Project showing path to medical home model

While the patient-centered medical home practice model continues to gain momentum, widespread adoption is dependent on restructuring payers' reimbursements. More specifically, in order for the model to work financially for medical practices, it's critical that they be paid for their care coordination, and—so far—a large nationwide experiment is showing that health plans paying per-member, per-month care-management fees may be the way to do this.

The Comprehensive Primary Care Initiative, launched last August by the Center for Medicare & Medicaid Innovation, has the potential to make or break the medical home model. But at least one participant is saying that the demonstration project is living up to its promise of fundamentally changing the economics of primary care.

“By any measure of performance, it's been successful,” said Patrick Gordon, associate vice president of Grand Junction, Colo.-based Rocky Mountain Health Plans and director of the Colorado Beacon Consortium. He adds, however, that it has not been “without some challenges along the way.”

The CPCI involves 502 practices with about 2,150 providers taking care of some 313,000 patients in the project. They are split between seven markets, including Colorado, where 74 practices are participating.

The four-year effort is built on the foundation that around 60% of the patient bases for participating practices will be covered by plans providing per-member, per-month management fees. In the case of Medicare, it will be a risk-adjusted average of $20, with varying fees for Medicaid and other participating private payers.

Medicare's monthly care-management fee will be cut to an average of $15 in years three and four, but providers will be eligible to share in savings they generated for Medicare after the second year. For the first two years of the program, Medicare is making per-member, per-month, risk-adjusted payments of $8, $11, $21 or $40. But, Gordon said, not all payers involved are either providing risk-adjusted payments or paying as high as Medicare.

“I think that there is a lot of variation in payment rates, so some practices are disappointed,” he said.

Also, some practices are not receiving as many payments as they expected from the local population.

Gordon said he received a call from one provider who was expecting monthly fees from Rocky Mountain Health Plans for 1,500 patients, but was only being paid for 1,100 and asked “What happened?”

Gordon said he had to explain to the doctor that, according to data the plan received, those 400 patients have had “zero experience” with him or were receiving healthcare services from someone else. In these cases, Gordon said the plan offers to help with outreach efforts to bring those patients into the practice.

That said, Gordon maintained that he's “still very bullish” on the initiative and so are the providers as they continue to meet milestones and participate in learning collaborations. He gives much credit to the CMS staff for being flexible and customer-service oriented.

He said there was one instance where there was a problem with the sequencing in which physicians were not receiving patient-experience data from Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys in time to file reports and meet milestones. According to Gordon, the CMS revised the sequencing and even e-mailed an apology.

“I've never seen anything like that happen,” Gordon said. “Little things like that keep people at the table.”

Gordon added that he has heard providers praise the format and content of the performance reports the CMS distributes. He said this is providing competitive motivation for Rocky Mountain and other private payers to improve their reports.

In fact, Gordon said he had to ask within his own company “How is it that we're not getting the same love notes as CMS?”