Maine – Medical Homes
In 2007-2008, the Maine Legislature created a bipartisan Commission to Study Primary Care Medical Practice. The Commission, in turn, recommended the development of the Patient-Centered Medical home (PCMH) Pilot. The legislature appropriated $500,000 for that purpose in 2009, and three collaborators – the Maine Quality Forum (part of the state’s Dirigo Health Agency), Quality Counts (a health care quality improvement collaborative), and the Maine Health Management Coalition (an employer-led coalition) – agreed to jointly lead the PCMH Pilot development. In 2009, 50 practices applied for participation; twenty-two adult practices and four pediatric practices were selected, together serving more than 68,000 Mainers.
Enhanced payments to practices began in January 2010. Participating practices receive per member per month (PMPM) payments from Medicaid, the state’s major commercial payers, and as of January 1, 2012, Medicare fee-for-service. They also receive a variety of transformation supports, including a learning collaborative, practice coaching, and consultation with key experts. Pilot leaders launched eight community care teams (CCTs) in early 2012 to support primary care providers in operating as medical homes. In April 2012, pilot leaders announced the pilot would expand to an additional 50 adult practices in its second phase, more than double the number planned. Practices were selected from a field of over 108 applicants in fall 2012, and joined the pilot in January 2013. The pilot also reopened the Community Care Team application process during summer 2012, selecting two new teams to serve the Aroostook and Brunswick-Midcoast regions through an RFP process. The new teams launched in January 2013.
Maine 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. Maine received $33 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 the Accountable Communities initiative, profiled on the Maine page of NASHP’s State Accountable Care Activity Map.
Maine is one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program.
On January 17, 2013, the Centers for Medicare & Medicaid Services (CMS) approved a Section 2703 health home state plan amendment for Medicaid enrollees with chronic conditions that is closely tied to the state’s PCMH pilot. To be eligible, patients must have two qualifying chronic conditions, or one qualifying chronic condition and risk for a second. Maine had previously received a planning grant from CMS to develop a state plan amendment to implement Section 2703. To learn more about Maine’s Health Homes program, visit MaineCare’s Health Homes website. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
The Bangor Beacon Community was awarded $12.7 million in 2010 over three years to improve care for patients with chronic disease, reduce acute care utilization, and increase the use of Maine HealthInfoNet (the state health information exchange). Some practices in the PMCH Pilot will likely benefit.
Maine PCMH Pilot: A variety of stakeholders have helped develop Maine’s Patient-Centered Medical Home (PCMH) Pilot, including:
The convening entities – the Maine Quality Forum, Quality Counts, and the Maine Health Management Coalition – also bring the perspectives of a diverse range of constituencies, including employers, unions, and providers.
ACA Section 2703 Health Homes: Maine’s health homes initiative is part of a broader Value Based Purchasing Strategy currently being pursued by MaineCare, Maine’s Medicaid agency. To learn more about Maine’s Value-Based Purchasing Strategy, visit the Maine page on NASHP’s Accountable Care Activity Map.
MaineCare has engaged state policymakers from a variety of offices within the state’s Department of Health and Human Services in planning for the state’s Value Based Purchasing Strategy, including the Maine Center for Disease Control, the Office of Adult Mental Health Services, the Office of Child and Family Services, the Office of Elder Services, the Office of Substance Abuse, and the Office of the State Coordinator for Health Information Technology, among others. MaineCare has also engaged the University of Southern Maine’s Muskie School of Public Service on planning committees.
|Defining & Recognizing a Medical Home||
Maine PCMH Pilot: According to the Maine Commission to Study Primary Medical Practice, “Principles of a patient centered medical home include a personal physician who leads a medical team that collectively takes responsibility for the ongoing care of patients with a whole-person orientation. Under the model, primary care is coordinated and integrated, and quality, safety and access are of the utmost importance. Hallmarks of the patient-centered medical home include planning, evidence-based medicine, clinical decision support tools, accountability, active participation in decision making by the patient and appropriate information technology supporting an environment of continual quality improvement and increased access through means including expanded hours, open scheduling and new options for expanded communication between doctor and patient.”
Maine PCMH Pilot: Under the Patient-Centered Medical Home (PCMH) Pilot, practices are expected to attain at least National Committee for Quality Assurance (NCQA) Level 1 recognition within six months of beginning participation in the pilot. Practices are also expected to meet ten “core expectations”:
ACA Section 2703 Health Homes: Health home practices are required to attain at NCQA Level I recognition, to meet ten “core expectations” required of practices participating in the Maine PCMH Pilot (listed above), and to participate in the state’s PCMH learning collaborative. In addition, practices must agree MaineCare’s Primary Care Case Management standards, which include additional standards around enhanced access, patient-education, and care management.
|Aligning Reimbursement & Purchasing||
Maine PCMH Pilot: For the duration of the Maine Patient-Centered Medical Home (PCMH) Pilot, participating practices will receive per member per month (PMPM) payments of $7.00 for each eligible MaineCare (Medicaid) beneficiary. Community Care Teams receive $2.95 PMPM from MaineCare. Medicare fee-for-service will be paying $6.95 PMPM to the practices and $3.00 PMPM to the CCTs.
In addition to MaineCare and Medicare fee-for-service, three commercial payers – Anthem Blue Cross Blue Shield, Aetna, and Harvard Pilgrim – are also voluntarily participating in the Pilot. Commercial plans contribute $0.30 PMPM to Maine’s CCTs. The amount that commercial insurers pay to practices is not publicly available.
ACA Section 2703 Health Homes: Health homes receive a $12.00 per-member per-month (PMPM) care management fee in addition to fee-for-service payments. Community care teams receive $129.50 PMPM.
Maine PCMH Pilot: The Maine Patient-Centered Medical Home (PCMH) Pilot is offering a variety of supports to participating practices. These supports include:
Maine launched eight community care teams (CCTs) in early 2012 to support medical home practices. “The primary goal of the CCT is to provide support for the most complex, high risk, high need, and/or high-cost patients served by ME PCMH Pilot.” According to Maine Quality Counts, “CCTs will coordinate and connect patients to additional healthcare and community resources in order to support their health improvement goals, achieve better health outcomes and reduce avoidable costs.” The state launched two new CCTs in January 2013 to support the pilot’s 50-practice expansion. The new teams were selected through an RFP process.
ACA Section 2703 Health Homes: Like Maine PCMH Pilot practices, health homes are also supported by Maine’s community care teams, who provide intensive care coordination and other wrap-around services to the top 5-percent of high-cost, high-risk beneficiaries.
Maine PCMH Pilot: The University of Southern Maine’s Muskie School of Public Service is undertaking an evaluation of Maine’s Patient-Centered Medical Home (PCMH) Pilot. The evaluation is assessing the impact of the PCMH Pilot on clinical outcomes, cost, and patient experience. PCMH Pilot sites are being compared with two control groups: (1) a group of highly capable practices that applied for participation in the Pilot but were not selected, and (2) a group of less capable practices (“usual care”).
The Centers for Medicare & Medicaid Services (CMS) is also evaluating the impact of the Maine’s PCMH Pilot on outcomes for Medicare and Medicaid patients through a contract with RTI International. NASHP and the Urban Institute are subcontractors to RTI.
ACA Section 2703 Health Homes: Maine will use claims, administrative data, qualitative data, quarterly progress reports from health home practices, and monitoring reports submitted by community care teams to measure success toward the state’s four goals for this state plan amendment:
Specific measures include hospital admissions and readmissions, emergency department utilization, and skilled nursing facility visits.