During the past few decades, family physicians increasingly have been challenged to transform the way they deliver care to their patients while still participating in a traditional fee-for-service (FFS) payment environment. However, substantial transformations in health care delivery systems can only be effective if accompanied by the adoption of innovative payment models.
One innovation that is growing in popularity is the blended payment model. In this model, a practice functioning as a patient-centered medical home (PCMH) is paid a combination (i.e., a “blend”) of enhanced FFS payment, incentives for quality performance, and a per member per month (PMPM) care management fee to cover care that falls outside of the traditional office visit.
The term “care management” refers to activities performed by health care professionals with a goal of facilitating appropriate patient care across the health care system. In order to increase patient satisfaction and improve outcomes (e.g., greater adherence to treatment recommendations; more effective self-management; improved health and wellness), care management programs provide services that typically are not reimbursed under traditional, FFS payment models. These services include patient education; medication management and adherence support; risk stratification; population management; and coordination of care transitions; and care planning.
The PMPM care management fee is not intended to defray start-up costs associated with implementing a care management program, nor to provide payment to practices for improved outcomes and/or savings that result from their care management efforts. Such additional payments are an important part of a blended payment model; however, they are distinct from reimbursement for care management services. The American Academy of Family Physicians (AAFP) considers the following eight elements to be core activities covered by a PMPM care management fee within the context of a PCMH.
ELEMENT 1: Nonphysician staff time dedicated to care management
Nonphysician staff can range from a full-time care manager who oversees all care management activities in the practice to part-time staff members who provide one-on-one care management and support to an assigned panel of patients. Patient support can be provided on site or remotely (e.g., via telephone or videoconferencing). Staff members who dedicate time to care management may not necessarily be employees of the practice or work at the practice location. Although many advocates emphasize the need for highly educated care management staff—preferably registered nurses or nurse practitioners—the optimal level of education and prior experience for a care manager is still undefined.
ELEMENT 2: Patient education
Health care professionals provide patient education to promote health literacy (i.e., the ability to understand health-related information and use it to make appropriate decisions about one’s health). Regularly scheduled learning sessions and group visits are examples of innovative approaches that care
management programs use to engage patients, broaden patients’ knowledge base, encourage behavior change, and teach self-management skills.
ELEMENT 3: Use of advanced technology to support care management
Technology enables practices to provide care management for their patients outside of the traditional face-to-face office visit. Advanced communication tools (e.g., secure email, audio, video, web portals) enable more frequent and timely exchange of information between the patient and the care management team.
Patients use in-home electronic devices (e.g., blood glucose meters, weight scales, blood pressure monitors) to collect real-time clinical information that is relevant to managing their care. Telemonitoring devices and services enable patients to transmit information about their vital signs, symptoms, and behaviors (e.g., blood pressure levels, blood glucose levels, exercise logs, medication schedules) directly to their care management team.
ELEMENT 4: Physician time dedicated to care management
Many physicians already spend a substantial amount of time engaged in non-face-to-face care management (e.g., communicating with other health care professionals who provide care for their patients). In addition, physicians often lead or supervise care management services provided by other staff members on the care management team.
ELEMENT 5: Medication management
Each patient participating in a care management program should have an individual medication plan. One aspect of a care manager’s role is to provide education and support to ensure that each patient is capable of adhering to his or her medication plan.
ELEMENT 6: Population risk stratification and management
Care management programs use risk-stratification tools to predict patients’ health care needs and recommend appropriate preventive services and/or chronic care management. These tools take into account information such as a patient’s self-identified health risks, clinical diagnoses, and utilization data
from payers (if available). Electronic health records and disease registries allow practices to monitor the provision of recommended care for each patient on an ongoing basis.
ELEMENT 7: Integrated, coordinated care across the health care system
Integrating other elements of health care (e.g., subspecialty care, home health care, inpatient and outpatient hospital care, behavioral health services) with primary care services is essential for the success of a care management program. A care management program provides the foundation for effective
communication, coordinated treatment, and well-managed care transitions across the “medical neighborhood” to optimize the quality of patient care and reduce unnecessary utilization. These efforts are facilitated by electronic health information exchanges, clinical registries, telehealth and/or telemedicine, and direct communication among health care professionals.
ELEMENT 8: Care Planning
Care management involves establishing, implementing, revising, and monitoring a comprehensive plan of care addressing all aspects of a patient’s health. This care plan should be patient-centered, reflecting the patient’s choices and values, and it should be based on a physical, mental, cognitive, psychosocial, functional, and environmental assessment of the patient as well as an inventory of resources available to the patient.
The AAFP believes that a PMPM care management fee needs to cover the costs to family medicine practices of dedicating staff time, physician time, and advanced technology to provide ongoing patient education, risk stratification, population management, medication management and adherence support, and coordination of care transitions, and care planning. Although additional research is required to determine the most effective and efficient way to implement each care management element in a PCMH, the AAFP believes that a successful care management program incorporates these essential elements. As blended payment models continue to evolve, additional core elements may be identified. (2004) (2016 COD)