Maryland – Medical Homes

In April 2010 Maryland enacted SB 855/HB 929. This legislation requires the Maryland Health Care Commission (MHCC) to establish a Maryland Patient Centered Medical Home (PCMH) multi-payer program. All payers with premium revenues of over $90 million are required to participate.

MHCC released a request for proposals (RFP) in December 2010, and selected 53 practices, employing 339 providers (including about 60 nurse practitioners and physician assistants). The selected practices are geographically dispersed throughout the state. Further information is available here. In January 2013, the Maryland Health Care Commission reported that 250,000 patients were attributed to participating medical homes.

The Maryland initiative is unique in that:

  • Explicit allowance is made for single-carrier PCMH programs (distinct from the multi-payer program), with authorization from the MHCC.
  • A unique payment methodology has been developed that makes special accommodation for small practices.
  • Shared savings payments are being calculated separately for each practice.

For more information, please see the Maryland Health Quality and Cost Council’s PCMH Workgroup website and the state PCMH website. The practice participation agreement is also available online.

In January 2012, Maryland was selected to join the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community. As a part of this Learning Community, Maryland was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Maryland’s participation in the IMPaCT project enhanced the state’s ability to provide support to primary care practices and share practice data for quality improvement through a number of strategies, including assisting practices in achieving PCMH transformation and adopting EHRs.<

