BUILDING MEDICAL HOMES: LESSONS FROM EIGHT STATES WITH EMERGING PROGRAMS Neva Kaye, Jason Buxbaum, and Mary Takach National Academy for State Health Policy December 2011 ABSTRACT: Many states are strategically engaging public and private payers in the design of medical home programs as a means of achieving better health outcomes, increasing patient satisfaction, and lowering per capita health care costs. The eight states profiled in this report— Alabama, Iowa, Kansas, Maryland, Montana, Nebraska, Texas, and Virginia—are at different stages in the development and implementation of a medical home program and have relied on different strategies to encourage primary care providers to adopt the model, including developing state medical home qualification standards instead of adopting national standards. As a whole, their experiences demonstrate that states can play a critical role in convening stakeholders, helping practices improve performance, and addressing antitrust concerns that arise when multiple payers come together to create a medical home program. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1569. CONTENTS About the Authors .............................................................................................................. iv Acknowledgments ............................................................................................................... v Executive Summary............................................................................................................ vi Introduction ......................................................................................................................... 1 Methods of Strategically Engaging Partners ....................................................................... 5 Engaging Multiple Payers ............................................................................................. 6 Setting Performance Expectations and Implementing a Process to Identify Practices That Meet Expectations ...................................................................... 8 Defining the Medical Home .......................................................................................... 8 The Qualification Process.............................................................................................. 9 Balancing the Desire for Improved Performance Against the Cost of Improvements ................................................................................................. 10 Compensating and Motivating Practices Through Enhanced Payment ............................ 12 Using Payment to Reward More Capable and Better-Performing Medical Homes ............................................................................................................ 13 Using Payment to Foster Links Between Primary Care and Other Service Providers ............................................................................................... 13 Helping Practices Meet Expectations and Improve Performance ..................................... 14 Providing Support for Care Coordination ................................................................... 15 Evaluating Program Performance...................................................................................... 16 Seeking to Ease the Evaluation Burden for Medical Home Providers ........................ 17 Summary............................................................................................................................ 18 Appendix. Medical Home Programs in Second Consortium States .................................. 19 Notes .................................................................................................................................. 21 iii ABOUT THE AUTHORS Neva Kaye is managing director for health system performance at the National Academy for State Health Policy (NASHP), where she manages major programs on Medicaid, directs the Assuring Better Child Health and Development program, and the State Consortium to Advance Medical Homes for Medicaid and Children’s Health Insurance Program Participants. She provides technical assistance to states in such areas as children’s health, purchasing, quality improvement, eligibility, and reimbursement strategies. Ms. Kaye has over 25 years of experience in state health policy. She joined NASHP in 1994 as director of the organization’s Medicaid Resource Center. Before joining NASHP, Ms. Kaye served as director of Wisconsin’s Medicaid managed care program. Jason Buxbaum is a policy analyst at NASHP, where he focuses on state efforts to improve primary care, especially through the medical home model. He also works on quality improvement, patient safety, and general health reform issues. Prior to joining NASHP in 2009, Mr. Buxbaum worked as an analyst with The Mellman Group. He has interned with the Maine Governor's Office of Health Policy and Finance and the U.S. Equal Employment Opportunity Commission. Mr. Buxbaum graduated Phi Beta Kappa and cum laude from Bates College in 2008, receiving a B.A. in political science and sociology. Mary Takach, M.P.H., is program director at NASHP, where she directs policy research focused on primary care, specifically patient-centered medical homes, health homes, federally qualified health centers, and delivery system issues. She is the lead researcher on a Commonwealth Fund multiyear project that is helping states advance medical homes in their Medicaid and Children’s Health Insurance Programs. Ms. Takach is also directing NASHP’s efforts in the five-year evaluation of the Multi-Payer Advanced Primary Care Practice Demonstration for the Centers for Medicare and Medicaid Services in partnership with RTI and the Urban Institute. She has a background in health policy and clinical care and has worked on Capitol Hill as a legislative assistant to two congressmen. She also worked in a wide variety of health care settings for nearly 15 years as a registered nurse. Ms. Takach holds a master’s degree in public health from the Johns Hopkins Bloomberg School of Public Health and a bachelor of science in nursing degree with honors from Northeastern University. iv ACKNOWLEDGMENTS The authors wish to thank the eight state teams that participated in the Second Consortium to Advance Medical Homes for Medicaid and CHIP Participants. Their diverse and impressive range of accomplishments reflects their commitment, talent, and dedication to building better health care systems. The authors also gratefully acknowledge their review of a draft of this report in November 2010. Core team members included: • Alabama—Cathy Caldwell, Y. Paige Clark, R.N., Kim Davis-Allen, Marsha Raulerson, M.D., and Robert Moon, M.D. • Iowa—David Carlyle, M.D., Bery Engebretsen, M.D., Thomas Evans, M.D., Beth Jones, and Jennifer Vermeer • Kansas—Susan Kang, Barbara Langner, M.D., Elizabeth Peterson, M.D., and Margaret Smith, M.D. • Maryland—John Folkemer, Virginia Keane, M.D., Karen Rezabek, Tricia Roddy, Ben Steffen, and Grace Zaczek • Montana—Mary Dalton, Rachel Donahoe, Michael Huntly, R.N., Mary LeMieux, Mary Noel, Wendy Sturn, and Nancy Wikle • Nebraska—Joan Anderson, Nebraska State Senator Mike Gloor, Jenifer Roberts- Johnson, Pat Taft, and Robert Wergin, M.D. • Texas—Michelle Erwin, Anita Freeman, Jose Gonzalez, M.D., Lesa Walker, M.D., and Leslie Weems • Virginia—Colleen Kraft, M.D., Tom Lawson, Meredith Lee, Daniel Plain, David Selig, and Bryan Tomlinson The authors also thank the officials from leading states who served as mentors, as well as the experts who gave generously of their time to consult with the second consortium states. Their efforts had significant impact, and helped make the progress of the second consortium states possible. The authors thank Charles Townley, research assistant at NASHP, for helping to edit and research this paper. Finally, the authors thank Melinda Abrams and The Commonwealth Fund for making this work possible. Ms. Abrams’ guidance proved invaluable throughout the project, and her assistance is gratefully acknowledged. Editorial support was provided by Sarah Klein. v EXECUTIVE SUMMARY There have been numerous efforts by payers and providers to improve patient access to high-functioning medical homes—an enhanced model of primary care that offers whole-person, comprehensive, ongoing, and coordinated patient- and family- centered care. Public payers, especially Medicaid, have been leaders in these efforts, with the hopes of preventing illness, reducing wasteful fragmentation, and averting the need for costly emergency department visits, hospitalizations, and institutionalizations. With the support of The Commonwealth Fund, the National Academy for State Health Policy (NASHP) has fostered these efforts through the Consortia to Advance Medical Homes for Medicaid and CHIP Participants. In 2007–09, NASHP provided its first round of assistance to eight states—Colorado, Idaho, Louisiana, Minnesota, New Hampshire, Oklahoma, Oregon, and Washington—that were seeking to build medical homes in their Medicaid and CHIP programs. This assistance consisted of an in-person kick-off meeting, a series of regular group technical assistance webinars, and ongoing individualized consultation with experts. Drawing on the combined experiences of these states and a small group of states that already had programs, NASHP developed a framework that other states could follow to implement medical home programs. The framework consists of five broad steps: 1. Strategically engage partners. 2. Set performance expectations and implement a process to identify practices that meet expectations. 3. Compensate and motivate practices through enhanced payment. 4. Help practices meet expectations and improve performance. 