New York – Medical Homes

New York Medicaid is directly participating in two medical home initiatives created in Chapter 58 of the Laws of 2009, the 2009-2010 state budget.

  1. The Adirondack Medical Home Demonstration, a five-year regional multi-payer initiative in the Northeast corner of the state.
  2. statewide Patient-Centered Medical Home Program for individuals enrolled Medicaid, Family Health Plus or Child Health Plus.

Additionally, Chapter 59 of the Laws of 2011, the 2011-2012 state budget, included a section that authorizes the Commissioner of Health to establish additional multi-payer medical home initiatives similar to the Adirondack demonstration throughout the state.

Governor Cuomo’s Medicaid Redesign Team’s has also supported a recommendation (Proposal 70) to expand the statewide Patient-Centered Medical Home Program to include new payers.

Federal Support: 

  • On February 3, 2012, CMS approved the first of three Section 2703 health home SPAs for “high-cost, high-need” Medicaid enrollees with chronic conditions in 10 counties. Two additional SPAs were approved in December 2012 (effective dates April 1 and July 1, 2012), expanding the program statewide. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
  • The Capitol District-Hudson Valley Region of New York is one of seven markets participating in CMS’s Comprehensive Primary Care Initiative (CPCi). In this multi-payer initiative, Medicare is collaborating with public and private insurers in the selected states and regions with the goal of strengthening primary care. In New York, CPCi launched in November 2012, bringing together seven payers, as well as 74 participating primary care practices with 287 providers in the region.
  • New York is one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program. Medicare joined the Adirondack Medical Home Demonstration as a payer in July 2011.
  • New York has 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.”
  • HEALTHeLINK received a Beacon Community grant, creating the Western New York Beacon Community.

