Massachusetts – Medical Homes
Chapter 224 of the Acts of 2012, signed in August 2012, includes a number of provisions specific to promoting the adoption of patient-centered medical homes (PCMHs) in Massachusetts. This legislation requires a newly formed Health Policy Commission to develop certification standards, a training program, and a model payment system for PCMHs by January 2014. Chapter 224 ensures that existing medical home initiatives, such as the PCMH Initiative described below, may proceed as planned.
In June 2009, the Massachusetts Executive Office of Health and Human Services (EOHHS) convened a state Patient-Centered Medical Home Initiative (PCMHI), when the state Secretary of Health and Human Services invited a wide range of stakeholders to participate in a PCMHI Council. The council developed the PCMHI model, and the state used a request for responses process to select practices to join the PCMHI. In December 2010, EOHHS announced that a diverse group of 46 practices throughout the state were selected to join the project. All 46 practices – which together employ about 500 providers – received a package of technical assistance to support practice transformation. Of these, 32 received enhanced payment in exchange for meeting medical home recognition standards within 18 months of project launch. PCMHI ended in April 2014.
The PCMHI represents one step towards meeting the EOHHS goal of having all Massachusetts primary care practices functioning as medical homes by 2015. Massachusetts’s work with the Safety Net Medical Home Initiative, which launched in 2009 with the goal of helping 14 community health centers become medical homes, represents another step towards the EOHHS vision.
Primary Care Payment Reform Initiative (PCPRI)
Chapter 224 of the Acts of 2012 also requires MassHealth to pursue alternative payment methodologies for enrollees; one way the state is doing so is through the Primary Care Payment Reform Initiative (PCPRI), a three-year initiative which seeks to improve access to care, patient experience, and quality of care, and to increase efficiency through the medical home model and integrated behavioral health services. The PCPRI – a joint project between MassHealth’s primary care case management program, known as the Primary Care Clinician (PCC) Plan, and the state’s Medicaid managed care organizations – will serve MassHealth members.
In March 2013, EOHHS released an RFA to practices seeking participants for a three-year Primary Care Payment Reform Initiative. The program seeks to implement a new payment model which incorporates payment for medical home services and a quality incentive payment, as well as shared savings and, for some, shared risk.
While practices participating in Massachusetts’s Patient-Centered Medical Home Initiative (see above) were eligible to apply for PCPRI, any PCMHI practices selected to participate in PCPRI would no longer be eligible to participate in PCMHI or receive medical home payments through PCMHI.
Massachusetts is one of six states selected in February 2013 by the Centers for Medicare and Medicaid Innovation (CMMI) to receive a State Innovation Model (SIM) Model Testing Award. Massachusetts received $44 million to implement and test its State Health Care Innovation Plan, which builds on the state’s work to advance patient-centered medical homes as well as accountable care organizations, profiled on the Massachusetts page of NASHP’s State Accountable Care Activity Map.
The federal government provides federal financial participation (FFP) for the enhanced reimbursements that Medicaid/CHIP and Medicaid managed care organizations pay to participating providers.
Massachusetts has also received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”
Last Updated: June 2014
Massachusetts Patient-Centered Medical Home Initiative: The Massachusetts Patient-Centered Medical Home Initiative (PCMHI) Council included representatives of:
For more information, please see the PCMHI Council webpage.
|Defining & Recognizing a Medical Home||
Chapter 224 of the Acts of 2012 defines a medical home as: “a model of health care delivery designed to provide a patient with a single point of coordination for all their health care, including primary, specialty, post-acute and chronic care, which is (i) patient-centered; (ii) comprehensive, integrated and continuous; and (iii) delivered by a team of health care professionals to manage a patient’s care, reduce fragmentation and improve patient outcomes.”
Primary Care Payment Reform Initiative (PCPRI): The PCPRI has identified ten core competencies for participating practices, many of which overlap with the PCMHI core competencies listed above:
Chapter 224 of the Acts of 2012 requires a newly formed Health Policy Commission, with consultation from the Office of Medicaid, to develop and implement medical home certification standards by January 1, 2014. The legislation requires the commission to consider existing accreditation standards, including those developed by the National Committee for Quality Assurance (NCQA). The legislation requires the standards to include:
Chapter 224 also requires certified medical homes to use adopt an electronic medical record by December 31, 2016.
Massachusetts Patient-Centered Medical Home Initiative: PCMHI practices were required to achieve at least National Committee for Quality Assurance (NCQA) Level 1 recognition, including three otherwise optional NCQA standards. Participating practices were required to achieve NCQA Level 1 “plus” recognition within 18 months of project launch.
Primary Care Payment Reform Initiative (PCPRI): PCPRI practices are required to achieve NCQA Level 1 recognition within 24 months of joining the program.
Participating practices must also have:
Participating practices are required to provide integrated primary care and behavioral health services, with coordination and information sharing between primary care and behavioral health providers. Participating practices must pursue one of three behavioral health integration strategies which align with the requirements listed below: non-co-located but coordinated; co-located; and clinically integrated.
Participating practices are assigned a Comprehensive Primary Care Payment (CPCP) Tier based on the level of behavioral health covered services provided by the practice (see Attachement K of the PCPRI RFA for a list of behavioral health covered services):
For more information, see section 3 of the PCPRI RFA.
|Aligning Reimbursement & Purchasing||
Chapter 224 of the Acts of 2012 requires the newly formed Health Policy Commission to develop a model payment system for certified patient-centered medical homes by January 1, 2014. The commission is required to consider per-patient payments, payments adjusted on patient-complexity; payments for care coordination/clinical management, performance-based payments, and shared savings.
Massachusetts Patient-Centered Medical Home Initiative:
The following payers and purchasers made enhanced payments through the Massachusetts Patient-Centered Medical Home Initiative (PCMHI):
Payers made several types of payments to support participating medical homes prior to the end of PCMHI in April 2014:
Primary Care Payment Reform Initiative (PCPRI): Participating practices receive three types of payments:
For more information on how the state plans to calculate CPCP, quality incentive, and shared savings/shared risk payments, including target spend and actual spend, see Attachement A of the PCPRI RFA.
Practice performance on 23 quality measures that will also impact P4R (all years), P4Q (Years 2-3), and SS (Year 3 only) payments. For more information on the selected measures, including impact on payment, see Attachement D of the PCPRI RFA.
Chapter 224 of the Acts of 2012 requires the newly formed Health Policy Commission to establish a patient-centered medical home training program; participation in the training program may be necessary for certification.
Massachusetts Patient-Centered Medical Home Initiative: Patient-Centered Medical Home Initiative (PCMHI) practices received a variety of supports, including:
Primary Care Payment Reform Initiative (PCPRI): Massachusetts Executive Office of Health and Human Services (EOHHS) provides participating practices with a variety of supports through learning collaboratives and other means:
Massachusetts Patient-Centered Medical Home Initiative: The University of Massachusetts Medical School’s Department of Commonwealth Medicine will conduct an evaluation of the Patient-Centered Medical Home Initiative (PCMHI).
Primary Care Payment Reform Initiative (PCPRI): The PCPRI RFA identifies 23 quality measures that participating practices will be required to report across six domains:
These measures will impact pay for reporting, pay for quality performance, and shared savings payments over the course of the three year initiative. For more information on the selected measures, including impact on payment, see Attachement D of the PCPRI RFA.