5. Evaluate program performance. In 2009–10, NASHP supported the efforts of a second group of states—Alabama, Iowa, Kansas, Maryland, Montana, Nebraska, Texas, and Virginia—as they sought to develop new medical home programs. The work of these states reinforced the importance of following the five key steps. From this work a number of common themes emerged, which are of relevance to states that are considering or are already promoting medical homes. vi • Tailoring the definition of “medical home” to reflect state needs, priorities, and circumstances. As they craft their definitions, state policymakers are frequently looking to national definitions and other states’ existing definitions to conceptualize their priorities. For example, Montana’s definition emphasizes the importance of culturally effective, community-based care. • Using payment policy to foster collaboration among primary care and specialty care physicians, as well as other service providers. As an example, Iowa is paying primary care providers for remote consultations with hospital- based specialists, while Alabama is paying more to practices that collaborate with their local community networks. The Alabama networks will help practices function as medical homes. Among other responsibilities, network staff will help primary care providers coordinate care for high-need and high-risk patients and teach self-management skills. • Using payment policy to reward more capable and better-performing medical homes. State medical home programs are rewarding practices that meet more demanding standards—such as effectively using a registry—with higher medical home payments. They are also distributing savings based on practice performance, with greater shares going to those that perform better on preselected performance measures. • Helping practices improve performance. In addition to offering enhanced payment, states are supporting practices by providing electronic health record systems, registries, and data as well as support in implementing these new tools. They are also offering learning collaboratives to bring teams from practices together to work toward common improvement goals and deploying coaches to help practices become high-performing medical homes. • Providing support for care coordination. States use various strategies to help primary care providers improve care coordination. Some states are explicitly directing participating practices to use a portion of their medical home payments to hire staff who coordinate care. Other states are developing community resources that link practices and patients to other services in the community and augment the primary care providers’ care coordination activities. • Easing the evaluation burden for medical home providers. Although there is evidence that medical homes improve quality and contain costs in Medicaid, each state needs to assess whether the medical home—as implemented in their state— succeeds. States are looking to assess improvements within primary care practices by monitoring changes in acute care utilization, cost containment, and patient and vii provider experience. When possible, medical home programs are relying heavily on data collected as a function of providing and paying for services (e.g., claims data) in their evaluation designs. This minimizes the extra reporting work that practices must do. Initiatives are also drawing measures from national data sets and incorporating information that practices must already report to other programs. • Basing medical home qualification criteria on models established by a national organization. State medical home programs need ways to translate their medical home principles into concrete, measureable expectations. To that end, many states are convinced that there is value in leveraging national medical home qualification processes, such as those administered by the National Committee for Quality Assurance (NCQA) or the Joint Commission. Some states are adopting national qualification standards outright, while others are modifying them. Using national standards leverages investments made by widely known, respected, neutral organizations and eliminates the need to devote limited resources to developing and administering a new recognition process. • Balancing the desire for improved performance with the cost of the improvements. The start-up and ongoing costs associated with transforming a standard primary care practice into a high-performing medical home can be significant for both practices and payers. Accordingly, some program leaders focus their resources on a limited number of practices at the start of a program and/or allow practices to receive medical home payments for a limited period before they achieve formal medical home recognition. • Addressing antitrust concerns that arise when multiple payers come together to create a medical home program. States that are seeking to build multipayer programs have critical roles to play in providing antitrust protection for interested private payers, and they have multiple options for providing this protection. In many cases, neutral state agencies are supervising sensitive meetings. Additionally, states are enacting legislation that explicitly provides antitrust protection. The state profiles contained in this report demonstrate that states can move forward with plans to improve primary care systems, even in the face of unprecedented budget constraints. The design of their projects has been greatly informed by the work of states that have already implemented medical homes. At the same time, states are innovating and learning lessons that can serve to advance the broader field.     viii BUILDING MEDICAL HOMES: LESSONS FROM EIGHT STATES WITH EMERGING PROGRAMS INTRODUCTION There have been numerous efforts by What  Is  a  Medical  Home?   payers and providers to improve patient According  to  the  four  major  primary  care  physician   access to high-functioning medical associations,  care  in  the  medical  home  is  guided  by  the   2 following  principles:   homes—an enhanced model of primary  Continuity—each  patient  has  an  ongoing,  personal   care that offers whole-person, relationship  with  a  physician   comprehensive, ongoing, and coordinated  Team-­‐based  care—collectively,  a  physician-­‐directed   patient and family-centered care. There team  assumes  responsibility  for  patient  care    Whole  person  orientation—the  care  team  ensures   are now pilots or programs in the private that  all  patient  needs  are  met,  whether  or  not  each   and public sectors, as well as a growing specific  service  is  offered  by  the  practice   number of multipayer initiatives that  Coordination—the  medical  home  team  organizes     include both public and private payers. a  patient’s  care  across  the  “medical  home   neighborhood,”  and  leverages  nonmedical  supports   For instance, the Medicare program is and  services  when  appropriate   also joining eight states to participate in  Quality  and  safety—the  medical  home  practice   their multipayer, public–private medical engages  in  continuous  quality  improvement,  draws  on   evidence-­‐based  guidelines,  reports  on  performance,   home projects.1 States have led many of promotes  patient  engagement,  and  uses  health   these efforts and made major information  technology  as  appropriate   contributions to others. More than three-  Enhanced  access—first-­‐contact  and  ongoing  care  is   quarters of all states have now made accessible  to  patients   efforts to advance medical homes for Medicaid or Children’s Health Insurance Program (CHIP) enrollees (Exhibit 1). Some of these states have well-established, mature programs that serve hundreds of thousands of patients, while others are just getting started. This interest in the medical home model has much to do with promising data that link medical homes to improvements in access to care, quality outcomes, patient and family experience, and provider satisfaction. In addition to these benefits, payers, purchasers, and policymakers are intrigued by the model’s potential to produce significant savings.3 Since 2007, the National Academy for State Health Policy (NASHP), with support from The Commonwealth Fund, has fostered and studied state efforts to advance medical homes. Through the Consortia to Advance Medical Homes for Medicaid and CHIP Participants, NASHP has identified 41 states that have engaged in some effort to 1 Exhibit  1.  The  states  shown  in  red  have  dedicated  resources  to  advancing  medical  homes     for  Medicaid  and/or  CHIP  enrollees  between  January  2006  and  September  2011.   advance medical homes since 2006.4 In 2007–09, the organization worked with a small group of states—Colorado, Idaho, Louisiana, Minnesota, New Hampshire, Oklahoma, Oregon, and Washington—to identify the strategies they used or planned to use to improve the access of Medicaid and CHIP participants to high-performing medical homes.5,6 NASHP identified five key steps for advancing medical homes, which together form a framework that states can use to develop and implement medical home programs: 1. Strategically engage partners. 2. Set performance expectations and implement a process to identify practices that meet expectations. 3. Compensate and motivate practices through enhanced payment. 4. Help practices meet expectations and improve performance. 