State Multi-Payer and CareFirst Models are Underway in Maryland
By: Linda Harder
Photography by: Mark Molesky
Two Patient Centered Medical Home (PCMH) programs are currently underway in Maryland. The 2010 legislative session established funding for the Maryland Multi-Payer PCMH program (MMPP) pilot program, which launched April 2011 for 53 practices and about 200,000 patients. A few months earlier, CareFirst BlueCross BlueShield launched a PCMH program that covers its insured patients in participating provider panels. Maryland Physician spoke with leaders of both programs plus four participating Maryland physicians to learn about their early progress and future challenges.
The American Academy of Pediatrics originated the PCMH concept in 1967 and made it policy by 1977, when it established standards to improve the access, planning, management, coordination and tracking of healthcare services, with the primary care provider as the hub. The National Committee for Quality Assurance (NCQA), developed a set of measures for physicians to achieve PCMH recognition that were recently updated to be aligned with CMS Meaningful Use requirements. These promote using electronic health records to track care, especially for the small fraction of high-risk patients that account for a third of healthcare expenditures.
MMPP Pilot Program
The three-year MMPP pilot program, under the aegis of the Maryland Healthcare Commission (MHCC), includes patients insured by Medicaid, Aetna, CareFirst, CIGNA, Coventry, United Healthcare, select self-insured employers, and possibly Medicare.
Ben Steffen, acting executive director of the Maryland Health Care Commission and director of Maryland’s PCMH program, says, “Governor Martin O’Malley, Lieutenant Governor Anthony Brown and Secretary of Health and Mental Hygiene Dr. Joshua Sharfstein are fully behind the PCMH program. The priority this program places on the primary care physician is long overdue.”
The enrolled practices are given financial, logistical and educational support to achieve NCQA Level 1 recognition in late 2011 and Level 2 recognition by late 2012. Overseeing that support is the Maryland Learning Collaborative, a partnership between the University of Maryland, Johns Hopkins Community Physicians and the MHCC that started in March, 2011.
Niharika Khanna, M.D., program director, Maryland Learning Collaborative and Associate Professor Family and Community Medicine at University of Maryland School of Medicine, explains, “MHCC selected us to be their partners in program administration. We announced the multi-payer program on April 14th. Fifty-three practices comprised of over 339 primary care providers signed up. Our practices are very diverse and include 15 practices that have 20% or greater Medicaid patients.
“The legislature approved the program and innovative payment model reforms totaling about $ 3.5 million were developed for prepared practices to ensure that payments go directly to the practices in two parts: 1) care management payments of about $3 to $7 per member per month (PMPM) and 2) a year-end share of any cost savings from reduced hospitalizations, readmissions, ER visits and the like. Additional state support was designated to establish the Maryland Learning Collaborative and the external evaluation team.”
She reflects, “Collaboration is the key strength of our model. We conducted a series of webinars on each NCQA standard and the practices decided which data they needed to identify high-risk patients. We offer multi-media, skills development and training workshops to practices to support a team-based care management model where a variety of healthcare personnel can learn to perform the functions of embedded care management. While not required, 51 of the practices have EHRs and most will interchange with CRISP’s Health Information Exchange (HIE). Patient advocates drawn from our practices have guided us at every step.”
Howard Haft, M.D., MMM, FACPE, medical director of Maryland Healthcare and Shah Associates, a multi-specialty group practice in Southern Maryland with multiple locations, notes that some of their locations are participating with the state model while others are in the CareFirst program. He is optimistic about the potential for the PCMH model to transform patient care.
“It’s a lot of work but it has its rewards,” he notes. “It provides better care. Before we started this, we relied on our patients to tell us when they were in a hospital or to return for follow-up appointments. Now, our care managers help us make the connections and ensure that they’re seen back in our practice within 72 hours of discharge.
“I really like it and patients like it,” Dr. Haft adds. “PCPs used to rely on a wing and a prayer that the patients would see the specialist when referred and that we’d get information back. Only 30 to 40% of diabetics, for example, were getting regular eye exams documented. Now, our staff gets a list of patients referred so that we can track their progress, with clinical information in that referral. It provides more integrated care.”
