BY LINDA HARDER | PHOTOGRAPHY BY TRACEY BROWN AND GARY MARINE
The literature presents a mixed picture of the effectiveness of Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs), which Maryland Physician first explored in 2012. Maryland experts provide their perspective, and discuss why the new Maryland Medicare waiver may provide an impetus to both.
In 2014, some 343 Medicare ACOs are operational in the US, with 15 of those in Maryland. Of the roughly 900,000 Medicare beneficiaries in the state, about 100,000 are now participating in an ACO.
“ACOs are pretty much aligned with other population health initiatives,” says Craig Behm, executive director, MedChi Network Services. “I’m optimistic about ACOs and the potential to work closely with hospitals because of the aligned goals. The ACO program certainly has flaws, such as the timelines the Centers for Medicare and Medicaid Services (CMS) established, but for the most part, it’s pretty good. The quality measures, for example, need some work but are an appropriate starting point.”
Mitch Gittelman, DO, is medical director of the Lower Shore ACO, one of the Maryland ACOs established under the CMS Advance Payment Model and managed by MedChi Network Services. Based largely in Wicomico County, it encompasses 11 practices with 33 physicians and mid-level providers serving approximately 10,000 Medicare patients.
CMS measures the ACOs on 33 quality measures, 23 of which they have to report on themselves. “The measures include items such as: Are patients with coronary artery disease taking a daily aspirin; Have patients with congestive heart failure had an echocardiogram in the past year; Has a woman had a mammogram; Have patients received pneumococcal vaccines, etc. I personally like the measures that are part of this model,” says Dr. Gittelman. “There’s strong evidence and good thought processes behind most of them.”
He further notes, “Going forward, we’ll need to be able to break out the data for individual practices so I can go back to an individual doctor about his or her results. The hope is that by providing data, physicians will change their practices. Doctors will only change when given evidence-based information and resources. It seeps into your consciousness. Building a web-based, protocol-driven platform that everyone in the ACO could use took most of our first year, but will be well worth the time spent.”
An independent evaluator determined that the first “Pioneer” group of ACOs as a whole improved the quality of patient care and saved CMS nearly $150 million in their first year. However, results varied widely among the ACOs participating in that pilot group. Evaluations of the next group of ACOs found that more than 50 of the Medicare Shared Savings Program ACOs spent less than their budgets, but that only 29 of them qualified for shared savings, while 60 ACOs spent more than their budgets.
CMS Advance Payment Model
“Quality scores did increase year over year for the two Maryland Advance Payments ACOs that have been established for two years,” Behm notes. “Even if the ACO program doesn’t last beyond the initial three-year contract period with CMS, it still has value in that it provides consistent care and greater communication. We’ve achieved the philosophical goal. In terms of savings, it’s still early and we didn’t expect significant cost reductions, but among the ACOs created in 2012, one had modest savings and the other did not.”
The CMS Advance Payment Model provided up-front funding as well as some ongoing funding in the form of non-recourse loans. MedChi Network Services also contributed to the ACOs, including that which was put in through in-kind services. To build and operate the clinical and technological infrastructure to manage about 28,000 beneficiaries, the ACOs received about $4 million. However, that amount is not sufficient to take on some of the care that the ACOs would like to have.
Behm notes, “There are lots of things we’d love to do but can’t afford, such as assigning nurse care managers to intensely manage high-risk patients for 90 days, offering multiple telehealth services, and even paying for transportation programs. We have a central team of care managers who do telephone outreach, and who guide practices in evidence-based medicine, but we can’t currently afford to do one-on-one care management.”
Demonstrating savings may not be easy within the fairly short three-year timeframe of the project. “You have to achieve a minimum savings rate to be eligible to share in the savings with CMS,” explains Behm. “The percentage of savings varies with the size of the ACO – with 10,000 beneficiaries, you need to achieve a savings of 3.7%, whereas if you have 50,000 beneficiaries, you need 2% savings. If a small ACO saves CMS 3%, it does not receive any savings back.
ACOs Have Changed Medical Practice
“Our ACO has changed my practice,” says Dr. Gittelman. “Before the ACO, I did many things well, but there were many things that hadn’t been on my radar screen until I was involved with this ACO. Things can get left out because there’s so much to do on any given visit. The ACO emphasizes prevention as well as treatment. We’re not just checking off boxes.”
He continues, “The new waiver plus the ACA represent a sea change, improving the quality of life for sicker populations by keeping them out of the hospital. Hospitals are appropriately scared about the changes, but my hope is that these changes provide an impetus to spend more on preventive care.”
The PCMH Controversy
The National Committee for Quality Assurance (NCQA) has granted NCQA medical home recognition status to about 6,000 practices representing nearly 30,000 providers. The Joint Commission and URAC have validated others.
Several recent articles have reviewed the success of the PCMH model. One of those, an article by Meredith Rosenthal et al., published in the Journal of the American Medical Association in September 2013, may have unnecessarily muddied the waters.
Niharika Khanna, MD, MBBS, director of the Maryland Learning Collaborative for the state’s Multi-Payer Program (MMPP) for PCMH, says, “This paper caused controversy, but it’s based on an advanced primary care program in Pennsylvania that started in 2008 as a chronic disease model and transitioned into a PCMH program. The program focused on efficient chronic disease management, but did not incentivize practices to achieve the triple aim, as PCMH programs do today.”