5. Evaluate program performance. From 2009 to 2010, NASHP worked intensively with teams from a second set of states—Alabama, Iowa, Kansas, Maryland, Montana, Nebraska, Texas, and Virginia—to use this framework to accelerate and guide the development and implementation of their 2 medical home programs. These eight states that make up the second consortium were selected through a competitive process that focused on their readiness for making improvements and commitment to doing so. The states received a program of technical assistance designed by NASHP that was based on the previously described framework— and delivered by NASHP staff, the teams’ peers in other states (including those pioneers whose early efforts led to the creation of the framework), and other experts. This assistance consisted of an in-person kick-off meeting, a series of regular group webinars with national experts and federal officials, and ongoing individualized consultation with state and national experts. This second consortium of states adopted some of the policy options implemented by the pioneer states, and each also developed new options for implementing the five key strategies for advancing medical homes. This report focuses on the lessons they learned. For background, the Appendix presents basic information on each project. Additional information on each state’s project is available online at http://www.nashp.org/med- home-map. In many instances, the second consortium states are following trails blazed by Colorado, Maine, Minnesota, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, and Vermont. Many of these states have developed medical home models that are showing early signs of success in three critical dimensions: quality, access and utilization, and cost. In terms of quality, several mature state medical home projects are reporting improvements in rates of adherence to evidence-based guidelines. • A 2009 study found that practices participating in the Vermont Blueprint for Health improved their performance on process measures such as lung-function assessment for patients with asthma and self-management goal-setting for patients with diabetes. Control practices did not show similar improvements.7 • A 2011 report showed that North Carolina’s medical home program, Community Care of North Carolina, ranks in the top 10 percent in performance on national quality measures for diabetes, asthma, and heart disease compared with Medicaid managed care organizations.8 • Oklahoma’s SoonerCare Choice medical home program has seen improvements in Healthcare Effectiveness Data and Information Set (HEDIS) quality measures—including increases in rates of HbA1c screenings for diabetics, 3 breast cancer screenings, and cervical cancer screenings—since implementing a medical home program in January 2009. Performance in 2009 and 2010 was better than performance in 2008.9 • Practices participating in Rhode Island’s Chronic Care Sustainability Initiative (CSI-RI) improved performance on process measures such as depression screenings and appropriate use of beta blockers between 2008 and 2009.10 Many states are hoping their medical home projects will improve access to and increase appropriate use of primary care. So far: • Oklahoma saw complaints to the agency about access to same-day or next-day care decrease from 1,670 in 2007 (the year prior to medical home implementation) to 13 in 2009 (the year following implementation).11 • A 2009 study found that 72 percent of children in Colorado’s medical home practices had had well-child visits, compared with 27 percent of children in control practices.12 States are also seeing decreases in acute care utilization, especially avoidable hospitalizations and emergency department visits. • In the Vermont Blueprint for Health’s two longest-running pilot communities, Medicaid saw 21.3-percent and 19.3-percent decreases in the rate of change of emergency department visits between pilot launch in 2008 and June 2010. These decreases were greater than the decreases observed statewide.13 • Inpatient hospital admissions for aged, blind, and disabled (ABD) Medicaid beneficiaries participating in Community Care of North Carolina decreased 2 percent between 2007 and the middle of fiscal year 2010. Inpatient hospital admissions for the unenrolled ABD Medicaid population increased 31 percent over the same time period.14 Some state medical home initiatives are now reporting cost savings, largely because of averted acute care utilization. • Vermont’s Blueprint for Health has seen cost savings in the longest-running pilot community, St. Johnsbury. There, overall per-person per-month costs for commercially insured individuals decreased by approximately 12 percent from 2008 to 2009. The second Blueprint for Health community, Burlington, has 4 shown an increase in costs of less than 1 percent over the same period.15 Information on cost savings is not yet available for the other pilot communities. • According to an analysis prepared by Treo Solutions, Community Care of North Carolina saved nearly $1.5 billion in costs between 2007 and 2009.16 • An evaluation of the Colorado Medical Home Initiative found a 21.5 percent reduction in median annual costs for children with a medical home ($785, compared with $1,000 for non-PCMH children) in 2009.17 • Oklahoma saw a decline in per capita expenses of $29 per patient per year from 2008 to 2010.18 As detailed in the following sections of this report, the second consortium states used models that have adapted many features of the leading states’ models and others to suit their specific needs, circumstances, and preferences. There is a great deal for policymakers in other states to learn by studying these unique, emerging projects. METHODS OF STRATEGICALLY ENGAGING PARTNERS Implementing a medical home program changes how primary care and other providers deliver services, how patients obtain services, and how Medicaid (and sometimes other payers) reimburse for services. Early adopters of the medical home model, Leading  State  Profile:  Colorado   such as Colorado and Oklahoma, have 19 As  mandated  by  2007  legislation,  the  Colorado  Medical   found that engaging stakeholders in Home  Initiative  has  established  a  statewide  medical  home   program design enabled the agencies to program  for  children  enrolled  in  Medicaid  and  the   Children’s  Health  Insurance  Program  (CHIP).  The  Colorado   make choices that achieve agency goals Department  of  Public  Health  and  Environment  leads  the   and enjoy stakeholder support. In project,  drawing  on  input  from  task  forces  and  providers.   addition, other partners can bring The  program  pays  qualified  medical  homes  an  enhanced   important resources to the table. Leading fee-­‐for-­‐service  visit  rate  for  select  well-­‐child  services.   Providers  receive  on-­‐site  assistance  in  undergoing  a     states such as Vermont and Minnesota state-­‐developed  qualification  process  that  includes   have found that universities bring requirements  to  undergo  quality  improvement  projects.   valuable expertise to their initiatives, There  is  no  requirement  that  providers  use  electronic   health  records.  The  state  conducts  annual  audits  of   particularly around evaluation. Leading 20 providers  to  ensure  compliance.   states have also found that their local physician chapters can serve as a valuable resource. For instance, Oklahoma’s chapter of the American Academy of Family Physicians provided an important communication link between Medicaid and physicians when Oklahoma launched its medical home initiative. 5 All eight second consortium states learned from their predecessors’ experiences and formed new stakeholder groups (or enhanced existing ones) to help plan their new initiatives. All of these groups included physicians. Most also included other providers, patients or advocates, commercial insurers, and other state agencies, such as public health agencies. These stakeholder groups engaged in two distinct activities: 1. Designing the program: In Montana, for example, a diverse stakeholder group composed of Medicaid, commercial insurers, provider organizations, the state- employee benefits group, and others developed the state medical home definition and reached consensus on the process for recognizing which practices meet that definition. 2. Building public support: Alabama’s stakeholder group was instrumental in building broad support for developing community networks to support primary care practices. The Alabama Medicaid program partnered with its physician-based advisory group to organize town hall meetings with local providers to gather their input and to build momentum for buy-in. Stakeholder meetings are important for gathering input to guide program development, but states also used other strategies to seek input from wider audiences. For example, Maryland held a series of provider symposia21 and most the states in this group established public Web sites.22 Engaging Multiple Payers A NASHP review of all states’ Medicaid medical home efforts in 2009 revealed that at least 12 states were actively planning or pursuing multipayer projects.23 In eight of these states, Medicare has also joined these efforts.24 Multipayer projects are advantageous because they reduce the administrative burden on primary care practices by creating consistent goals, expectations, and payment policies. Multipayer projects also spread transformation costs among all payers seeking to improve both quality and costs. Maryland and Montana are participating or plan to participate in multipayer projects. Like most of the leading multipayer states, they sought to avoid antitrust concerns, which can occur when payers gather to discuss common payment terms. A state’s ability to address antitrust issues is a unique and important contribution to multipayer initiatives. These states’ actions illustrate two options to address antitrust concerns. 6 Leading  State  Profile:  New  York   State serves as a neutral New  York’s  Adirondack  region  encompasses  a  land  area   convener: Similar to the role of the the  size  of  Connecticut,  but  contains  a  fraction  of   Rhode Island Health Insurance Connecticut’s  population.  The  area  faced  an  impending   Commissioner, the Montana primary  care  workforce  shortage,  and  payers  and  other   stakeholders  also  wanted  to  improve  quality  and  slow  cost   Commissioner of Securities and growth.  Medical  homes  were  seen  as  a  solution.   Insurance is planning and Legislation  created  the  Multipayer  Demonstration,  and   convening a multipayer effort in provided  antitrust  protection  for  commercial  payers  to   Montana. Montana’s commissioner work  together  on  a  common  payment  methodology.   Medicaid  and  the  commercial  payers  began  making   took over the leadership role from payments  in  2010;  CHIP  plans  and  Medicare  fee-­‐for-­‐service   Medicaid for its multipayer joined  in  2011.  Practices  are  expected  to  meet  modified   medical home effort in September NCQA  standards,  and  each  practice  has  developed  a   customized  work  plan  for  transformation.  Practices  are   2010. This strategic decision to receiving  health  information  technology  implementation   develop the program through a assistance,  practice  coaching,  and  care  coordination   state-led process can help provide services  from  shared  health  teams  known  as  “pods”  to   26 assurances that antitrust concerns assist  them  in  functioning  as  medical  homes.  