There is good news and bad news from the Medicaid Council’s PCCM committee meeting last Friday. The good news is that the department has agreed to revise the PCCM evaluation to be a constructive tool to move the program forward. PCCM program plans unfortunately are not as hopeful. There are no current plans to expand the program beyond Putnam and Torrington, as directed under a law that passed unanimously last year.
DSS is beginning from scratch to re-design the program with a lot of open questions. While advocates and providers have had difficulty having input, DSS has promised to update us regularly on their decisions. Advocates and providers expressed frustration that DSS will not be pursuing a more collaborative process or building on the work already done three years ago in a collaborative group with DSS staff. DSS expressed goals of having 30% of Medicaid members in patient-centered medical homes (PCMHs) by January 1, 2012, 60% by Jan. 2013, and 100% of Medicaid members in PCMHs by January 2014. DSS suggested that the new PCMH program might be based on national standards, but they did not make any commitment.
In a troubling suggestion they opened the door to changing the definition of provider from an individual to an entity. While the paperwork burden is higher for large clinics, literature suggests that better health outcomes are linked to a strong patient-provider relationship. Research on best practices was the basis for this decision by the prior DSS/advocate working group. PCMH patients have far better outcomes if they are connected in a continuous relationship with an individual and they know that person’s name. This is a problem in large clinics, where turnover and large staffs make a continuous, productive relationship most difficult.
The department also opened the door to changing the hard-fought $7.50 pmpm care management fee negotiated in the DSS-advocate working group. They expect to conduct a survey of other states’ care management rates, and will likely find that rates are often lower elsewhere; however it is critical to also survey expectations of providers, supports and resources available and fee structures in those states. Any reduction in the care management rate will be a significant barrier to engaging and retaining participating providers. The $7.50 pmpm is far below the $18.18 pmpm rate paid to HMOs in HUSKY during the recent ASO arrangement, for a different but largely administrative set of services requiring far less labor-intensive patient contact. Some states link reimbursement to accreditation levels.
Other design questions include voluntary vs. mandatory assignment of patients to PCMHs, hospital inpatient rates, patient attribution to PCMHs, marketing restrictions, and performance incentives. We are puzzled by DSS’ need to review removing the unnecessary and intimidating Freedom of Information provision in provider PCCM contracts; this is one place DSS could easily free up some of their staff time and resources. Thankfully, their documents make clear that risk-adjusted capitation rate setting and gain sharing are “not applicable” to the PCCM program. Unfortunately DSS’ plans are silent on monitoring and enforcement, always a weak point for CT’s programs. There was a troubling suggestion of tying PCMH performance incentives to health IT meaningful use measures – a symptom of general misunderstanding about the nature of the PCMH model. Technology is only a small part of PCMH practice transformation and is linked to many other health reform initiatives. Advocates urged DSS to acknowledge the integrity and commitment of current PCCM providers who agreed to participate in a program that was not historically supported by DSS, because they believe strongly in empowering patients, care coordination, and the PCMH model.
Advocates renewed concerns about including care coordination responsibilities in the ASO contract, especially in the absence of evaluation and monitoring to ensure conflicting interests do not inhibit PCMH development. In a promising development, DSS plans to hire consultants to help design, research and gather stakeholder input for this process – a very welcome change that has potential to move past barriers and get this program off the ground.