Purchaser and Health Plan Initiatives to Support Medical Home Development

1
Purchaser and Health Plan Initiatives to Support
Medical Home Development

• Don Liss, MD
• Regional Medical Director
• Aetna

2
Why are Payers Involved?

• Frustrated by well established problems with our
  current delivery system
• Cost, quality, access, satisfaction,
• Disorganized, uncoordinated,
• Impending shortage of physicians in primary care
  specialties
• Appreciation that primary care is good
• Responsive to Customers

3
How Health Plans and Purchasers are Getting
Involved?

• Individual Health Plan Programs
• Network wide efforts
• Single practice or medical group efforts
• Multi-Stakeholder Programs
• More complicated require compromises
• Purchasers (Large Employers)
• Asking about their health plans involvement
• Demanding involvement

4
Challenges for Health Plans

• There is no direct, compelling evidence
  demonstrating that PCMH will result in lower net
  medical costs
• There is a body of literature supporting this
  conclusion, but it is indirect
• Collaborating in multi-stakeholder pilots
  surrenders a competitive advantage
• Customers differ in their interest
• Operational complexities in mechanics and
  accounting

5
Patient Centered Medical Home Demonstration in
Philadelphia

• Convened by the Pennsylvania Governors Office of
  Health Care Reform through the Chronic Care
  Commission as part of Gov. Rendells Rx for
  Pennsylvania
• Supported by all of the major health plans in
  Southeastern Pennsylvania
• Aetna, Independence Blue Cross, Cigna
• All 3 Medicaid plans
• Promoted by the primary care professional
  organizations (ACP, AAFP, AAP) and their PA
  affiliates

6
How it works

• 32 Practices agree to transform into Patient
  Centered Medical Home practices
• Participate in 4 Learning Collaborative sessions
  over 7 days
• Delivered by MacColl Institute under contract to
  GOHCR
• Learn to implement the Wagner Chronic Care Model
• Use a patient registry for diabetes (adults) and
  asthma (peds)
• Intent is to expand to more conditions in the
  future
• Engage with practice coaches from PA Improving
  Performance in Practice
• Assistance with nuts-and-bolts of transformation
  to PCMH
• Assistance with application for NCQA designation
  as PCMH
• Achieve NCQA PPC PCMH designation at Level 1 by
  the end of first year

7
What practices get

• Health Plans make enhanced payments to practices
  in addition to existing compensation
• 20,095 (in the aggregate) per practice in year 1
  for participating in Learning Collaborative,
  using registry and applying for NCQA designation
• 35,000 to 80,000 per FTE physician (or NP) per
  year upon achievement of NCQA designation through
  year 3
• Varies by practice size and PCMH Level achieved

8
Some details

• GOHCR is the organizing entity
• Establishes the schedule for enhanced payments
• Monitors performance
• Organizes/staffs Learning Collaborative
• invoices health plans for enhanced payments due
  to practices
• Enhanced payments are allocated to participating
  health plans in direct proportion to their
  penetration in a given primary care practice
• 3 Year Commitment with intent to establish a
  common set of outcome measures to be used in a
  payment model in the future
• Formal evaluation to be conducted to assess
  clinical, financial, patient satisfaction/engageme
  nt and professional acceptance outcomes.