New  York  is   also  pursuing  a  Medicaid-­‐only  medical  home  program   are being addressed, enabling the outside  of  the  Adirondack  region.   27 payers and providers to work together to reach common goals. State legislation: Maryland’s governor tasked the Maryland Health Care Commission (a state agency that does not, itself, pay for services) to work with the Medicaid agency to develop and implement the medical home program. These agencies worked to engage commercial insurers, Medicaid managed care plans, and other stakeholders in their efforts. Both the Medicaid plans and commercial insurers raised concerns that a joint payment model for Leading  State  Profile:  Rhode  Island   medical homes would violate federal Rhode  Island’s  Chronic  Care  Sustainability  Initiative,  first   antitrust law. Like legislative efforts in launched  in  October  2008,  is  unique  among  established   Minnesota, New York, and Vermont, the programs  in  that  the  Office  of  the  Health  Insurance   2010 Maryland legislature passed Commissioner  has  taken  the  lead  in  convening  the  pilot.   SB855/HB929 to provide the antitrust Participating  payers  now  include  Medicaid  managed  care   plans,  all  state  regulated  commercial  insurers,  several  large   protection that Maryland payers needed employers,  and  Medicare  Advantage  plans.  Medicare  fee-­‐ to participate in this pilot.28 (The for-­‐service  is  joining  as  well.  Practices  are  expected  to   legislation also required all payers with meet  NCQA  standards  and  participate  in  a  learning   collaborative.  In  exchange,  practices  receive  a  flat  per-­‐ premium revenues of over $90 million to member  per-­‐month  fee  (in  addition  to  standard  payments)   participate.29) as  well  as  the  support  of  on-­‐site  nurse  care  managers.   25 7 SETTING PERFORMANCE EXPECTATIONS AND IMPLEMENTING A PROCESS TO IDENTIFY PRACTICES THAT MEET EXPECTATIONS A majority of the leading states and the second consortium states began their medical home journey by reaching agreement on a definition of a medical home to clearly establish the vision of what one is and what it should do. Qualification processes establish concrete performance expectations to let practices know what they need to do to meet that vision. Together, definition and qualification standards should: • Establish common principles and terms to build a medical home initiative; • Establish concrete expectations for practices, providers, and patients; • Reassure payers that practices that receive enhanced payments are providing high- quality primary care; and • Reassure practices that investments they make to improve the way they deliver care will be rewarded. Defining the Medical Home Among the second consortium states, all but Virginia have developed their own state-specific definition rather than adopt a national one. All align with the national definitions, including those developed by the American Academy of Pediatrics and the organizations that created the Joint Principles of the Patient Centered Medical Home.30,31,32 Most wanted a definition firmly rooted in local values and standards of practice. Two examples of state-specific definitions follow. • Kansas: ‘‘Medical home’’ means a health care delivery model in which a patient establishes an ongoing relationship with a physician or other personal care provider in a physician-directed team, to provide comprehensive, accessible and continuous evidence-based primary and preventive care, and to coordinate the patient’s health care needs across the health care system in order to improve quality and health outcomes in a cost-effective manner.33 • Montana: A patient-centered medical home is health care directed by primary care providers offering family-centered, culturally effective care that is coordinated, comprehensive, continuous, and, when possible, in the patient’s community and integrated across systems. Health care is characterized by enhanced access, an emphasis on prevention, and improved health outcomes and satisfaction. Primary care providers receive payment that recognizes the value of medical home services.34 8 The Qualification Process Leading  State  Profile:  Maine   Seven out of eight second consortium Maine’s  multipayer  Patient-­‐Centered  Medical  Home  Pilot   states and all of the leading states have includes  the  participation  of  the  state’s  major  commercial   adopted or plan to adopt medical home payers  and  Medicaid.  Medicare  fee-­‐for-­‐service  will  begin   making  payments  in  2012.  The  project  conveners   qualification standards to support their conducted  consumer  focus  groups  and  maintained  a   initiatives. The qualification processes diverse  working  group  to  ensure  the  program  was   selected by these states fall into one of responsive  to  stakeholder  priorities.  Practice  transforma-­‐ tion  support,  which  now  includes  a  learning  collaborative   three categories. and  coaching,  started  in  2009.  Per-­‐member  per-­‐month   payments  began  shortly  thereafter.  As  a  condition  of   Use of a process established by participation,  practices  are  expected  to  achieve  NCQA   a national organization: There are recognition  and  meet  10  additional  core  expectations,   which  include  reducing  waste  and  partnering  with  local   currently several national organizations public  health  organizations.   40 that have developed medical home qualification criteria. These organizations include the National Committee for Quality Assurance (NCQA),36 The Joint Commission,37 the Accreditation Association for Ambulatory Health Care (AAAHC),38 and URAC (formerly the Utilization Review Accreditation Commission).39 Like many of the leading states, Leading  State  Profile:  Vermont   including Rhode Island and Vermont, Under  Vermont’s  multipayer  Blueprint  for  Health,  all     Iowa has decided to use recognition state-­‐regulated  payers  and  Medicare  offer  enhanced   standards developed by NCQA. (The reimbursement  to  practices  that  meet  NCQA  standards.   Joint Commission’s process was not Recognized  practices  in  pilot  communities  receive  per-­‐ member  per-­‐month  payments  in  addition  to  standard  fee-­‐ completed at the time Iowa established for-­‐service  reimbursement.  In  addition,  all  payers  share  in   this policy, but providers in Iowa can now the  costs  for  local  community  health  teams  that  support   choose to use that standard.) Virginia is patients  and  practices  through  services  such  as  health  and   also considering this approach. Among wellness  coaching  and  care  management.  Policymakers   have  found  the  early  results  sufficiently  compelling  to   other reasons, both states found using mandate  statewide  expansion  by  October  2013.   35 national processes attractive because they leverage investments made by widely known, respected, neutral organizations and eliminate the need to devote limited resources to developing and administering their own recognition process. Modification of a process established by a national organization: Two second consortium states (Maryland and Montana) have adopted or plan to adopt the NCQA medical home standards with modifications, an approach pioneered by the leading states of Maine, New York (Adirondack region), and Pennsylvania. All of these states are involving commercial payers, and they recognize that their commercial partners are 9 generally familiar with NCQA and receptive to using the program. But these states value customization. Maryland, for example, is requiring practices to meet some NCQA elements that are optional under NCQA, such as having dedicated staff who work with patients on treatment goals, assess patients’ barriers to meeting their goals, and follow-up with patients after visits; providing 24-hour phone response for urgent needs; performing medication reconciliation at every visit; and maintaining a patient registry that identifies care opportunities and diagnoses. The elements were selected based on their potential for reducing acute care utilization—an outcome of great interest to payers. Creation of a process administered by the state: Kansas, Nebraska, and Texas took their cues from states such as Colorado and Minnesota in developing their own state medical home qualification standards. Their decision frequently arose out of concerns that national standards are too demanding and costly and thus discourage practice participation. There may also be concern that national tools may not be rigorous enough or may not sufficiently emphasize important elements such as patient-centeredness. Balancing the Desire for Improved Performance Against the Cost of Improvements Meeting qualification criteria, regardless of the process, almost certainly requires an investment by practices. Paying practices for meeting those criteria requires an investment by the state and any other partnering payers. States, providers, Leading  State  Profile:  Minnesota   and other payers (if applicable) need Minnesota’s  multipayer  Health  Care  Home  Program   to balance the desire for improved requires  all  state  regulated  payers  to  pay  for  health  come   homes  in  a  “consistent”  manner.  The  state  statute   performance against the cost of these specified  a  definition  for  health  care  home,  and  the  state   investments. States and partnering payers engaged  a  broad  group  of  stakeholders  to  develop   also have limited resources to invest and Minnesota-­‐specific  practice  certification  standards.  The   need to know that their investments are resulting  standards  require  ongoing  participation  in   learning  collaboratives.  Certified  practices  receive   paying off. To address these challenges, enhanced  payments  for  each  patient  with  one  or  more   second consortium states pursued one or chronic  conditions.  Payment  amounts  vary  by  the  patient’s   both of the following options. number  of  chronic  conditions  and  an  additional  payment  is   provided  if  the  patient  or  caregiver  has  a  language  barrier   or  a  mental  illness.  