As State Governments Push Ahead With Health Care Reform, FPs Are Poised to Play Major Role

Family physicians are heavily involved in health care reform efforts on the state level, putting them in a strong position as states begin to implement various provisions of the Patient Protection and Affordable Care Act. That was one of the major themes to emerge from the 2010 AAFP State Legislative Conference and a special preconference seminar on states' roles in implementing health reform held here Nov. 12-13.

Mary Takach, R.N., M.P.H., a program manager for the National Academy of State Health Policy in Portland, Maine, addressed preconference attendees on Nov. 12. She told the audience that she travels throughout the United States as part of her job of advancing patient-centered medical home, or PCMH, initiatives.

"I will tell you that in every state I have traveled to, the state chapter of the Academy of Family Physicians always has been present," said Takach. "Being there at the table, they provide some of the most valuable insight and some of the most important advocacy that has really propelled state medical home initiatives forward."

She noted that states are pushing ahead with primary care initiatives, a trend that is not likely to abate, regardless of what happens with federal health care reform efforts. "States see the potential to bend (the health care) cost curve with more investments in primary care delivery," said Takach.

She noted that, for the most part, states are engaged in five core strategies that promote primary care and the PCMH. These strategies are

"Forming key partnerships is extremely important," said Takach. "Physicians are the most important group states are partnering with. If you are going to ask physicians to do more and change the way they are going to get paid, you better get their buy-in early, or those efforts are going to get greatly stymied. Physician input and their advocacy at the state level is hugely important."

States also are working with private payers to develop multipayer medical home initiatives, an extremely important development, according to Takach.

One of the first steps taken by states and other stakeholders is to define medical home criteria to determine who can be a medical home. Although definitions are nonbinding, they drive the entire recognition process, laying out expectations for payers and physicians alike and influencing payment rates for medical homes. In most instances, payment for the medical home falls into the category of a per-member, per-month fee on top of a fee-for-service payment structure. There also may be additional payments for performance.

Most states use criteria established by the National Committee for Quality Assurance, or NCQA, as a basis for recognizing a PCMH. Some states, such as Maine, Maryland and Pennsylvania, have modified the NCQA's standards to make them more stringent. Other states, such as Minnesota, Nebraska, North Carolina, Oregon, Texas and Washington, have developed their own recognition criteria for the PCMH because they "don't believe the (NCQA standards) are patient-focused enough or friendly to nurse practitioners," said Takach.

"The NCQA is in the process of revising their standards and will come out with new ones in January," she said.

Takach, meanwhile, urged conference attendees to remain active at the state level. "Know what your states are doing around medical home initiatives, know what they are requiring for recognition," she said. "If you have not aligned your own practices with your state medical home initiatives, you probably want to do that. Your payment, particularly for Medicaid patients, is going to hinge on whether you are recognized."

Specific state-level multipayer medical home initiatives were featured during the conference. For example, Chris Koller, commissioner of health insurance for Rhode Island, told attendees about his state's Chronic Care Sustainability Initiative, or CSI Rhode Island, which includes 13 practices and 47,000 patients.

All of the physician practices in the initiative are recognized as Level 1 medical homes by the NCQA, and all of them receive a per-member, per-month fee for their patients, as well as additional funds for nurse care managers.

Koller emphasized that CSI Rhode Island is a multipayer project, involving the state's three commercial payers, Medicaid fee-for-service and a Medicaid managed care plan. "We have identical contracts across all payers and providers," he said. CSI Rhode Island also employs common utilization and quality measures for all participating practices.

According to Koller, some of the accomplishments of CSI Rhode Island are that the program has led to enhanced care coordination, better patient engagement and higher quality. It also relies on advanced health information technology to better manage populations.

"It is pretty compelling when you have primary care docs telling politicians that 'For the first time, I have hope for my practice,'" Koller said.