician-driven, the bill does not specify the exact composition of the medical management committee, prompting concerns from the AAFP.

"This committee, like the steering committee, should be required to have mostly primary care physicians," Kellerman said.