Last Updated: April 2014

Forming Partnerships
The New York Legislature has guided current and future medical home partnerships:
  • Chapter 59 of the Laws of 2011 authorized the state health commissioner to establish an advisory group of state agencies and stakeholders (including professional organizations/associations and consumers) to identify care management and coordination barriers and make recommendations for statutory and/or regulatory changes to address them.
  • Chapter 58 of the Laws of 2009 provided the Adirondack Medical Home Demonstration Parker state action immunity to providers and commercial payers to plan, implement, and operate future multi-payer initiatives. Chapter 59 of the Laws of 2011 provides the same protections for future multi-payer initiatives.
In addition, Governor Cuomo tasked a multi-stakeholder Medicaid Redesign Team to reduce costs and increase quality and efficiency in the Medicaid program for the 2011-12 Fiscal Year. This team endorsed Medicaid Redesign Proposal 70, which includes the creation of a medical home advisory group to provide recommendations for the development of Health IT-derived quality, safety, and efficiency measures for pay-for-performance demonstrations.
Adirondack Medical Home Demonstration: The Adirondack Medical Home Demonstration is currently governed by a multi-stakeholder committee of payers and providers chaired by a New York State Department of Health official.
Defining & Recognizing a Medical Home
New York Medicaid further describes a medical home as a physician-led care team that is responsible for providing all of a patient’s health care needs, including referrals to other physicians as necessary. Medical homes provide enhanced care that is accessible and culturally and linguistically appropriate.
ACA Section 2703 Health Homes: Health homes are not required to achieve formal certification or recognition. They are required to meet state-developed qualification standards in five areas:
  • Comprehensive care management (includes individualized, patient-centered care plans);
  • Care coordination and health promotion (includes care manager assigned to each patient);
  • Comprehensive transitional care (includes admission and discharge notifications, coordinated transfers, and follow-up post-discharge);
  • Patient and family support (includes a culturally competent care plan is accessible to patients and families); and
  • Referral to community and social support services (includes collaboration with community-based resources and supports).
Comprehensive Primary Care Initiative (CPCi): Practices were selected for participation in CMS’s Comprehensive Primary Care Initiative through a competitive application process. Under CPCi, practices are not required to attain formal PCMH recognition; however, formal PCMH recognition through NCQA, AAHCC, the Joint Commissioner, URAC, or a state-based recognition program was viewed favorably in practice selection. Additional criteria included:
  • Health information technology, including attestation to Stage 1 Meaningful Use and engagement with local Regional Extension Center (REC);
  • Percentage of practice revenue earned from participating payers; and
  • Participation in practice transformation programs through organizations like quality improvement organizations, RECs, or learning collaboratives.
Aligning Reimbursement & Purchasing
Adirondack Medical Home DemonstrationParticipating payers made incentive payments totaling $84 per-member per-year to support practice transformation and new care coordination services. Payment frequency was left to each payer (i.e., some paid $7 monthly, some $21 quarterly). Providers must reach NCQA PCMH Level 2 or 3 recognition within 12-18 months to continue receiving these enhanced payments.
Providers receiving Adirondack Demonstration payments are not eligible for additional payments under the Statewide Patient-Centered Medical Home Program.
Statewide Patient-Centered Medical Home ProgramNCQA-recognized hospital outpatient clinics and office-based practitioners are eligible to receive enhanced service rates for certain evaluation and management (E&M) and preventative medicine codes for participating enrollees. Payments vary by NCQA level.
Hospital outpatient clinics (including FQHCs):
  • Level 1: $5.50
  • Level 2: $11.25
  • Level 3: $16.75
Office-based practitioners:
  • Level 1: $7.00
  • Level 2: $14.25
  • Level 3: $21.25
Medicaid discontinued payments to Level 1 NCQA PCMH providers in December 2012. The state announced in May 2013 that it would discontinue payments to practices recognized as Level 2 under the NCQA 2008 standards and reduce payment to practices recognized as Level 3 under the 2008 standards in July 2013.
Managed care plans pay a per-member per-month (PMPM) incentive payment for each participating enrollee. This payment is also tiered by NCQA recognition:
  • Level 1: $2.00 PMPM
  • Level 2: $4.00 PMPM
  • Level 3: $6.00 PMPM
ACA Section 2703 Health Homes: Health homes receive a risk-adjusted per-member per-month care management fee that varies based on geography and case mix. Fees range from $75-$390. Health homes are paid the full PMPM rate for patients in the “active care management group” (those who are fully enrolled and have been assigned a care manager who have received at least one core health home service during the quarter), or 80% of the PMPM rate for up to six months for eligible patients in the “case finding group” (patients identified as eligible and attributed to a health home but not yet enrolled or assigned a care manager).
Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in November 2012, includes seven payers in New York’s Capital District-Hudson Valley market: Medicare, Aetna, Capital District Physicians’ Health Plan, Empire Blue Cross, Hudson Health Plan, MVP Health Care, and Teamsters Multi-Employer Taft Hartley Funds.
Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee, which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.
The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.
Supporting Practices
Adirondack Medical Home DemonstrationEach participating Adirondack Medical Home Demonstration practices received a readiness assessment to develop individualized work plans to guide practice transformation. Practices are receiving grant-supported consulting assistance from EastPoint Health to achieve practice transformation.
Practices also receive additional support from one of three sub-regional Pods (community-based organizations providing shared care coordination services to participating practices including patient education and care management). The Adirondack Health Institute is serving as an umbrella organization for the three Pods.
A $7 million HEAL NY Phase 10 grant (HEAL NY 10) enabled all participating providers to implement an electronic health record.
It also should be noted that Chapter 59 of the Laws of 2011 authorizes the commissioner of health to provide technical assistance to regional multi-payer program participants (providers, payers and consumers), which may impact the Adirondack initiative as well as future initiatives as well.
Statewide Patient-Centered Medical Home ProgramThere is limited practice support from a quality organization contracted by the state.
HEAL NY 10 grants were also made available to support health IT infrastructure development for non-Adirondack medical homes.
ACA Section 2703 Health Homes: Health Homes Learning Collaborative, intended to identify and discuss best practices and lessons learned, launched in September 2012. Findings will inform ongoing implementation and state policymaking.
Measuring Results
Adirondack Medical Home Demonstration: The four major goals of the Adirondack Medical home demonstration are to:
  • improve quality and outcomes
  • lower overall health care costs
  • improve access; and
  • create a new clinically integrated model that can be replicated in other parts of the state.
Statewide Patient-Centered Medical Home ProgramChapter 58 of the Laws of 2009 requires the state health commissioner to report on the Statewide Patient-Centered Medical Home Program’s impact on quality, cost, and outcomes to the legislature and governor by December 31, 2012.
In addition, Chapter 59 of the Laws of 2011 requires the state health commissioner to prepare a similar annual report for the effects of regional multi-payer medical home initiatives on Medicaid, Family Health Plus, and Child Health Plus enrollees.
ACA Section 2703 Health Homes: New York will use claims and pharmacy data to measure success toward the state’s five goals for this state plan amendment:
  1. Reduce utilization associated with preventable inpatient stays;
  2. Reduce utilization associated with preventable emergency room visits;
  3. Improve outcomes for persons with mental illness and/or substance use disorders;
  4. Improve disease-related care for chronic conditions; and
  5. Improve preventative care.
New York is also developing a patient experience survey tool that includes elements of AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys and implement learning collaborative with health home providers and high-risk enrollees to discuss program successes, challenges, and lessons learned.