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Practices receive pay for medical home services
e-Reports, Sept. 3, 2013
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Finally, insurer support for the patient-centered medical home (PCMH) is coming to Indiana. That means availability of per member per month payments to help cover the costs of care coordination, preventive care, extended hours and other PCMH services. ISMA Reports explained the PCMH concept in a three-part series last year (see the 2012 ISMA Reports archives).

Anthem, the state’s largest insurer, is now contracting with central Indiana primary care physician practices for its new Patient-Centered Primary Care Program. If you deliver primary care elsewhere in the state, Anthem representatives will likely visit you this fall. And other major commercial insurers are not far behind Anthem, as ISMA Reports will discuss in future issues.

However, Anthem believes it has the numbers to really make a difference. An AMA report last year indicated the insurer has 56 percent of the Hoosier market. And, so far, Anthem representatives say they’re getting a positive response.

“Doctors know this is where we need to go,” said Meredith Carlson-Cristo, Anthem’s state network director for Payment Innovation. Central Indiana is a starting point because Jan. 1 many area physicians will stop receiving bonuses from Quality Health First, started in 2006 by the Employers Forum of Indiana. The Anthem program is expected to fill the financial gap left by Quality Health First.

Twelve states are already on board with the new program; Indiana and Kentucky are now being added. “We learned a lot from others, so we think we will be more successful here,” said Carlson-Cristo. The program is open to group practices, as well as solo physicians; small practices will be combined with others for calculating shared savings.

Patients will be attributed in two ways: 1) Anthem will use past claims histories to determine where patients are receiving care or 2) patients will select their physicians.

Program fee structure
Primary care practices in the program will file claims as usual and still be paid on a fee-for-service basis; however, they will also receive a:

  • Per member per month (PMPM) payment to cover costs of care planning and follow up that are integral to PCMH
  • Shared savings bonus that reflects how much the practice saves

“The PMPM rate depends on a risk score of patients and projects future costs,” explained Carlson-Cristo. “Doctors will get a list of attributed patients, each with a risk score.”

The standard PMPM base rate is $3.50 per month, which will be multiplied by members’ risk scores to reach the PMPM payment. For example, payment for a pediatric patient may be $1.75 PMPM due to a lower risk score. The PMPM for chronic disease patients with co-morbidities who are more resource-intensive will be higher than $3.50.

Shared savings dollars are dependent on a physician’s quality score. “If doctors do really well, they can earn up to 35 percent of any savings,” said Carlson-Cristo.

However, a quality threshold, a minimum level of quality, must be achieved before any savings will be awarded. For physicians, Anthem has 29 clinical measures and 3 utilization measures that include avoiding ED visits and potentially avoidable hospitalizations, plus use of generic drugs.

Anthem case managers will help patients and provide resources. Anthem will deliver care management reports to the practice, showing gaps in care and patients pre-certified for an inpatient admission, while identifying patients who need more intensive management.

Practices will gain access to Anthem’s Member Medical History Plus, an internal record offering a larger view of the patient’s overall health. An electronic health record is not required, but Internet access will be essential for viewing reports.

Find an Anthem brochure and a listing of the clinical and quality measures here.

Reaction from some physician leaders
Dr. Patel“Overall, I think this is good for Indiana, said Risheet Patel, M.D., chairman of the board and immediate past president, Indiana Academy of Family Physicians. “As a state, we’ve been behind in having actual programs that paid money for PCMH transformation. This is the first widespread program that will reward a practice for becoming a PCMH. Hopefully, other payers and programs will follow.”

Risheet Patel, M.D., chairman of the board and immediate past president, Indiana Academy of Family Physicians

Dr. Emkes“Coordinated care is better for patients than uncoordinated care,” said Bernard J. Emkes M.D., medical director of Managed Care Services, St. Vincent Health and past ISMA president. “This is a way for Anthem to promote the medical home model of care. Shared savings should be possible and could be significant as a result of less ER use – extended physician office hours – less duplication of tests, coordination of care, etc. Primary care physicians can be properly rewarded for better access and improved care coordination, which reduces overall health care costs”.

Bernard J. Emkes, M.D., medical director of Managed Care Services, St. Vincent Health and ISMA past president

Dr. Ratiliff“Anthem’s PC2 program appears to be a good start for providers and insurers to work collaboratively to improve the value of care we extend to our patients, said Wesley Ratliff, M.D., president of Premier Healthcare. “Changing the delivery model of healthcare is not flipping a switch, it requires a significant investment in technology and personnel. The PMPM payment will help give PCPs the resources needed to increase their time and services to better coordinate care and thus improve quality while hopefully decreasing costs.”

Wesley Ratliff, M.D., president of Premier Healthcare

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