Structuring Payment to Medical Homes After the Affordable Care Act

Edwards, Samuel T.; Abrams, Melinda K.; Baron, Richard J.; Berenson, Robert A.; Rich, Eugene C.; Rosenthal, Gary E.; Rosenthal, Meredith B.; Landon, Bruce E.

doi:10.1007/s11606-014-2848-3

Cited by 43 publications

(48 citation statements)

References 23 publications

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“…Medicaid programs, as the largest insurers of children in the United States, may have particular motivation to better understand child health care spending as they align financial incentives with outpatient case management targeting child HRUs. [20][21][22] The objectives of this study are to describe the clinical attributes and the health care spending and utilization of children with HRU who use Medicaid and to compare the distribution of spending and health service utilization across children with high and low resource use. …”

Section: What This Study Addsmentioning

confidence: 99%

Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance

et al. 2015

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Section: What This Study Addsmentioning

confidence: 99%

Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance

et al. 2015

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“…Recent changes in the health care landscape, including the implementation of the Patient Protection and Affordable Care Act (ACA), led some states to experiment with alternative payment methodologies as a way to achieve the triple aim of reducing utilization and costs while improving the quality and experience of care (Edwards et al, 2014;Kocot et al, 2013). At the forefront of this movement is Oregon's Alternative Payment Methodology (APM) demonstration project, which provides Federally Qualified Health Centers (FQHC) the option of shifting from a prospective payment system to receiving a capitated permember-per-month rate for their Medicaid patients.…”

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confidence: 99%

“…No conflicts of interest were declared by any of the authors. et al, 2014;Merrell & Berenson, 2010). …”

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Reporting From the Front Lines

Cottrell¹,

Hall

Kautz

et al. 2017

Journal of Ambulatory Care Management

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Alternative payment models have been proposed as a way to facilitate patient-centered medical home model implementation, yet little is known about how payment reform translates into changes in care delivery. We conducted site visits, observed operations, and conducted interviews within 3 Federally Qualified Health Center organizations that were part of Oregon's Alternative Payment Methodology demonstration project. Data were analyzed using an immersion-crystallization approach. We identified several care delivery changes during the early stages of implementation, as well as challenges associated with this new model of payment. Future research is needed to further understand the implications of these changes. Keywordscapitation; Federally Qualified Health Center; Medicaid; patient-centered medical home; payment methodologyThe patient-centered medical home model of primary care strives to provide accessible, comprehensive, and coordinated team-based care that responds to the full range of individuals' health care needs (Jackson et al., 2013). Adoption is widespread and emerging evidence points to multiple benefits of this model, including increased provision of preventive services and improvements in the experience of care for both patients and staff (Carlin et al., 2016;Jackson et al., 2013).However, under traditional fee-for-service payment methodologies that link payment to the volume of face-to-face visits, health care organizations are not reimbursed for the many patient-centered medical home activities that occur outside of the visit, such as phone consultations, medication management, patient education, or panel management (Olson, Correspondence: Glenn Kautz, MPH, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (kautz@ohsu.edu). No conflicts of interest were declared by any of the authors. et al., 2014;Merrell & Berenson, 2010). HHS Public AccessRecent changes in the health care landscape, including the implementation of the Patient Protection and Affordable Care Act (ACA), led some states to experiment with alternative payment methodologies as a way to achieve the triple aim of reducing utilization and costs while improving the quality and experience of care (Edwards et al., 2014;Kocot et al., 2013). At the forefront of this movement is Oregon's Alternative Payment Methodology (APM) demonstration project, which provides Federally Qualified Health Centers (FQHC) the option of shifting from a prospective payment system to receiving a capitated permember-per-month rate for their Medicaid patients. FQHCs are nonprofit health centers committed to providing high quality comprehensive primary and preventive care to persons of all ages, regardless of their ability to pay or health insurance status. FQHCs primarily serve uninsured and Medicaid populations and are a critical component of the health care safety net. In 2015, more than 24 million patients were served by 1375 FQHCs, 68% of which were recognized as patient-centered medical homes (HRSA, 2015).Three FQHC org...

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“…2 Health plans usually support the PCMH model through additional fees to support non-visit aspects of primary care on top of fee-for-service payments that continue to reward face-to-face visits. The authors contrast the PCMH and ACO models in terms of organizational structure, payment models, scope of accountability, and hypothesized degree of integration of specialists and hospitals.…”

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Beyond PCMHs and Accountable Care Organizations: Payment Reform That Encourages Customized Care

Colla

2014

J GEN INTERN MED

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H ealth care, like electricity, is an instrumental good, a means to an end. 1 We don't want kilowatt hours; we want hot showers and cold beer. We don't want to trek to the physician's office, we want health. How markets are structured determines how people behave. Energy policies have begun to reward utility companies for keeping people warm at the least possible cost, for example, through home insulation programs. Similarly, payment reforms in health care have begun to move away from those that reward volume to alternative approaches intended to improve the value of care. Patient-centered medical homes (PCMHs) were an important step, as fee-for-service payment provided no direct support for many key functions of primary care. Accountable care organizations (ACOs) were another advance, as they encourage collaboration across providers to improve care and lower costs. As we approach the fifth anniversary of the passage of the Affordable Care Act, it is a good time to reflect on how we are doing in payment policy-and how we might do better.The commentary by Edwards and colleagues in this issue focuses on the need to restructure payment for primary care, with a particular focus on how this might be accomplished within ACOs. 2 Health plans usually support the PCMH model through additional fees to support non-visit aspects of primary care on top of fee-for-service payments that continue to reward face-to-face visits. The authors contrast the PCMH and ACO models in terms of organizational structure, payment models, scope of accountability, and hypothesized degree of integration of specialists and hospitals. They conclude by suggesting possible approaches to integrating the PCMH model in ACOs: health plans could include explicit payments to primary care providers in ACOs (as in the PCMH model) and the performance-based payment component of ACOs could be restructured to more strongly reward the achievement of primary care principles.The commentary is an excellent reminder that how health care is organized and paid for is important. Both the PCMH and ACO models have strengths and limitations. The PCMH model provides additional resources to practices enabling them to more easily expand access. The limitations, however, are substantial: the payment model focuses on adherence to a set of structural criteria that have a variable evidence base; the model continues to rely on fee for service and thus emphasizes visit-based care, and the model leaves unaddressed the challenge of how primary care relates to specialists or hospitals (thus current attention to the medical neighborhood). 3 At the same time, because of the strong consensus on the need to strengthen primary care in the US, medical home initiatives are proliferating-with a still limited evidence base on their effectiveness. 4 The ACO model includes a commitment to ensuring high-quality primary care. But it differs in several important ways. The ACO model was intentionally designed to encourage the emergence of organizations that could be responsible for the full contin...

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Structuring Payment to Medical Homes After the Affordable Care Act

Cited by 43 publications

References 23 publications

Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance

Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance

Reporting From the Front Lines

Beyond PCMHs and Accountable Care Organizations: Payment Reform That Encourages Customized Care

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