The  state  audits  the  practices  and   Limiting the number of practices provides  transformation  support  through  learning   collaboratives.  Medicare  joined  the  program  in  2011.   41 that participate at the start of a program: Because of limited resources, several states launched modest pilots with a small number of practices. Many of the leading states, including Minnesota, North Carolina, Pennsylvania, and Vermont, have similarly started small and expanded the projects over time. The approaches of the second consortium states vary. In Alabama, for example, the state has limited participation to 10 three regions. A more common approach is limiting the pilot to a predetermined number of sites, such as in Nebraska (two sites), Texas (proposed pilot had eight sites), or Maryland (50 sites). The small pilots tend to attract or specifically seek out practices that have demonstrated a commitment to testing the medical home model, and in some cases, already dedicated resources to improving office systems or processes of care. In most instances, the states plan to expand these modest programs after the pilots have demonstrated the ability of the model to improve outcomes and control costs. Small pilots also provide opportunities for the Leading  State  Profile:  North  Carolina   payers and stakeholders to identify In  the  Community  Care  of  North  Carolina  program,  primary   and cultivate local champions; test care  providers  and  14  locally  operated  networks  receive   per-­‐member  per-­‐month  payments  to  offer  medical  home   recognition, payment, and practice support  services  to  patients  and  providers.  These  services   support systems; and refine include  care  management,  pharmacy  support,  and  hospital   reimbursement and practice discharge  planning.  Practices  and  network  staff  receive  key   support strategies to make the best data  such  as  real-­‐time  hospital  and  emergency  department   censuses,  pharmacy  claims,  medical  claims,  and  lab  results.   use of resources. Providers  can  also  view  condition-­‐specific  patient   Allowing a grace period for registries,  and  they  receive  regular  feedback  on  their   performance.  As  a  condition  of  participating  in  the   sites to meet medical home program,  practices  must  meet  state-­‐developed  standards.   qualification criteria: In (In  regions  where  Medicare  is  participating,  practices  must   recognition of the upfront cost to meet  NCQA  standards.)  First  launched  in  1998,  the   the practices of transforming how program  now  serves  Medicaid  patients  statewide.  In   addition,  other  payers  (Medicare,  Blue  Cross  Blue  Shield  of   they deliver care, some states are North  Carolina,  the  state  employees  plan,  and  certain  self-­‐ not requiring that participating insured  groups)  are  participating  in  select  regions.   42 practices meet medical home criteria before receiving enhanced payment. Rather, payments are conditioned upon providers meeting the criteria within a specific amount of time. This approach was adopted by leading states such as Pennsylvania and Rhode Island, but it is important to note that states using this approach—including Iowa, Nebraska, and Texas—carefully selected practices to ensure that they were committed. States also devoted resources to work extensively with selected practices to make necessary improvements. Iowa, for example, plans to give participating FQHCs in the pilot one year to achieve NCQA recognition, while Nebraska allowed six months to achieve criteria through the state process, which is administered by TransforMED. (TransforMED, a subsidiary of the American Academy of Family Physicians (AAFP), provides consultation to support primary care practice transformation.)43 The proposed Texas pilot planned to dedicate all of its resources to practice transformation—requiring each practice to complete the transformation within two years, but making no commitment to ongoing payments. 11 COMPENSATING AND MOTIVATING PRACTICES THROUGH ENHANCED PAYMENT Medicaid agencies can use a number of different reimbursement strategies to encourage, support, and reward primary care providers for functioning as high-performing medical homes. Most states use a combination of strategies. As of September 2011, five of the second consortium states had selected a payment model. Four (Alabama, Iowa, Maryland, and Nebraska) base their model in a per-member per-month payment to the practice to compensate for the ongoing costs of functioning as a medical home. This approach has been used by nearly all of the leading states. Like many of the leading states Leading  State  Profile:  Pennsylvania   (North Carolina, Oklahoma, Minnesota, An  executive  order  from  the  state’s  governor  created  the   Pennsylvania  Chronic  Care  Commission  in  2007.  The   Vermont, and Pennsylvania), Alabama, Chronic  Care  Commission  developed  a  plan  that  combines   Iowa, Maryland, and Nebraska vary their the  chronic  care  model  and  medical  home  and  includes   payments by at least one factor that they multipayer  support.  The  state’s  Southeast  rollout  of  the   Chronic  Care  Initiative  was  launched  in  May  2008.  Six   believe to either differentiate among the additional  regions  were  added  subsequently.  Later  rollouts   capabilities of all recognized medical benefited  from  lessons  learned  in  the  earlier  rollouts:  the   homes or reflect the intensity of resources state  refined  its  approaches  to  practice  payment  and   that will be needed in varying practice  recognition  on  the  basis  of  previous  experience.   One  refinement,  for  instance,  included  allowing  additional   circumstances. time  (18  months,  rather  than  12)  for  practices  to  obtain   modified  NCQA  recognition.  The  program  supports   For example, Maryland has practices  through  learning  collaboratives  and  practice   coaching.  In  select  regions,  practices  are  eligible  for   established a maximum per-member per- performance-­‐based  payment.  Medicare  plans  to  join  the   month fee that varies based on payer type program  in  2012.   44 (i.e., commercial plans, Medicaid plans, or Medicare Advantage plans). Within each type, practices receive different per-member per-month payments that vary based on “medical homeness,” allowing higher payments for higher NCQA recognition levels. Rates also vary on practice size, with smaller practices receiving higher payments. The state’s rationale for paying higher per-member per-month fees to smaller practices is twofold. First, they will generally have proportionately higher fixed transformation costs than larger practices. Second, smaller practices are more likely than larger practices to experience greater fluctuations in shared savings payments because of chance. Including small practices in the Maryland pilot was important to the state, and planners felt that higher per-member per-month payments would make the program more attractive. 12 Using Payment to Reward More Capable and Better-Performing Medical Homes Several leading states including Oklahoma45 and select regions of Pennsylvania use performance-based payment. Alabama, Maryland, and Nebraska also have implemented payment strategies that reward medical home practices that meet more demanding recognition criteria or achieve better performance. Alabama and Maryland will share the savings produced by the program with participating medical home practices. Alabama plans to share a greater portion Leading  State  Profile:  Oklahoma   of the savings with practices that meet or Oklahoma  implemented  a  Medicaid-­‐wide  medical  home   exceed performance outcomes and that program  called  SoonerCare  Choice  in  2009.  Operating   serve more Medicaid beneficiaries. under  an  expectation  of  budget  neutrality,  the  state   Maryland plans to provide a greater share shifted  its  primary  care  case  management  program  from  a   partially  capitated  approach  to  a  combination  of  fee-­‐for-­‐ of savings to practices that produce more service  payments,  per-­‐member  per-­‐month  payments  that   savings, report on a greater number of are  adjusted  for  population,  and  pay-­‐for-­‐performance   quality measures, and achieve more payments.  To  receive  enhanced  payment,  all  participating   utilization performance goals. practices  must  meet  state-­‐developed  medical  home   recognition  standards.  The  recognition  system  is  tiered,   and  practices  that  achieve  higher  levels  of  recognition  are   Nebraska Medicaid pays an initial rewarded  with  higher  per-­‐member  per-­‐month  payments.   per-member per-month payment to Oklahoma  Medicaid  audits  the  practices  and  provides   46 practice  coaching  if  requested.   