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PCMH: MCO Demonstrates Characteristics of an Advanced Patient-centered Medical Home Model
A Colorado managed care organization, Rocky Mountain Health Plans (RMHP), aligns clinical decision-making through advanced analytics, behavioral health integration, data quality, and improved process, said Patrick Gordon, MPA, associate vice president, RMHP, during a session at PCMH Congress 2015. He believes that RMHP is one to emulate when establishing a patient-centered medical home (PCMH) model.
AN ADVANCED PCMH SETTING
RMHP, which serves about 350,000 people in Western Colorado, is a fully integrated, team-based organization that is connected to the community and uses advanced measures of value, predictive analytics, and feedback driven data quality process to inform clinical judgment and patient decision-making. Virtual clinics, asynchronous practice, and care management are used for patient care. Accepting all forms of insurance coverage, it uses a payment model that is based on risk adjustment and shared savings, with a goal of delivering value-based care.
Common characteristics of advanced PCMH settings, according to Mr Gordon include persistence through multiple learning initiatives, active engagement in all aspects of transformation, connection to external partners and supporters, and recognition of PCMHs. Variations among advanced PCMH settings include varying degrees of business competencies; patient volume; multiple electronic health record platforms and configurations; and type of institution (small, multi-specialty, independent, or hospital-owned).
A critical facet of an advanced practice, he said, is behavioral health integration. To create team-based, whole-person care, global payment is based on defined practice budgets for personnel, interventions, and related infrastructure. “RMHP global payments to advanced primary care practices for integrated behavioral health represent <1% of total spending for attributed patients, but create a tremendous opportunity to improve patient experience and clinician experience while reducing costs,” Mr Gordon said.
“It is essential that integrated behavioral health models include medication review and management practices,” noted Catherine Cooke, PharmD, research associate professor, University of Maryland School of Pharmacy, when contacted by First Report Man-aged Care. “Since medications are the cornerstone of chronic management of disease, pharmacists need to be integrated into the model to provide these services.” According to Mr Gordon, a practice needs to have 20% to 30% of its patients come from RMHP to create a return on investment, given the practice-specific budget to finance behavioral health RMHP uses. “Greater multi-payer commitment to funding advanced primary care would enable RMHP to fund integrated behavioral health in a broader network of advanced practices,” he said. “RMHP actively sup-ports the Colorado State Innovation Model (SIM) program for this reason.”
SIM aims to transform the Colorado health system by integrating behavioral health and primary care to achieve lower costs, better care, and improved population health. A cornerstone of this program is to improve access to behavioral health services and programs for most Coloradoans.
OWNING BEHAVIORAL HEALTH RESOURCES
Mr Gordon emphasized that behavioral health providers at RMPH “are not trapped in a workflow designed to maximize volume-based payments, or pigeon-holed into distinct ‘physical’ and ‘mental health’ coding categories.”
“Primary care practices ‘own’ their own behavioral health resources and are fully accountable for mea-sured outcomes,” he said.
To measure outcomes, he said that advanced primary care practices are compared longitudinally with network peers in conventional fee-for-service contracts. Quality is assessed over validated prac-tice baselines and milestone progress, and regular feedback is given to practices (ie, via monthly reports providing information on comparative utilization and total cost statistics and regular in-person review with health plan staff ).
“RMHP often sees relatively rapid improvement in longitudinal clinical quality score once practice data is validated and baselines are set,” Mr Gordon said. “Significant improvement in several measures, from tobacco cessation to diabetes and cardiovascular management, has been achieved by RMHP partner practices participating in the Centers for Medicare & Medicaid Services’ Comprehensive Primary Care Initiative.”
Designed to strengthen primary care, the Comprehensive Primary Care Initiative is a 4-year, multi-payer initiative launched in October 2012 in collaboration with commercial and state health insurance plans. Participating primary care practices are offered population-based management fees and shared savings opportunities to support a core set of comprehensive primary care functions.
Mr Gordon also said that RMHP has seen meaningful reductions in the total cost of care for members because of advanced primary care practices, about a 3% to 4.5% lower cost of care for their patients compared to their peers in conventional fee-for-service arrangements.
“Cost reductions are attributable to lower inpa-tient utilization, fewer hospital admissions, lower emergency department utilization, and referrals to lower-cost, higher-quality sources of specialty, outpatient, and inpatient care,” he said.
MAKE “LESS IS MORE” AN INTENTIONAL STRATEGY
For quality measurement, Mr Gordon emphasized making “less is more” an intentional corporate strategy that focuses on practice competency and data quality. To work with Medicare, the exchanges through the Affordable Care Act, and Medicaid, he said that measures should be aligned with major Healthcare Effectiveness and Data Information Set domains. He also highlighted a number of better measures of value being pursued in select programs and practices, including Patient Activation Measure and Global Outcomes Score/Averted Events Incentives.
Overall, Mr Gordon said that RMHP intends, over the next 3 to 5 years to push aggressively the advanced primary care model and fully replace evaluation and management reimbursement with risk adjusted, global payment. He also said they intend to expand across multiple lines, and emphasized the importance of incorporating multi-payer initiatives.—Mary Beth Nierengarten
