Most patient-centered medical homes serving Medicaid patients will not count as an alternative pay model under the final MACRA rule. The efforts, which target beneficiaries with chronic conditions or serious mental illness, aim to improve outcomes and lower costs of treatment by coordinating care. However, the models, now operating in 22 states, have shown mixed results.
Providing Medicaid patients with primary care via a medical home was shown to cut costs of their care by as much as $4,100 a year and lowered their number of doctor visits and hospitalizations, according to a study published in June in the Journal of General Internal Medicine that looked at Medicaid beneficiaries in Pennsylvania. That might not seem like much until knowing that more than 1 million Medicaid beneficiaries are signed up in medical home models around the country, according to the CMS.
The models have also shown to reduce unnecessary ER use.
In the proposed rule, the CMS said it was considering allowing Medicaid medical homes to count as an alternative payment model if participating practices risked at least 4% of their revenue in 2019 and 5% in 2020.
“Medical homes were intended to be a protected group under the (Affordable Care Act) and the assumption of any risk could pose a threat to their viability,” Dr. Robert Wergin, board chair of the American Academy of Family Physicians, said in a comment letter on the proposed rule.
To avoid penalties under MACRA, providers will use either the Merit-based Incentive Payment System, known as MIPS, or an APM that carries significant risk.
Industry stakeholders asked that the CMS strike the minimum risk requirements, while still counting the models as APMs. The AAFP noted that the ACA did not intend for medical homes to assume risk of any amount. However, the CMS points out, participants in Medicaid medical homes will receive full credit in one category of MIPS.
“CMS' failure to make a medical home model available as an APM … would undercut more than a decade of progressive transformation in primary-care practices—not to mention demoralize tens of thousands of primary-care physicians,” Wergin said.
The CMS acknowledged the comments and is finalizing the proposal on minimum risk. The agency said since other doctors participating in eligible APMs are taking on risk, so should physicians in Medicaid medical homes.
“We understand that Medicaid clinicians may have less risk-bearing capacity than other clinicians, particularly in cases in which they serve a relatively high proportion of high-risk patients,” the CMS said in the final rule. “We believe the proposed nominal amount standard allows Medicaid APMs and Medicaid Medical Home Models to create meaningful incentives for improving the care for their populations.”
The decision may repel some providers from participating in the Medicaid medical home model. But Fred Bentley, a vice president at healthcare consulting firm Avalere, believes others will be drawn to the benefit to patients and lower costs for practices.
Others agreed. “I don't think that this is enough to make providers abandon the medical home model.” said Dr. James Becker, medical director of West Virginia's Medicaid program and professor of family medicine at Marshall University in Huntington, adding that private payer support the models.