medical homes that participate in their medical home pilot. When a practice achieves recognition as a “Tier 1” medical home, its per-member per-month payment is increased. Any practice that chooses to meet the higher standard of “Tier 2” continues to receive the per-member per-month payment and is also paid 105 percent of the standard fee-for-service rates that Medicaid pays to other practices for certain preventive and evaluation and management services. Using Payment to Foster Links Between Primary Care and Other Service Providers Alabama and Iowa have adjusted per-member per-month payment strategies to foster collaboration among different service providers. Alabama plans to make per-member per- month payments to regional care networks that will support primary care providers who agree to serve in the Medicaid agency’s medical home pilot. Their project is modeled on the Community Care of North Carolina program. As in North Carolina, primary care providers located in one of Alabama’s network catchment areas and participating in the pilot will receive a special per-member per-month payment. In Alabama, this per- member per-month payment will reach up to $3.10—an increase from the standard 13 maximum of $2.60 per-member per-month. Networks will receive $5 per-member per- month for each aged, blind, and disabled (ABD) enrollee and $3 per-member per-month for other enrollees.47 The networks are intended to link providers, care coordinators, and resources at the local level. To improve care for complex patients, Iowa is paying primary care providers for remote consultations with hospital-based specialists. This is also an important strategy for coordinating the care of hospitalized patients in remote areas of the state where face-to- face consultations between hospitals and medical home practices are impractical. HELPING PRACTICES MEET EXPECTATIONS AND IMPROVE PERFORMANCE Appropriate payment is an important tool for recognizing and supporting practice improvement. However, states also provide other resources to support improvements in the delivery of care. The second consortium states offer three types of support to medical home practices seeking to improve their performance. Supporting the use of electronic health records, registries, and data: Alabama, Iowa, Maryland, and Nebraska are providing support to adopt technology and use data to improve care. In many ways, they are learning from and replicating aspects of North Carolina’s work in this area. (See profile on page 11.) Alabama is working with providers to help them adopt an electronic health record (the Q-Tool) and also provides quarterly utilization reports to medical home practices. Iowa has explicitly directed participating practices to use a portion of the per-member per-month payment made by the state to establish and maintain a registry for tracking key information and develop a system for sharing clinical information with a key hospital. Nebraska is offering medical home practices funding for a patient registry and assistance in implementing it. This state is also providing medical home practices with access to data from Medicaid claims for services provided to their patients. Using learning collaboratives: Iowa and Nebraska are offering some form of learning collaboratives, as are the leading states of Maine, Minnesota, Pennsylvania, Rhode Island, and Vermont. Learning collaboratives are typically short-term (six- to 15- month) learning systems that bring together teams from participating practices to seek improvement in a particular area. Learning collaborations rely on face-to-face learning sessions, monthly conference calls, and progress reports and not only help practices improve in key focus areas, but also familiarize practices with a process they can use to improve performance in other areas.48 Topics for learning sessions can include themes such as change management, leadership, and waste reduction. 14 Deploying practice coaches: Maryland and Nebraska are securing practice coaches—a strategy adopted by nearly all of the leading states. Practice coaches are consultants (or other individuals) who offer on-site technical assistance to a practice to identify what it needs to change and how it will make those changes. The practice coach can also provide ongoing support to refine and maintain the improvements and/or help practices meet state or national medical home recognition standards. Coaches can also help practices better integrate information technology resources such as registries and electronic health records to improve care processes. Providing Support for Care Coordination States have placed a high priority on ensuring that patients and practices have access to dedicated care coordinators—professionals who specialize in organizing care across settings to make sure patients get the right care at the right time. States expect that the medical home payments they make to practices will be used to pay for care coordination. Iowa has made this expectation explicit, directing participating providers to use a portion of the per-member per-month payment from the state to hire a dedicated care coordinator. In addition, Alabama, Maryland, and Nebraska plan other funding or supports for care coordination. Specifically: • Alabama’s networks, which are modeled after Community Care of North Carolina networks, are designed to provide a platform for practices to share care coordination resources. • Nebraska is making a payment to participating practices that is explicitly directed to fund care coordinators. Similarly, Pennsylvania and Rhode Island are making payments that are specifically targeted to pay for care coordinator or care manager services. • The Maryland Health Care Commission is working with the Community Health Resources Commission (an independent commission established by the legislature) to explore with several other states how to use area health education centers (AHECs) and other state organizations to train care coordinators. North Carolina is one state that has informed Maryland’s efforts. North Carolina’s AHEC has worked directly with primary care providers to promote electronic health record adoption and the effective use of health information technology to improve quality. 15 EVALUATING PROGRAM PERFORMANCE State Medicaid agencies are making the investments described in this report with the expectation that high-performing medical homes will produce improved clinical outcomes, increased patient satisfaction, and contained costs. There is evidence that medical homes do produce these returns.49 As detailed in the first section of this report, there is also evidence from more mature Medicaid medical home programs that these investments produce similar results in Medicaid programs. However, Medicaid agencies need to know that their medical home programs are succeeding to justify continued funding that would allow broader spread of the model. Although most of the second consortium states have not yet identified the specifics of their measurement and evaluation plans, six (Alabama, Iowa, Maryland, Nebraska, Texas, and Virginia) have identified the key outcomes they plan to measure. Many of these outcomes are the same as or similar to the outcomes that leading states are tracking. These outcomes can be grouped into the four major categories, which are described below. Improvements within primary care practices: Alabama, Iowa, Maryland, Nebraska, Texas, and Virginia intend to assess the effect of their programs on primary care, particularly the program’s impact on access and clinical processes. Here are some examples of the targets and measures these states are considering: • At least 75 percent of all members enrolled in pilot practices have had their smoking status documented (Iowa); • 100 percent of all members referred to the University of Iowa Hospitals and Clinics for secondary and tertiary care should be tracked via a referral tracking system (Iowa); • Wait time to get an appointment for both urgent and routine care (Nebraska); • Use of appropriate medication for asthma (Maryland); and • Adoption of health home model: progress as measured by the Medical Home Index Quotient, a tool developed by TransforMED to gauge the capabilities of primary care practices (Texas proposed pilot).50 Effect on services delivered by other providers: All states identified above plan to examine the effects of their programs on other aspects of the delivery system. While many of these services are not under the direct control of primary care providers, states believe that empowered primary care can lead to improved patterns of utilization. Among the measures the states are monitoring: 16 • Percentage decrease from the baseline in emergency department visits per 1,000 members (Year 2, 2 percent decrease; Year 3, requirement increases to 4 percent) (Maryland); • Number of inpatient hospital admissions for ambulatory care–sensitive conditions: chronic obstructive pulmonary disease, congestive heart failure, diabetes, and pediatric asthma (Nebraska); and • Decreased hospitalizations and emergency department utilization (Virginia). Cost containment: Many of the specific measures and targets already listed were chosen because improvements in these areas should produce significant cost savings for Medicaid. In addition, these states plan to measure actual changes in Medicaid costs, most often as a change in the per-member per-month cost of care. Patient and provider experience: Alabama, Nebraska, and Texas seek to examine patient satisfaction and experience. Alabama further specified that they plan to use the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tool.51 Nebraska reported that they will examine provider satisfaction. Seeking to Ease the Evaluation Burden for Medical Home Providers The second consortium states are seeking to ease the burden of evaluation and performance measurement on medical home providers, in ways described below. Relying upon data generated during the course of providing and paying for services: All the states are working to minimize the resources that practices will need to devote to measurement. To this end, states are looking to potentially rich data sources that already exist for other purposes, such as claims databases and practice registry data. Maryland plans to use claims data from its multipayer database to assess its multipayer initiative, as are the leading states of Maine, Vermont, and soon, Rhode Island. Drawing measures from national data sets: States are also seeking to ease and enhance evaluation by drawing measures from national data sets. This potentially reduces the burden of producing the measures. In some cases the same measure may serve multiple purposes. As an added benefit, measures developed by an organization that specializes in that activity add to the credibility of the results. Common sources of measures include those developed by NCQA or those endorsed by the National Quality Forum. 