Dr. Haft agrees that care management is key. “Care managers are embedded at all of our sites,” he says. “I can’t tell you how valuable that is for us and our patients. They focus on patients who need more help in between visits and prevent a chronic problem from becoming a disaster.”
“We’re not trying to make more money but to build a better healthcare system. We’re newborns at this. It will be a journey, but at least this time the path on that journey is lit.”
Seth Eaton, M.D., an internist and pediatrician with MedPeds, participated in the BC Collaborative pilot program as well as the current state multi-payer model. He notes, “We chose the state pilot because it involves so many more of our patients. Additionally, as a practice that has had an EHR since 2004, we didn’t want to duplicate our existing documentation processes. With the state model, we can integrate the care coordination into our existing workflow.”
Dr. Eaton describes some of the changes that PCMH has brought. “We’re in the process of hiring an additional LPN to serve as the care manager for all eight of the MAs in our practice and one of our other nurses is working to reach out to 50 of our sickest patients. We’re starting up holiday and Sunday hours in 2012 and will be part of the CRISP HIE so that we can mine hospitalization and ER data to better coordinate care. To share in year-end savings, we have to hit both process measures, such as making sure we’ve measured hemoglobin A1C in diabetics, and outcome measures,” he adds.
In a short time, the vast majority of MMPP practices met the October 28, 2011 submission deadline to meet Level I NCQA. Notes Dr. Khanna, “It’s mind boggling that they completed them in time. We think we’ll be ready for Wave 2 of NCQA recognition by July 2012. It’s hard to know yet if the dollars provided will be adequate until we have the cost data. “
What can interested PCPs do to join? Dr. Khanna advises, “Write a letter to us or the MHCC. We’re seeing a lot of interest throughout the state.”
CareFirst’s PCMH program builds on the lessons of its three-year pilot program that concluded in 2010. The current program, according to Chet Burrell, president and CEO of CareFirst, has signed up about 2,900 physicians and 300 nurse practitioners in Maryland, DC and Virginia, making it the largest in the country.
“In our program, the PCP cannot join as a solo practitioner,” says Mr. Burrell. “They need to be part of a virtual panel or small group of five to 15 providers. The average panel size is 10 providers and about 3,000 members, in line with early predictions that this size would generate sufficient patient volumes to spread risk without being unwieldy.”
Mr. Burrell adds, “What doctors need most are the ability to see their roster of patients, make a care plan for high-risk patients, have a longitudinal record of care and have powerful analytics and support. We supply all of those things.”
George Lowe, M.D, vice president, Mercy Health Services, Medical Director of Lutherville Personal Physicians, a unit of Maryland Family Care Inc., a group of 75 PCPs, participated in both the pilot and current CareFirst PCMH programs. He observes, “Most of the practices in the pilot successfully achieved NCQA Level 3 recognition. The current model adds in a case management component for at-risk patients and promises to share in cost savings based on outcomes and patient satisfaction.”
Patricia Czapp, M.D., medical director for eight practices and 20 physicians in Anne Arundel, and also a participant in both CareFirst programs, is enthusiastic about the changes PCMH has wrought. “It has transformed our practice, and the patient really is the focus. Before, we felt we couldn’t afford to hire more staff; PCMH forces you to build an effective internal team and redesign care delivery so that doctors perform fewer clerical tasks and go home earlier, while seeing more patients during their work day.
“We used to have one or one-half medical assistants per physician; now we have two,” she continues. “We train them to comprehensively review each patient’s needs beyond that visit’s particular focus, such as scheduling an overdue mammogram, updating immunizations, refilling chronic medications and periodic specialty referrals. Most of the keyboard work has been done by the time the physician sees the patient, so the doc gets more “face” time with each patient. The staff find it more rewarding, too – like the docs, they now get cookies and fruit baskets from grateful patients!”
