Pennsylvania – Medical Homes

Pennsylvania’s Chronic Care Initiative (CCI) began as a project of the state’s Chronic Care Commission, which former Governor Ed Rendell created by Executive Order in 2007. Phase I of CCI (2008-2011), which combines elements of Wagner’s Chronic Care Model and the patient-centered medical home, was staged in seven regional rollouts. The program model varied regionally during Phase I, with differences over requirements to obtain NCQA medical home recognition, payments to practices, and other features. The Southeast Pennsylvania region was the first to launch, beginning with a learning session in May 2008. Six payers participated in the Southeast rollout, and practices were encouraged to focus on diabetes and pediatric asthma. Subsequent rollouts in other regions of the state followed similar models. As subsequent regions launched, the state refined the programs on the basis of lessons learned, and added components, such as shared savings. Four of the seven rollouts featured ongoing enhanced reimbursement from multiple payers. Three offered more limited assistance, without ongoing payment for medical home expenses.

Medicare joined CCI as a payer in two regions through the MAPCP Demonstration on January 1, 2012, launching Phase II of the initiative. Phase II features a single payment methodology for the Northeast and Southeast Pennsylvania regions, as well as coordinated requirements and learning collaborative activities for participating practices. In conjunction with a change in governor’s administration in 2011, oversight of the program has moved to the Pennsylvania Department of Health.

Federal support: Pennsylvania is one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program.

Also, the federal government provides federal financial participation (FFP) for the enhanced reimbursements that Medicaid managed care organizations and Medicaid fee-for-service pay to participating practices.

Last Updated: April 2014

Forming Partnerships
The Chronic Care Commission, which developed the Chronic Care Initiative (CCI), included representatives from the following groups:
  • Providers, including primary care physicians, registered nurses, nurse practitioners, physician assistants, pharmacists, and specialists
  • Health insurance carriers
  • Hospitals
  • Home health care
  • Philanthropy
  • Consumers
Defining & Recognizing a Medical Home
Definition:
Pennsylvania has adopted the Joint Principles of the Patient-Centered Medical Home as the state’s medical home definition.
Recognition:
The Chronic Care Initiative (CCI) requires practices to achieve National Committee for Quality Assurance (NCQA) Level 1 recognition, as well as certain otherwise optional standards at specified levels of performance. As practices’ NCQA 2008 recognitions expire, they are required to achieve obtain recognition under the NCQA 2011 standards.
Aligning Reimbursement & Purchasing
Under Phase I, different rollouts of the Chronic Care Initiative (CCI) in Pennsylvania tested different payment models, including lump sum payments to practices to cover start-up infrastructure costs, per member per month payments, and shared savings. Enhanced payments were stratified by practice recognition, with higher level practices receiving greater enhanced payment than lower level practices. From 2009 to 2011, the state’s contracts with Medicaid managed care organizations (MCOs) required MCOs to participate in  CCI; this requirement was removed prior to the start of CCI Phase II in January 2012.
Under Phase II, practices receive per member per month (PMPM) payments from participating payers, including Medicare, Medicaid MCOs, and Medicaid fee-for-service. The amounts of these PMPM payments will vary by initiative year and patient age. Payers are making two PMPM payments to practices:
  1. All practices are receiving “Physician Coordinated Care Oversight Services” PMPMs. The amounts are as follows:
  • Year 1: $1.50
  • Year 2: $1.28
  • Year 3: $1.08
  1. Practices are receiving “Coordinated Care Fees” that vary by patient age. These PMPMs are intended to provide funding for care coordinators.
  • The amounts are as follows for those age 18 or younger:
Year 1: $0.60
Year 2: $0.51
Year 3: $0.43
  • The amounts are as follows for those age 19-64:
Year 1: $1.50
Year 2: $1.28
Year 3: $1.08
  • The amounts are as follows for those age 65-74:
Year 1: $5.00
Year 2: $4.25
Year 3: $3.61
  • The amounts are as follows for those age 75 or older:
Year 1: $7.00
Year 2: $5.95
Year 3: $5.06
Practices are eligible for shared savings payments that will take into consideration practice performance on key quality metrics, including diabetes and hypertension management, as well as utilization and cost metrics. As the PMPM amounts decrease from Year 1 to Year 3, practices will be eligible for greater shares of any savings: 40% in Year 1, 45% in Year 2, and 50% in Year 3.
Supporting Practices The Chronic Care Initiative (CCI) rollouts have provided for learning collaboratives, including funding to cover lost time and revenue when providers and practice staff were out-of-office. CCI has also provided web-based patient registries and practice coaching. Under Phase II, the Department of Health is leading the learning collaboratives, holding monthly group calls for all practices, and overseeing practice transformation consulting. Practices are asked to regularly submit clinical data for quality improvement purposes. Priorities for further practice transformation have also been identified.
Measuring Results The Commonwealth Fund funded researchers at RAND and Harvard School of Public Health to conduct an evaluation of Phase I of the Chronic Care Initiative (CCI). The Centers for Medicare & Medicaid Services (CMS) is evaluating the impact of the Phase II CCI on outcomes for Medicare patients through a contract with RTI International. NASHP and the Urban Institute are subcontractors to RTI. Final evaluation results are not yet available, but the state has seen promising improvements in process measures as determined by Pennsylvania’s Improving Performance in Practice (IPIP) program.