17 Selecting measures that practices must already report to other programs: The states are also seeking to align measurement and evaluation activities across programs. In Alabama, for example, the Alabama Healthcare Improvement and Quality Alliance Workgroup—a public–private effort—is working to establish measures based on national standards to assess progress on all programs throughout the state. The Maryland Health Care Commission is working with the Medicaid and CHIP programs to ensure that the measures used in the medical home program are drawn from those already in use when possible. SUMMARY The eight states profiled in this report demonstrate the role of the state in improving primary care systems through the medical home model. Budget pressures in three of these states (Kansas, Virginia, and Texas) have resulted in delayed implementation. Across the consortium, project design has been greatly informed by the work of states such as Colorado, Maine, Minnesota, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, and Vermont. At the same time, emerging states are developing innovations and learning lessons that can serve to advance the broader field. All states that are building medical homes have faced a multitude of key decision points and design considerations. Throughout the United States, these questions are being addressed differently. From the stakeholders at the planning table to the nature of practice qualification standards, from the number of participating payers to the type of practice support systems, these projects are unique. This makes sense given the differences in delivery systems across the country, as well as the diversity in state and stakeholder goals. But there is much in common. States that are building medical homes have their eyes on the same broad vision: strong primary care systems that deliver better outcomes while helping to rein in unsustainable cost growth. In other words, states want better value from their health care systems, and they are finding that the medical home model is part of the answer. 18 Appendix.  Medical  Home  Programs  in  Second  Consortium  States   (as  of  August  2011)   State   Program  Overview  and  Status   Alabama   Alabama  is  enhancing  its  Medicaid  primary  care  case  management  program,   Patient  1st,  through  community  networks.  These  entities,  referred  to  as  the   Patient  Care  Networks  of  Alabama,  will  support  primary  care  practices  in   functioning  as  medical  homes.  Among  other  responsibilities,  the  network  staff  will   help  primary  care  providers  coordinate  care  for  high-­‐need  and  high-­‐risk  patients   and  teach  self-­‐management  skills.  Alabama  consulted  with  North  Carolina,  a  state   with  much  experience  in  this  model.  Alabama’s  Medicaid  program  identified  local   champions  and  built  broad  provider  buy-­‐in  through  a  series  of  regional  town  hall   meetings  and  webinars.  Through  a  request-­‐for-­‐proposal  process,  the  state   identified  three  county  organizations  to  serve  as  network  hubs  on  a  pilot  basis.   The  Centers  for  Medicare  and  Medicaid  Services  (CMS)  approved  a  state  plan   amendment  in  May  2011,  and  Alabama  began  making  network  payments  in   August  2011.  Alabama’s  share  of  Medicaid  funding  for  this  project  came  from   monies  that  would  otherwise  be  available  for  Patient  1st  shared  savings   payments.  The  program  aims  to  cover  about  80,000  Medicaid  beneficiaries,  and  it   has  been  structured  as  a  two-­‐year  pilot.  Depending  on  results,  the  state  may   expand  the  initiative  statewide.52   Iowa   Iowa  has  legislative  backing  to  establish  and  spread  the  medical  home  model  as  a   standard  of  care  for  all  citizens.  Legislation  in  2010  provided  the  Medicaid  agency   with  the  authority  to  transform  IowaCare  (a  §1115  Medicaid  demonstration   waiver  program  that  offered  a  limited  benefit  package  to  low-­‐income  childless   adults)  into  a  medical  home  program  based  in  Federally  Qualified  Health  Centers   (FQHCs).  Participating  FQHCs  are  required  to  attain  medical  home  recognition  and   work  with  the  state,  hospitals,  and  each  other  to  deliver  excellent  primary  care.   Iowa  has  developed  a  new  Medicaid  payment  model  for  IowaCare’s  FQHC  sites   that  aligns  with  medical  home  recognition.  State  funding  for  payments  has  come   from  reallocating  existing  IowaCare  funding.  In  addition  to  enhanced  payments,   IowaCare  sites  are  receiving  support  through  a  learning  collaborative.53  The   program  was  launched  with  two  FQHCs  in  October  2010.  By  the  end  of  2012,  the   Medicaid  agency  plans  to  expand  the  program  to  13  geographically  dispersed   FQHC  sites  capable  of  serving  39,000  members.54  (Iowa  is  also  working  with   payers  to  establish  a  multipayer  program  for  children.)   Kansas   Kansas  Medicaid  has  led  the  state’s  medical  home  initiative.  The  state  has  not  set   a  launch  date  because  of  budget  setbacks,  but  it  continues  to  lay  the  foundation   for  a  medical  home  program  that  the  state  plans  to  implement  when  fiscal   matters  improve.  In  2010,  the  Medicaid  agency  reengaged  a  primary  care  provider   stakeholder  group  and  reached  out  to  local  foundations  and  private  payers.  They   have  also  drafted  practice  recognition  standards  that  implement  their  legislatively   established  medical  home  definition.  The  provider  stakeholder  group  provided   feedback  on  those  standards.   19 Maryland   The  Maryland  Health  Care  Commission  (MHCC)  is  leading  implementation  of  a   multipayer  patient-­‐centered  medical  home  pilot.  Legislation  enacted  in  2010   addressed  antitrust  concerns  and  brought  the  large  commercial  insurers  to  the   table.  Practices  are  receiving  support  through  a  learning  collaborative  to  help   them  meet  modified  NCQA  medical  home  standards.  In  exchange,  they  receive   increased  payment  from  all  of  the  large  commercial  payers  in  the  state  and  select   Medicaid  managed  care  organizations.  Participating  Medicaid  managed  care   organizations  are  not  receiving  enhanced  capitation  payments  from  the  state.   Maryland  has  launched  a  learning  collaborative  to  support  practice   transformation  and  will  be  conducting  an  independent  evaluation  of  that  effort.   MHCC’s  initiative  is  designed  to  enroll  50  practices  that  together  serve  200,000   patients.  Payments  for  the  three-­‐year  pilot  began  in  July  2011.55   Montana   Montana  has  convened  a  large  group  of  diverse  stakeholders  to  plan  a  multipayer   pilot.  The  stakeholders  have  agreed  on  a  medical  home  definition,  and  consensus   has  coalesced  around  using  a  modified  NCQA  system  for  practice  recognition.   Initially,  Medicaid  convened  the  project;  however,  in  order  to  more  effectively   engage  commercial  payers  and  address  potential  antitrust  concerns,  Montana’s   Commissioner  of  Securities  and  Insurance  took  the  leadership  role  in  September   2010.56  The  stakeholder  group,  which  includes  all  commercial  payers,  has  developed   and  is  now  carrying  out  a  work  plan  for  implementing  a  multipayer  initiative.     Nebraska   Consistent  with  legislation  enacted  in  2009,  Nebraska  is  implementing  a  Medicaid   medical  home  pilot.  The  governor-­‐appointed  Medical  Home  Advisory  Council  used   a  request-­‐for-­‐information  process  to  select  two  pilot  practices.  Together,  the  two   practices  serve  about  7,000  patients.  Each  is  receiving  enhanced  payment  from   Medicaid  in  exchange  for  meeting  state-­‐developed  medical  home  standards.  The   practices  are  also  receiving  support  through  state-­‐funded  practice  coaches  and   embedded  care  coordinators.  The  pilot  will  last  two  years  and,  depending  on   results,  the  state  may  expand  the  program.  The  program  operates  under  the   authority  of  a  Medicaid  §1932(a)  state  plan  amendment  that  CMS  approved  in   January  2011.  Nebraska’s  share  of  the  Medicaid  costs  is  funded  with  modest  state   start-­‐up  funds.57   Texas   Texas  previously  planned  to  develop  a  two-­‐year,  $20.2-­‐million  Health  Home  Pilot   project  using  funding  from  the  settlement  of  a  lawsuit  over  children’s  access  to   preventive  services  under  Medicaid.  The  state  had  begun  a  request-­‐for-­‐proposals   process  to  select  practices.  Each  practice  would  have  received  cost-­‐based   reimbursement  for  expenses  related  to  transformation.  The  state  planned  to   evaluate  several  domains  of  practice  transformation,  including  patient  access  and   experience,  provider  experience  and  satisfaction,  service  utilization,  clinical  care   quality,  and  annual  and  trended  per-­‐member  per-­‐month  costs.  Texas  had  planned   on  funding  and  evaluating  about  eight  health  home  practices  across  the  state,   each  using  unique  approaches,  to  determine  which  were  the  best  models  to   replicate  once  the  pilot  concluded.  In  June  2011,  the  Texas  Legislature  did  not   appropriate  funds  for  the  pilot  and  the  request  for  proposals  was  cancelled.58   Virginia   Virginia  Medicaid  is  working  to  develop  a  medical  home  initiative  with  a  rural,   multisite  FQHC.  A  stakeholder  group  is  considering  using  a  national  recognition   process.  Options  for  increased  payment  commensurate  with  achieving  recognition   are  being  explored.   