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States make progress with medical homes

Exclusive of the health reform law, a majority of states have established delivery system qualifications and payment policies to promote Medicaid's medical homes program.

But even not depending on the Affordable Care Act, those proactive states have found the health reform law's incentives are useful to push providers who were previously undecided to get on board with transforming their care delivery.

Twenty-six states over the past several years have adopted policies to make payments to healthcare providers that meet medical home standards, said Mary Takach, program director, National Academy for State Health Policy (NASHP).

To receive payments, providers meet the National Committee for Quality Assurance's (NCQA) medical home standards, but some states also have their own qualifications and standards or a mix of both, she said. The NCQA sets conditions for recognition of medical homes that foster teamwork between patients and their physicians and the care team.

With a medical home, providers use electronic health records (EHRs), health information exchange and registries to make sure that patients get the appropriate care.

Providers typically receive a monthly Medicaid care coordination payment, while some states add a performance-based payment retrospectively.

"But there is a lot more interest now among states in evolving the performance-based payments to shared savings," she said at the May 31 Medicaid Congress.

The Patient Protection and Affordable Care Act has driven the expansion of the medical home concept to a medical neighborhood with community services outside provider practices because the federal government will fund a 90 percent match for two years.

ACA has moved some states "that have been on the bench, not doing a whole lot on delivery system reform to move off the bench to get their primary care delivery system in line," Takach said.

The additional services integrate behavioral services, transition from the hospital and other community services. Five states have approved such plans -- Missouri, Rhode Island, Oregon, New York and North Carolina, while 15 states have received planning grants.

Lisa Letourneau, MD, executive director of Maine Quality Counts, a regional healthcare improvement collaborative, is a physician champion for the Maine Patient-Centered Medical Home pilot. The Maine pilot includes Medicaid and private payers, the majority of which had also participated in the Medicare Multi-Payer Advanced Primary Care Practice demonstration started two years ago.

Maine was able to develop a process and eligibility criteria for the expansion of the multi-payer pilot with the state's emerging health homes initiative and launched it as a joint process earlier this year.

"We require NCQA recognition as an opening bar for the multi-payer pilot, but there are other features that need to be included, like helping to control costs, accountability and including patients in redesign effort," she said.

She said that 108 practices have applied for the Medicaid health home pilot, and the opening bar was that they had to have NCQA medical home recognition or applied for it, have an EHR and commit to 10 core expectations of medical home that go beyond NCQA conditions.

Connecticut started later than many other states. It only launched in January its Medicaid medical home program to move away from a traditional capitated managed care model, said Mark Schaefer, director of medical care administration in Connecticut's Department of Social Services.

Connecticut offers some enhanced reimbursement for practices that agree to get on the glide path to NCQA, conduct a gap analysis and work plan, have a dedicated champion in the practice to move it along and a business plan for EHR adoption.

"We felt the need to fuel the interest in transformation, to get folks from sitting at a traffic light to meeting the NCQA standard. So we will give you an immediate bump in your reimbursement if you can demonstrate to us that you have a plan for getting there within 18 months," he said.

This could help federally-qualified health centers (FQHCs) and small practices that wanted to get to NCQA recognition but couldn't easily without some additional funding.

The FQHCs also needed technical assistance and practice support, so Connecticut started a medical administrative service organization (ASO), contracting with specialty vendors for data analytics, behavioral health, dental and transportation services – in a sense bringing managed care technologies to the whole state.

In addition to NCQA standards, Connecticut added requirements to be eligible for the enhanced reimbursement, including timely behavioral health services and smoking cessation programs.

"We see medical home as a way to get advanced primary care practice, which is the beginning, not the end," Schaefer said. "You have advanced primary care practice as a ticket to admission to being able to do great things like health home and complex things because that's just better basic care."