She adds, “The majority of PCMH programs in the US have demonstrated success in several areas, including reducing ED use and lowering length of hospital stay and overall costs, but some PCMH programs have not demonstrated overt success; hence the controversy. There is a need for PCMH programs to mature over time in order to truly assess the return on investment.”
Maryland: Two PCMH Models
In Maryland, two PCMH programs exist – the state’s MMPP and a PCMH available to physicians participating in CareFirst Blue Cross Blue Shield. Both are demonstrating results, with CareFirst touting savings of $98 million in 2012 and $38 million in 2011.
The MMPP program has demonstrated success in a variety of ways, including enhanced teamwork, embedded care coordination, increased use of medical assistants to the top of their licenses, enhanced satisfaction for both patients and providers and health information technology optimization. Outcomes in the first year are significant for a decrease in the number of asthma admissions, an increase in the use of primary care, decreased use of specialty care and relative decrease in costs of care.
CareFirst: Coordinated Care
More than one million CareFirst members are patients of physicians participating in the PCMH program, and about 80% of eligible primary care physicians in the CareFirst network participate.
CareFirst CEO Chet Burrell says, “We are now well into the fourth year of the PCMH program. In each of the first two years, more than 60% of participating primary care providers earned performance-based increased reimbursements – called Outcome Incentive Awards – through PCMH, and costs for CareFirst members covered by the program were lower than expected. We are still finalizing year-three results, but we expect those positive trends to continue. Just as importantly, we see trends on a number of quality measures that suggest the program is having a positive impact on CareFirst members.”
The program’s success spurred CareFirst to obtain an Innovation Challenge Grant from CMS to expand its PCMH model to Medicare patients, and is expected to launch in a pilot program this summer. CareFirst received $24 million to manage 25,000 beneficiaries through this program.
MMPP: A Better Way to Practice
Data from MMPP is more difficult to obtain, but Dr. Khanna says, “Our program has consistently seen qua
lity enhancements and demonstrated improved teamwork. Emergency visits are decreasing and patient satisfaction is high.”
Melvin Gerald, MD, whose Gerald Family Care practice in Glenarden, Bowie and Washington, DC, has participated with MMPP since 2011, couldn’t agree more. “I was tired of doing things the same way. When the idea of the Maryland PCMH program came along, I was excited. We went electronic in February 2010, which helped.”
Dr. Gerald describes how PCMH changed their way of practicing medicine. “Before PCMH, I thought I was the superstar and the only one who could take care of patients, but I realized that when my staff worked up to their level of certification, they did a better job than I did. It allowed us to see more patients, distinguish ourselves from other practices and enjoy our jobs more.”
He adds, “I’m extremely happy. Patients are receiving better care, and electronic data allows us to act on issues more quickly. Since being recognized as an NCQA Level-3 provider, some insurers are also sending more patients to us.”
Dr. Gerald observes that every patient who comes into their practice, not just their Medicare patients, are benefiting from the PCMH model. He says, “Before seeing any patients, we huddle every morning to discuss patients who may have problems or needs. It’s a cultural change. I used to sign off on lab work, but now our mid-level providers do it. Our patient portal also helps patients be more aware of their health.
“My advice to other primary care physicians is that, if they want to stay in practice and provide optimal care, they should be involved in a program like MMPP,” Dr. Gerald continues. “I have more time to practice medicine thanks to this model. There is more time involved but patients get better care. I totally embrace it.”
The Waiver Impact
The new Maryland Medicare waiver, which went into effect in early 2014, is expected to provide added impetus to ACO and PCMH-like models.
“We have to have hospitals and mental health caregivers involved in the care of patients who are chronically ill and need treatment for end stage diseases,” says Dr. Khanna. “Maryland hospitals are interested in the PCMH model. If they can give us some resources, such as mental health and community health workers, we can help them keep patients healthier and out of the hospital. Many patients still have needs such as housing, transportation and equipment that impact their health. We’re in early discussions with the Maryland Hospital Association and the Health Services Cost Review Commission to figure out the role of the PCMH in the waiver, which gives us a very big opportunity.”
Behm concurs. “I think that the waiver will further incentivize communities to work together to save costs. I’m optimistic about ACOs and hospitals working together.”
Community Integrated Medical Home
Dr. Khanna closes by saying, “Today, primary care is truly at the table and we hope that every new innovation in healthcare reform will consider the foundational role that advanced primary care can play. I personally prefer the term ‘Patient Centered Care’ to PCMH, but reimbursement is challenging if you don’t call yourself a PCMH and obtain recognition through NCQA, the Joint Commission or URAC.
“A new term is the Community Integrated Medical Home (CIMH),” she adds, “where an integrated platform for care delivery is envisioned and public health joins with primary care and hospitals. Howard County is undertaking a pilot program to determine what a CIMH might look like, and the Maryland Learning Collaborative is providing technical assistance to involve primary care in the model and understand how community-based care teams can integrate into the PCMH. Following recommendations from the legislature, a state advisory body, is reviewing many of the issues around CIMH and expects to make a recommendation by December 2014.”
Mitch Gittelman, DO, family practitioner and medical director of the Lower Shore ACO
Craig Behm, executive director, MedChi Network Services
Niharika Khanna, MD, MBBS, director of the Maryland Learning Collaborative and associate professor of Family and Community Medicine, University of Maryland School of Medicine
Melvin Gerald, MD, family practitioner and founder of Gerald Family Care