20 NOTES 1 Centers for Medicare and Medicaid Services, “Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Fact Sheet,” retrieved Aug. 2, 2011, see: https://www.cms.gov/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf. 2 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, “Joint Principles of the Patient Centered Medical Home,” retrieved Aug. 2, 2011, see: http://www.pcpcc.net/content/joint- principles-patient-centered-medical-home. 3 C. Bielaszka-DuVernay, “Vermont’s Blueprint for Medical Homes, Community Health Teams, and Better Health at Lower Cost,” Health Affairs, March 2011 30(3):383–86; K. Grumbach and P. Grundy, “Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Prospective Evaluation Studies in the United States” (Washington, D.C.: Patient-Centered Primary Care Collaborative, 2010), see: http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf; Illinois Department of Healthcare and Family Services, “Illinois’ Care Management Programs Save $320 Million in Successful Third Year,” press release dated April 28, 2010, retrieved Aug. 2, 2011, see: http://www.illinois.gov/PressReleases/ShowPressRelease.cfm?SubjectID=19&RecNum=8406; R. A. Paulus, K. Davis, and G. D. Steele, “Continuous Innovation in Health Care: Implications of the Geisinger Experience,” Health Affairs, Sept. 2009 27(5): 1235–45; T. C. Rosenthal, “The Medical Home: Growing Evidence to Support a New Approach to Primary Care,” Journal of the American Board of Family Medicine, Sept. 2008 21(5):427–40; B. D. Steiner, A. C. Denham, E. Ashkin et al., “Community Care of North Carolina: Improving Care Through Community Health Networks,” Annals of Family Medicine, July 2008 6(4): 361–67; M. Takach, “Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results,” Health Affairs, July 2011 30(7):1325–34. 4 National Academy for State Health Policy, “Medical Home States,” 2011, retrieved Aug. 2, 2011, see: http://www.nashp.org/med-home-map. 5 The pioneering states included Colorado, Idaho, Louisiana, Minnesota, New Hampshire, Oklahoma, Oregon, and Washington. (North Carolina, Pennsylvania, and Rhode Island served as faculty for this group, and their experience also informed the policy options and strategies that contributed to the framework.) 6 For a more complete discussion of these strategies and the policy options developed by the leading states, please see: N. Kaye and M. Takach, Building Medical Homes in State Medicaid and CHIP Programs (Portland, Maine: National Academy for State Health Policy, 2009), see: http://www.nashp.org/node/1098. 7 Department of Vermont Health Access, Vermont Blueprint for Health 2010 Annual Report (Williston, Vt.: DVHA, 2011), see: http://hcr.vermont.gov/sites/hcr/files/final_annual_reprt_01_26_11.pdf. 8 Community Care of North Carolina, “North Carolina Employer Coalition to Offer Medical Homes,” retrieved Sept. 9, 2011, see: http://newsite.ncafp.com/files/First%20in%20Health%20news%20release_8-26- 2011_FINAL.pdf. 9 Personal communication with Rebecca Pasternik-Ikard, Oklahoma Health Care Authority, Jan. 5, 2011. 10 D. S. Gifford, The RI Chronic Care Sustainability Initiative: Update on Rhode Island’s Multi-Payer Patient-Centered Medical Home Initiative (Cranston, R.I.: Rhode Island Office of the 21   Health Insurance Commissioner, 2010), see: http://www.ohic.ri.gov/documents/Committees/HealthInsuranceAdvisoryCouncil/2010%20Octob er%20affordability%20Materials%20/2_HIAC%20Rhode%20Island%20Chronic%20Care%20Su stainability%20Initiative.pdf. 11 P. Johnson and K. Botten, “SoonerCare Choice: Evaluating the Patient-Centered Medical Home: Potential and Limitations of Claims-Based Data,” retrieved Sept. 9, 2011, see: http://nashp.org/sites/default/files/webinars/Johnson-Botten_Evaluating_the_PCMH.pdf. 12 Grumbach and Grundy, Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States, 2010. 13 Department of Vermont Health Access, Vermont Blueprint for Health 2010 Annual Report, 2011. 14 Treo Solutions, Highlights of Treo Solutions Report (Troy, N.Y.: Community Care of North Carolina, 2011), see: http://www.communitycarenc.org/elements/media/related- downloads/treo-analysis-of-ccnc-performance.pdf. 15 Department of Vermont Health Access, Vermont Blueprint for Health 2010 Annual Report, 2011. 16 Community Care of North Carolina, “Our Results.” retrieved Sept. 9, 2011, see: http://www.communitycarenc.org/our-results. 17 Personal communication with Gina Robinson, Colorado Department of Health Care Policy and Financing, Jan. 22, 2011. 18 Personal communication with Rebecca Pasternik-Ikard, Oklahoma Health Care Authority, Jan. 5, 2011. 19 Chapter 346 of the 2007 Colorado Session Laws, “An Act Concerning Medical Homes for Children, and Making an Appropriation Therefor,” retrieved Sept. 12, 2011, see: http://www.state.co.us/gov_dir/leg_dir/olls/sl2007a/sl_346.pdf. 20 For additional information, please visit: http://www.coloradomedicalhome.com/. 21 Maryland Health Care Commission, “Maryland Patient Centered Medical Home: Join a 2010 Regional Provider Symposium,” retrieved Aug. 2, 2011, see: http://mhcc.maryland.gov/pcmh/Symposia.aspx. 22 Alabama Medicaid Agency, “Patient Care Networks of Alabama, ” retrieved Aug. 2, 2011, see: http://www.medicaid.state.al.us/programs/patient1st/Community_Care_Networks.aspx; Iowa Department of Public Health, “ Medical Home System Advisory Council,” retrieved Aug. 2, 2011, see: http://www.idph.state.ia.us/hcr_committees/medical_home.asp; Maryland Health Care Commission,“Maryland Patient Centered Medical Home,” retrieved Aug. 2, 2011, see: http://mhcc.maryland.gov/pcmh; Montana Commissioner of Securities and Insurance, “Patient Centered Medical Homes Initiative in Montana,” retrieved Sept. 12, 2011, see: http://www.followupfast.com/medhome/index.asp; Nebraska Department of Health and Human Services, “Nebraska Medicaid Medical Home Pilot Program,” retrieved Aug. 2, 2011, see: http://www.hhs.state.ne.us/med/Pilot/index.htm. 23 M. Takach, State Involvement in Multi-Payer Medical Home Initiatives (Portland, Maine: National Academy for State Health Policy, 2009), see: http://www.nashp.org/sites/default/files/MedHomes_State_Chart_11-2009.pdf. 24 CMS, “Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Fact Sheet.” 22   25 For additional information, please visit: http://www.pcmhri.org/. 26 For additional information, please visit: http://www.adkmedicalhome.org/. 27 New York State Medicaid Update, “Announcing New York Medicaid’s Statewide Patient- Centered Medical Home Incentive Program,” retrieved Sept. 12, 2011, see: http://www.health.state.ny.us/health_care/medicaid/program/update/2009/2009-12spec.htm. 28 AcademyHealth, “Navigating Antitrust Concerns in Multi-Payer Initiatives” (Washington D.C.: AcademyHealth, 2010), see: http://www.academyhealth.org/files/publications/AntitrustMultipayer.pdf. 29 Maryland Senate Bill 855/House Bill 929, approved April 13, 2010, see: http://mlis.state.md.us/2010rs/chapters_noln/Ch_5_sb0855T.pdf. 30 Virginia does not have a formal definition of medical home but is considering using NCQA’s PPC-PCMH recognition process, which is rooted in the “Joint Principles of the Patient Centered Medical Home” developed by the four physician primary care specialty societies. 31 American Academy of Pediatrics, “National Center for Medical Home Implementation,” retrieved Aug. 2, 2011, see: http://www.medicalhomeinfo.org. 32 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, “Joint Principles of the Patient Centered Medical Home.” 33 Kansas Statutes Annotated, §75-7429, retrieved Aug. 2, 2011, see: http://kansasstatutes.lesterama.org/Chapter_75/Article_74/75-7429.html. 34 Proceeds of the multistakeholder patient-centered medical home workgroup. 35 For additional information, please visit: http://hcr.vermont.gov/blueprint_for_health. 36 National Committee for Quality Assurance, “Physician Practice Connections—Patient- Centered Medical Home,” retrieved Aug. 2, 2011, see: http://www.ncqa.org/tabid/631/default.aspx. 37 The Joint Commission, “Primary Care Medical Home,” retrieved Aug. 3, 2011, see: http://www.jointcommission.org/accreditation/pchi.aspx. 38 Accreditation Association for Ambulatory Health Care, “Medical Home Accreditation,” retrieved Sept. 12, 2011, see: http://www.aaahc.org/eweb/dynamicpage.aspx?webcode=mha. 39 URAC, “URAC PCHCH Practice Achievement,” retrieved Sept. 12, 2011, see: https://www.urac.org/healthcare/pchch/index.aspx. 40 For additional information, please visit: http://www.mainequalitycounts.org/major- programs/patient-centered-medical-home.html. 41 For additional information, please visit: http://www.health.state.mn.us/healthreform/homes/index.html. 42 For additional information, please visit: http://www.communitycarenc.org. 43 For additional information, please visit: www.transformed.com. 44 http://www.pcpcc.net/content/pennsylvania-chronic-care-initiative. 45 Oklahoma Health Care Authority, “SoonerExcel,” retrieved Sept. 12, 2011, see: http://www.okhca.org/providers.aspx?id=9426&menu=74&parts=8482_10165. 46 http://www.okhca.org/providers.aspx?id=8470&menu=74&parts=8482. 23   47 Alabama Medicaid Agency, Request for Proposals: Patient Care Networks of Alabama (Montgomery, Ala.: Alabama Medicaid Agency, 2010), see: http://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.4_Procurement/2.4_RFP_Patient _Care_Networks_12-1-10.pdf. 48 Institute for Healthcare Improvement, see www.ihi.org. 49 Bielaszka-DuVernay, “Vermont’s Blueprint for Medical Homes, Community Health Teams, and Better Health at Lower Cost,” 2011; Grumbach and Grundy, “Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States, 2010”; Paulus, Davis, and Steele, “Continuous Innovation in Health Care: Implications of the Geisinger Experience,” 2009; Rosenthal, “The Medical Home: Growing Evidence to Support a New Approach to Primary Care,” 2008. 50 TransforMED, “TransforMED MHIQ Scoring,” retrieved Aug. 2, 2011, see: http://www.transformed.com/MHIQ/scoring.cfm. 51 Agency for Healthcare Research and Quality, “CAHPS Home,” retrieved Aug. 2, 2011, see: https://www.cahps.ahrq.gov/default.asp. 52 Alabama Medicaid Agency, “ Patient Care Networks of Alabama,” retrieved Aug. 2, 2011, see: http://www.medicaid.state.al.us/programs/patient1st/Community_Care_Networks.aspx. 53 For more information, please visit: http://www.ihconline.org/aspx/initiatives/medicalhome.aspx. 54 Iowa Department of Public Health, “ Medical Home System Advisory Council,” retrieved Aug. 2, 2011, see: http://www.idph.state.ia.us/hcr_committees/medical_home.asp. 55 Maryland Health Care Commission. “Maryland Patient Centered Medical Home,” retrieved Aug. 2, 2011, see: http://mhcc.maryland.gov/pcmh. 56 For additional information, please visit: www.followupfast.com/medhome/index.asp. 57 Nebraska Department of Health & Human Services, “Nebraska Medicaid Medical Home Pilot Program,” retrieved Aug. 2, 2011, see: http://www.hhs.state.ne.us/med/Pilot/index.htm. 58 Texas Health and Human Services Commission, “Medicaid Health Home Pilot Project RFP# 529-10-0057,” retrieved Sept. 12, 2011, see: http://www.hhsc.state.tx.us/contract/529100057/announcements.shtml. 24