Some physician practices may consider the transition to becoming a patient-centered medical home (PCMH) to be a rough one, but thanks to the support of both public and private insurers, physicians in one state are moving aggressively to make the model work.
Nurse practitioner Nicole Grimm, R.N., examines a patient at the Family Health Center in Sandpoint, Idaho. The center has been designated a medical home.
In Idaho, two state initiatives are underway: the Idaho Health Home Program(healthandwelfare.idaho.gov) and the Idaho Medical Home Collaborative(imhc.idaho.gov). Although some overlap exists between the programs because Medicaid participates in both of them, they are intended to work in tandem.
But getting them off the ground required a combination of high-level political support from the governor, acceptance of risk by primary care physicians and the willingness of the state's largest private insurers to participate.
Health Home Program
Introduced as a two-year pilot, the Idaho Health Home Program began in 2013 with Medicaid and private insurers. Medicaid pays practices that participate in the initiative a per-member, per-month fee, with a focus on patients with multiple chronic conditions.
- One medical home pilot project was launched with the goal of encouraging physicians to continue accepting Medicaid patients.
- The governor of Idaho lent support to a second medical home project that focuses on patients with chronic conditions.
- Idaho's largest insurers agreed to participate in the projects and agreed on standards of measurement for success.
Initially created to encourage physicians to continue to accept Medicaid patients -- as well as to entice those in practices already considering medical home transformation to move forward -- payments vary based on the complexity of patients' care needs but average between $2.50 and $3.50 per patient. An enhanced monthly payment of $3 or $3.50 is available for clinics that maintain extended hours.
In addition, practices can receive an enhanced payment of $15.50 per month for select patients -- namely, those who are receiving chronic care treatment for asthma, diabetes or hypertension.
A total of 9,100 patients now are enrolled in the program, and 25 primary care organizations offer the medical home model at 51 sites. Currently, more than 90 percent of primary care physicians in the state accept Medicaid patients, and CMS has made a commitment to keeping the medical home program operating indefinitely.
Scott Dunn, M.D., past president of the Idaho AFP, is co-chair of the Idaho Medical Home Collaborative, an initiative that is assisting physician practices as they transform to a medical home. He told AAFP News that he is tracking the progress of both initiatives.
From the family physician's perspective, the daily interaction with patients in a PCMH practice is similar to that in a traditional practice. The chief difference is that in the new model, physicians are able -- and often willing -- to delegate more of the basic care delivery tasks to other team members.
"Before, physicians tended to be controlling and wanted to do everything," Dunn said. "Patients (in a medical home) see the team as more integral to their care rather than always looking to the physician for answers."
Yet despite the change to a team-based approach to care delivery, practices still depend largely on patient volume to operate, according to Dunn. "It doesn't change the overall nature of payment, which is still 99 percent generated by fee-for-service," he said.
Medical Home Collaborative
Gov. C. L. Otter formed the Idaho Medical Home Collaborative in 2010 as a collaboration of primary care physicians, private health insurers, health care organizations and the state's Medicaid program to make recommendations to the governor on the development, promotion and implementation of the PCMH model of care statewide.
Jeremy Waters, M.D., is just one of the physicians on the health care team at the Family Health Center in Sandpoint, Idaho.
In tandem with the Medicaid project, the collaborative involves Medicaid and the three largest private insurers in the state. Payment varies depending on the insurer, but most pay between $15.50 and $22 per-member, per-month. About 6,000 patients -- many of whom also participate in the Idaho Health Home Program -- are enrolled in the collaborative, and 17 primary care organizations offer the medical home model in 34 locations throughout the state.
The collaborative began as a two-year pilot project in January 2013. When the pilot ends this month, the initiative will transition into the Idaho Health Care Coalition, maintaining the same infrastructure and basic operations. The private insurers involved in the pilot have pledged to continue participating in the medical home venture, and practices will begin being paid according to an incentive-based system.
"We are continuing to recruit and expand the model," said Meg Hall, primary care program manager in the Idaho Department of Health and Welfare's Division of Medicaid.
Chicken or Egg?
One initial hurdle that program officials needed to overcome was the risk-averse nature of both physician practices and private insurers, according to Dunn. Physicians did not want to make a financial commitment without some commitment from the payers, who were similarly hesitant to provide upfront funding with no assurance of a return on their investment.
Physicians who operate small practices typically view the medical home skeptically, Hall explained, and question whether a small monthly fee is adequate to achieve the transformation. "Providing financial support for the practice transformation is the No. 1 question we receive," she said, also pointing to other resources that support physician practices in transitioning to the new model, such as a mentoring program and lunchtime lecture sessions.
"We are sensitive to the implementation phase and built requirements into the program that meet the variety of clinic needs, whether it's a one-doc shop or an integrated health system," Hall said. "We were careful not to be too scripted in our program."
For their part, the insurers were hesitant to pony up the initial investment in the practices. "The payers were reluctant to make additional payments without any changes to the practice and some assurance of different outcomes," Dunn said. "We had to have mutual faith, hold hands and jump in together to try this out. It's a pilot."
The program boasts a patient advocacy group on its advisory board that provides feedback on the quality of care provided. Specific patient management expectations are spelled out that practices are expected to meet every six months.
Eighteen quality measures are used to grade performance for practices in the collaborative, and a health data exchange collects all the required quality measures from participating institutions. Full data reports have yet to be released, but ER visits have dropped by 19 percent, according to Hall.
"The reporting of quality measures and reporting expectations are clear," she said. "It is very important. That was a bit of a struggle to collect information for payers."
Getting all the insurers to agree on which quality measures would be used to determine success was another initial hurdle. But Hall said participants have recognized the program cannot work if each insurer insists on practices meeting its own measures.
Physicians considering the model also ask whether it offers long-term financial viability and question if the model will actually reduce costs.
"In making the transformation, hiring a care manager was the major expense," Dunn said. "Some practices took a different approach by moving an existing staff member into the role or hiring someone part-time for the task."
State officials are awaiting response from CMS on their application for an innovation grant that could be valued at $63 million. If Idaho is awarded the grant, the funds would allow officials to expand the PCMH model statewide.
Ends Justify the Means
A supporter of the PCMH concept, Dunn acknowledges all the anticipated fears of his fellow physicians. But he emphasizes that the end result is better care for patients and higher morale among staff members, who are confident they have more resources to meet patient needs.
"The medical home model gets us back to why we went into family medicine in the first place," said Dunn. "There is higher satisfaction among staff and physicians. The patients are reporting higher satisfaction."
Even so, he said, "It doesn't change overnight. The differences are subtle. You interact with patients in different ways."
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