Lots of agreement on medical home concept, but little on details

State officials and physicians gathered Thursday to tout a new model for providing medical care to nearly 600,000 Medicaid recipients.

The model, known as a person-centered medical home, centers on having health care providers coordinate patients’ care and monitor their health–and receive payment for it. It has support from health care providers, legislators, patient advocates and the Malloy administration, which sees it as central to its overhaul of how Medicaid is administered.

But many of the key details of the program must still be determined before it rolls out in January. Among the unresolved questions: What standards will practices have to meet to be considered medical homes? Will they need to have electronic medical records, as some national standards require, or would the state’s definition be less stringent? How will providers be rewarded for participating? And how can the typically low-paying Medicaid program entice practices–particularly the small practices that dominate the state–to take the often costly steps to beef up their ability to coordinate care?

State Department of Social Services officials said those details will be worked out in the coming months, in a process that will include health care providers and consumers.

“There’s a conversation that we need to have throughout the summer,” DSS Commissioner Roderick L. Bremby said. “We need to define the standards together. This will not be a DSS-defined, driven process.”

The department doesn’t expect all Medicaid patients to be in medical homes by next year, but hopes that most or all will have access to one by the end of 2014, said Mark Schaefer, DSS’ director of medical care administration.

During a press conference at the state Capitol complex, Dr. Robert McLean, a New Haven internist and rheumatologist and governor of the Connecticut Chapter of the American College of Physicians, described the dilemma the state could face in achieving that goal.

“This model of primary care delivery will make it easier for patients to get good care. We all want that,” he said. “It will be less expensive for those paying for it through fewer unnecessary ER visits and avoidable hospitalizations, which is going to make it safer care. Everyone wants that.”

“The problem is that this is really, really hard for doctors to do,” he added. “And it’s expensive, and this also needs to be addressed as the plans go forward.”

Coordinated care

The move toward medical homes in Medicaid is part of a larger shift in how the program is administered. The HUSKY program, which covers close to 400,000 mostly low-income children and their parents, is now administered by managed care companies, which are paid a per-person fee each month that they use to pay claims. Patients in other Medicaid programs that cover low-income adults and aged, blind and disabled residents have no care management; the state pays directly for the services they receive.

The Malloy administration plans to shift all of those programs into a new system in which the state pays medical claims and pays an outside organization to administer the programs and coordinate patient care. The administration expects the move to save money because the state will no longer be paying insurance companies to take on the risk for medical claims, and because the care of all Medicaid recipients, not just some, will be coordinated.

When the administration announced the move in February, it also announced plans to expand the use of medical homes. Since then, there has been confusion about how the model would be expanded, and Thursday’s press conference was aimed in part at explaining the concept. A medical home isn’t a physical place; it’s a type of medical practice.

Bremby offered an example. Young children with asthma tend to show up frequently in emergency rooms, but that will be less common with medical homes, he said.

Why? The best intervention for asthma is an inhaler, Bremby said, but it takes practice and education to know how to use one properly. Practices that are medical homes would have someone available to train the child and parents on how to use an inhaler and teach them what to do during an attack.

Bremby noted that many states are moving Medicaid programs into managed care, but he said the medical home concept is preferable.

“We believe that this model is the best model because it incentivizes good outcomes,” he said. “We want to encourage physicians and their practices to do what they believe is the right thing to do, along with the patient, and at the end of the day, we believe that this will result in those savings that I know [budget director] Ben [Barnes]’s looking for and I am too.”

Barnes noted that one in five Connecticut residents is now covered by a public health care program, and said that reducing costs while maintaining quality “is one of the biggest challenges facing the public sector, and American society, in some respects.”

“This seems like the direction that is most likely to produce savings and improve quality of care,” he said. “We’re going to do everything we can to make it be successful.”

Setting the standards

Physician organizations have embraced the medical home concept, but many health care providers have said meeting the commonly used standards for a medical home can be difficult, particularly in Connecticut, where the vast majority of doctors work in practices with five or fewer physicians. McLean said becoming a medical home is a “huge, huge undertaking” that requires hiring additional staff and restructuring how providers work.

Schaefer said one of the challenges that the group designing the program will face is defining the standards for what a medical home is.

There’s no set definition, although multiple national accrediting bodies have standards. The most frequently cited, the National Committee for Quality Assurance, has requirements that include prescribing electronically, following up on tests and procedures done at other facilities, using data to manage patients and being accessible to patients outside office hours.

In Connecticut, only 113 practices and providers have received NCQA recognition as medical homes. Other practices say they meet the standards but have not yet sought official recognition, which is a lengthy process.

Overall, the medical home model is in its infancy in the state, although certain elements of it are already being used, according to a report last year by the Connecticut State Medical Society.

Thirty-nine percent of primary care doctors surveyed in 2009 said they used electronic medical records, and 56 percent used “open access scheduling,” in which some appointments are kept open each day to accommodate patients with urgent needs. But less than 25 percent said their practices had or planned to have nurse care managers for patients with chronic diseases.

“One of the big challenges for the group over the summer is do we define a medical home that is less than a national standard that doesn’t require [electronic health records] to get in in order to create the revenue streams so that folks make the investment, or not?” Schaefer said.

Patient advocates have argued for building off an existing medical home pilot program, called HUSKY Primary Care, that pays providers $7.50 per patient each month to coordinate care. It does not require practices to use electronic medical records or meet national standards, and supporters say it would allow providers to participate at a level they can achieve, rather than having to meet higher standards now.

“You’ve got to bring people into the system,” said Sheldon Toubman, a lawyer with the New Haven Legal Assistance Association. “Once they’re in the system, you’ve got them engaged and then you can help them to go to a higher standard.”

Toubman said it’s unrealistic to expect to get even a quarter of Medicaid patients access to medical homes in the next year if the state requires providers to meet national standards.

McLean urged the state not to accept standards below what NCQA requires, saying it would create confusion later on. He said the prospect of payments for care coordination could be an incentive for physicians to get electronic medical records.

Schaefer said achieving the outcomes the state wants will require certain standards, and said his own bias is toward establishing requirements that providers will have to reach for. But he noted that in a behavioral health program that serves Medicaid recipients, the state allowed some providers that did not meet its standards to participate if they had a “credible plan” to reach them by a certain date.

Aligning the state’s requirements with national standards would also make it more likely that they would match care coordination standards set by commercial insurers, Schaefer said.

“There’s an advantage to using a national accreditation that the commercial payers will get behind, because you don’t want just Medicaid, which may be 30 percent of a practice or significantly less, being the sole source of revenue to support getting to the standard,” he said. “So we have to be mindful of a model that other folks can get behind.”

Officially, DSS is referring to the model as a “person-centered medical home.” Typically, the term is “patient-centered medical home,” but DSS substituted the word person because some people with disabilities are sensitive to the term “patient,” Schaefer said.

“Among folks with disabilities, they feel the health care system has really not served them well,” Schaefer said. “They feel it’s too paternalistic, there’s not informed choice, that there’s a focus on medical solutions as opposed to the soft supports that enable people to live independently in the community.”