Medicaid PCMH update

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Today’s Care Management Committee meeting (formerly the PCCM Committee) in Hartford was frustrating. DSS and their consultants outlined their final plan for CT Medicaid’s person-centered medical home (PCMH) transformation. Unfortunately the final plan is not substantially different than the original proposal which raised concerns among advocates. Most contentious was DSS’ refusal to match consumers and PCMHs prospectively, and to pay providers based on that linkage. Based on strong evidence of improved health outcomes, advocates argued for an enrollment/attribution process to ensure that every person knows who their personal PCMH is — who they should call first with a problem, who is watching out for their health. It is equally important that every PCMH understand, up front, which people they are responsible for. The lack of attribution also creates the possibility that NCQA-certified PCMHs will get enhanced payment rates for services provided to patients whose care is being coordinated by another practice, similar to criticisms of retail clinics by primary care practices. DSS raised some operational issues within the department as barriers to creating that essential linkage and remains committed to an enhanced fee-for-service (FFS) payment system. Advocates and others have criticized FSS for encouraging duplication and over-utilization of services, and discouraging care coordination and non-traditional care delivery such as email, phone communication, group visits, etc. Enhanced FFS also provides practices with incentives to hire more clinicians to drive more visits while per member per month prospective payments support whatever resources are most effective to improve care, including hiring care managers. The modest increase in payment rates (10% to 20%) DSS is proposing will occur in the context of much larger Medicaid primary care rate increases in 2013 under national reform when, for example, adult medicine rates will double on average, for all providers regardless of whether they are PCMHs or not. DSS acknowledged the issue and stated that they intend the program to serve only as a bridge to a wider transformation of Medicaid and will likely only appeal to providers who already serve a significant Medicaid population and are already planning PMCH transformation. While improved over the last version, the proposal’s reimbursement model budget justification continues to emphasize physicians over other members of the PCMH team, devoting almost half of total on-going costs to physician time. They did increase upfront payments to small practices (5 FTEs or less could get up to $25,000 per year for 3 years) above the original glide path payments before practices are PCMH certified. While providers and consultants were intimately involved in development of the plan and their concerns are reflected in added costs for the proposal, advocates strongly objected to representations that the process was respectful and inclusive of all voices.
Ellen Andrews