Care Managers, Care Plans and Medical Health Records
Mr. Burrell comments, “We give providers the data to determine who in their patient roster might benefit from a care plan.” Providers are paid $200 to develop a care plan for higher risk patients and $100 to maintain these plans. More than 1,000 care plans were initiated in 2011.
To better manage high-risk patients, CareFirst employs regional care coordinators, each of which oversees seven to eight care managers in 18 sub-regions. The care managers, contracted through a vendor, are local nurses with practice management experience.
Mr. Burrell explains, “We weren’t sure if the doctors would accept the nurses into their practices, but by and large, they have. The care managers learn the patient’s history, document what they need and serve as the navigator to ensure that the patient receives necessary services. It’s all conducted on a web-based application. The physicians need a PC and broadband access, and that’s it.”
CareFirst’s other key feature is an online Medical Health Record for each patient that tracks episodes of care, medications, and other key health data.
Both PCMH models provide immediate increases in physician compensation and share in any savings at the end of the year.
Mr. Burrell explains how the CareFirst shared savings works. “We set up a Patient Care Account in which we deposit virtual global credits; actual healthcare utilization costs are subtracted from those virtual credits. For example, a panel might accrue $10 million in their account by receiving a $200 to $300 PMPM credit for a panel of 3,000 patients. Health expenses would be debited against those credits.
“While each region has a different amount based on historical care experience,” he continues, “your job is to beat the global expected cost of care and we help by giving you the nurse support and the data you need. The program is data-intensive, not anecdotal. Unlike some past models, there is no downside risk for physicians. If you spend more than anticipated, it’s a no lose situation.”
Mr. Burrell concludes, “There is more time involved to participate in a PCMH, but it’s enlightened self-interest. We provide powerful rewards for providing more managed patient care. Even though the shared savings piece is somewhat complex, it’s amazing how many providers readily grasp it. My gut is that about half of the panels will see shared savings.”
“I’m optimistic,” exclaims Dr. Lowe. “Primary care physicians have always wanted the ability to help our patients outside the office and to keep them healthy. Thanks to PCMH, that’s becoming a reality. We’ve extended both our practice hours and the ways that patients can contact us, including a patient portal where patients can register, request appoints or referrals, or renew prescriptions.”
Remaining Challenges for Both Programs
Mr. Steffen observes that access to data is one of the major challenges facing PCMHs, due in large part to restrictions in state law limiting what information can be shared. “We worked to make it easier for physicians to obtain data without violating the law, but we need to revisit this issue in the future. Practices need to have data on patients that need treatment. “
Dr. Khanna concurs. “We need to know which patients to target because we can’t follow everyone. Access to care is a second critical issue. We’re exploring the possibility of group visits, where, for example, diabetic patients might have a group session with a PA or NP to learn how to monitor their disease and when to get preventive care.”
A third issue is the continued refinement of the shared savings methodology. “All of the PCMH models have complex methodologies,” Mr. Steffen notes.
Despite the issues, all interviewees were optimistic about the potential of the PCMH model. “This is a wonderful opportunity for primary care physicians. It’s what we thought we would do when we set out to practice medicine,” Dr. Khanna concludes.
Maryland’s PCMH Models At a Glance
|MD Multi-Payer PCMH||CareFirst BCBS PCMH|
|Launch date||Mid April 2011||January 2011|
|Payers||Aetna, CareFirst, Cigna, Coventry, United, Medicaid, select self-insured employers||CareFirst only|
|Number of Enrolled Physicians/Practices||339+/53||2900 MDs/nearly 200 panels; also 300 NPsMust be in panel of 5 to 15|
|Timeframe||3 year pilot||2011 launch with ongoing registration|
|Support||MD Learning Collaborative – webinars & other support, coaches, etc.||Care managers paid for by CareFirst, web apps, etc.|
|Features||Each practice can create its own care management model within NCQA guidelines||Common web-based model for all participating panels|
|EHR Requirement||Not required but most have EHR||Encouraged, not required|
|Payments||$3-7 PMPM; up to $55,000 per MD per yrShared savings end of year||12% fee schedule increase $200 per care plans; $100 to maintain planShared savings end of year|