Last Updated: April 2014

Federal Support:
  • On September 27, 2013, CMS approved a Section 2703 health home state plan amendment, creating health homes for Medicaid enrollees with opioid substance use disorder. The SPA became effective as of October 1, 2013. Maryland was a recipient of a planning grant from CMS to develop its state plan amendment. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
Forming Partnerships
The Governor’s Council created the Patient Centered Medical Home (PCMH) Workgroup in 2009 to work toward creating an all-payer medical home pilot. Three subgroups—focusing on foundations, practice transformation, and purchaser/consumer education—of workgroup members and other stakeholders were formed. The subgroups were instrumental in selecting the program participation criteria, transformation activities, quality performance measures, and payment strategies.
Project staff has met with a wide range of stakeholders, including:
  • The state medical society;
  • Professional family practice and pediatric associations;
  • The hospital association;
  • Federally qualified health centers (FQHCS);
  • Nurse practitioners;
  • Private payers and managed care organizations (MCOs);
  • Local health departments;
  • The Department of Health and Mental Hygiene (DHMH) Office of Minority Health & Health Disparities; and
  • Private, academic, and hospital based practices.
The Maryland Health Care Commission (MHCC) has also created a web PCMH portal for providers and hosted seven regional symposia to introduce the initiative to providers.
Maryland participated in the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community, where it was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Through participation in this project, Maryland strengthened partnerships between state government and universities, among hospitals, and between practices and external partners such as provider associations and non-profits.
Defining & Recognizing a Medical Home
Definition: SB 855/HB 929 defined a patient centered medical home (PCMH) as: “a primary care practice organized to provide a first, coordinated, ongoing, and comprehensive source of care to patients to:
  1. Foster a partnership with a qualifying individual;
  2. Coordinate health care services for a qualifying individual; and
  3. Exchange medical information with carriers, other providers, and qualifying individuals.”
Recognition: National Committee for Quality Assurance (NCQA) medical home recognition, with additional expectations. Practices without NCQA recognition or with recognition expiring after March 2011 must meet the NCQA 2011 standards; others may meet the NCQA 2008 standards. The additional expectations are specified on page 25/B-3 of the practice participation agreement, and include capabilities around 24/7 access, registry use, medication reconciliation, e-prescribing and more. Practices show that they have these additional capabilities by achieving certain NCQA elements that are optional under the standard NCQA system.
Practices were required to achieve Level 1+ recognition no later than March 31, 2012. The state announced that, as of April 2012, all pilot practices achieved this milestone. Practices were required to submit an application for Level 2+ recognition no later than September 30, 2012.
Nurse practitioner-led practices are eligible for state recognition as medical homes.
Aligning Reimbursement & Purchasing
The five largest commercial payers in Maryland – Aetna, CareFirst BlueCross BlueShield, CIGNA, United Healthcare, and Coventry – are required to make payments to participating practices under SB 855/HB 929. Medicaid has budgeted $1.5 million for fiscal year 2012 and $2.89 million in fiscal year 2013 to provided fixed transformation payments. Further information on the methodology that these payers will use to attribute patients is available in the practice participation agreement.
Participating providers are eligible for ongoing per member per month payments (PMPM) referred to in Maryland as “fixed transformation payments.” Fixed transformation payments, paid twice a year, facilitate practice-level infrastructure improvements. Practices may also be eligible for “shared savings payments” as described below.
Fixed transformation payments are calculated as specified below. In general, smaller practices receive higher PMPM payments than larger practices all else being equal. Likewise, practices with higher recognition levels receive greater PMPMs. Federally qualified health centers (FQHCs) are not eligible for fixed transformation payments. The exact amounts of the fixed transformation payments are adjusted annually on the basis of the Medicare Economic Index.
Commercial Population
Practice sites with fewer than 10,000 patients:
Level 1+: $4.68 PMPM
Level 2+: $5.34 PMPM
Level 3+: $6.01 PMPM
Practice sites with 10,000-20,000 patients:
Level 1+: $3.90 PMPM
Level 2+: $4.45 PMPM
Level 3+: $5.01 PMPM
Practice sites with more than 20,000 patients:
Level 1+: $3.51 PMPM
Level 2+: $4.01 PMPM
Level 3+: $4.51 PMPM
Medicaid Population
All practice sizes:
Level 1+: $4.54 PMPM
Level 2+: $5.19 PMPM
Level 3+: $5.84 PMPM
Medicare Advantage Population
All practice sizes:
Level 1+: $8.66 PMPM
Level 2+: $9.62 PMPM
Level 3+: $11.54 PMPM
All participating practices—including FQHCs—are eligible for shared savings payments if they meet performance criteria. The performance criteria include measures around evidence-based practices and utilization reduction such as:
  • Blood pressure measurement (also a Centers for Medicare & Medicaid Services (CMS) electronic health record (EHR) meaningful use core measure);
  • Adult Weight Screening and Follow-Up (also a CMS EHR meaningful use core measure);
  • Reduction in 30-day readmission rate;
  • Reduction in number hospital days per 1,000; and
  • Reduction in emergency room visits per 1,000.
Practices that meet the performance criteria will then be entitled to payments of 30 percent to 50 percent of any savings generated by the practice. FQHCs will be able to share in 65 percent of savings for patients with Medicaid coverage.
Savings will be calculated separately for the commercially insured, Medicaid, and Medicare Advantage populations. The calculations will entail comparing expected costs for a given practice’s population (as derived from baseline data) with actual costs for the practice population. Expected costs will be adjusted to include medical inflation. It should be noted that fixed transformation payments will be included in determining actual costs. Therefore, practices must generate savings beyond the amount of the fixed transformation payments in order to be eligible for incentive payments. (FQHCs are eligible for “first dollar” shared savings, as they are not receiving fixed transformation payments.) Provision is made for the Maryland Health Care Commission (MHCC) to adjust the incentive payment algorithm in recognition of changes in practice case mix or for outliers.
The MHCC announced in October 2012 that 23 of the 52 participating pilot practices received shared savings payments from Aetna, CareFirst BlueCross BlueShield, CIGNA, United Healthcare, and Coventry. The total incentive payments, based on 2011 performance metrics and savings, were $815,669.62.
Full details on the payment methodology are available online in the practice participation agreement.
Supporting Practices
According to the practice participation agreement, the Maryland Health Care Commission (MHCC) is responsible for establishing a learning collaborative with the support of the Community Health Resources Commission (CHRC). The objectives of the learning collaborative are to support practices in obtaining medical home recognition and effectively using a care manager. Practice staff are required to participate in the learning collaborative. A timeline of learning collaborative activities— which include webinars, in-person large group meetings, site visits, and regional meetings—is available here.
The CHRC is also providing the MHCC with resources to hire “practice transformation coaches.” Coach responsibilities include:
  • Providing registry support for practices without electronic medical records (EMRs);
  • Developing practice-specific medical home implementation plans and timetables; and
  • Providing support for achieving National Committee for Quality Assurance (NCQA) medical home standards.
Practices will be expected to use an MHCC-provided registry unless they have an acceptable EMR.
Maryland participated in the North Carolina Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Learning Community, where it was one of four states to receive technical assistance and guidance from North Carolina on how to develop a primary care support and quality improvement system. Through participation in this project Maryland provided support to primary care practices. Mary supported all of the practices participating in the Maryland Multi-Payer Patient-Centered Medical Home Program (MMPP) in implementing an Electronic Health Record (EHR). Additionally, 65% of the practices now participate in the State-Designated Health Information Exchange. The Maryland Learning Collaborative (MLC) used an expert consultant to train Practice Transformation Coaches who provide logistical and educational support to primary care practices in transforming into PCMH. Additionally, the MLC secured a care manager responsible for implementing the changes necessary for practices to become PCMHs in each of the pilot practices.
Measuring Results
SB 855/HB 929 directs the Maryland Health Care Commission (MHCC) to adopt a, “uniform set of health care quality and performance measures that the participating patient centered medical home is to report to the commission and,” health plans. MHCC has contracted with Impaq International to conduct an evaluation of the program.
The evaluation will draw on multiple data sources including: claims information, condition-specific quality measures, and patient/provider satisfaction surveys. MHCC expects to use a, “pre/post treatment with a quasi-experimental control group of similar practice.” As of August 2011, the evaluation was expected to be more expensive than had originally been estimated.