Medicare MAPCP Medical Home Demo: CMS Kicks Sands in the States’ Faces

by Jaan Sidorov, MD and Vince Kuraitis

The Medicare MAPCP (Multi-Payer Advanced Primary Care Practice) demo promised to be Medicare’s Biggest Change in 40 Years

…but the emerging reality isn’t living up to the promise.

In this post, we’ll discuss:

  1. The Promise
  2. An Overview of the MAPCP Demo
  3. Our Main Takeaway: Emerging Reality Suggests Medicare Will Be a “Difficult” Partner
  4. Conclusion: Think Twice Before Signing Up

1) The Promise

The sandbox metaphor was first used by the National Academy for State Health Policy:

For the 10 or more states that are active stakeholders in multi-payer medical home initiatives, the promise of Medicare getting in the sandbox with them and playing (a.k.a. paying) is an exciting proposition. The addition of Medicare as payer to some of these state initiatives may be the critical tipping point that results in widespread primary care delivery system reform in states by involving more practices, payers and patients.

Three Years Of Medical Home Demonstration Preparation Down the Drain?

Do you remember the scene in the movie Animal House where Bluto Blutarski laments “…seven years of college education down the drain?”

Why aren’t primary care physicians expressing similar laments about  the shelving of the MMHD (Medicare Medical Home Demonstration) in favor of the MAPCI (Multi-Payer Advanced Primary Care Initiative).

My colleague Jaan Sidorov, MD and I pick up on no signs of discontent.  Read our essay “Three Years of Medical Home Demonstration Preparation Down the Drain?” on Dr. Sidorov’s blog.



CMS Shelves Medicare Medical Home Demonstration

I just received an email from CMS announcing the latest official word on the Medicare Medical Home Demonstration (MMHD):

10/26/2009 – In Washington, the efforts to reform health care and health insurance include proposed legislative language that would have an impact on the Medicare Medical Home Demonstration as described in section 204 of the Tax Relief and Health Care Act of 2006 and amended by section 133 of the Medicare Improvements for Patients and Providers Act of 2008. Specifically, section 1302 of House Bill 3200 contains a provision to repeal this demonstration and replace it with an independent practitioner-based medical home pilot described further in the bill. In addition, the House bill includes a second medical home pilot to evaluate community-based medical home models.

At this time, CMS believes it would be impractical to pursue clearance of the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot. CMS is moving forward with an Administration-initiated demonstration announced by Secretary Sebelius on September 16, 2009, whereby Medicare would partner with existing multi-payer medical home pilots to improve the delivery of care. This demonstration, titled the Multi-Payer Advanced Primary Care Practice Demonstration, would be implemented in 2010.

What does this mean? As one who has followed the MMHD closely, here are some of my top-of-mind reactions:

Part II — The Medicare Medical Home Demonstration: Crawling Out From Under the Rock

In Part I of my guest post on The Collaborative Forum blog, I wrote that the Medicare Medical Home Demo is in BIG Trouble. Here’s a recap:

  • Political reality dictates that the MMHD must save costs.
  • As currently structured, the MMHD cannot achieve cost savings
    • In any given year, only a small percentage of patients account for the vast majority of costs
    • Lessons from previous Medicare disease/care management demonstrations has shown that effective care coordination interventions must be targeted at this population
    • Medicare has structured the MMHD so that any patient with one or more chronic condition is eligible; this includes 86% of all Medicare patients.
    • Physicians will be paid risk-adjusted care coordination fees for this entire population — the 86% of patients with one or more chronic condition.
      The MMHD cannot achieve cost savings. 

Dr. Randy Williams, MD — CEO of Pharos Innovations — has written Part II of this series: The Medicare Medical Home Demonstration: Crawling Out From Under the Rock. It’s insightful and provocative reading!


Table of contents for the series--Medicare Medical Home Demo Challenges

  1. Medicare Medical Home Demo (MMHD) is in BIG Trouble
  2. Part II — The Medicare Medical Home Demonstration: Crawling Out From Under the Rock

Medical Home Savings Claims in Medicaid are Not Plausible

by Al Lewis, Disease Management Purchasing Consortium International, Inc.

AlLewisMedical homes probably do save money in very controlled settings, where the entire team is literally or at least figuratively under one roof, such as Kaiser.  However, the belief that one can overlay a traditional medical home model across an entire state and save money in the process turns out to be total fiction.

The poster child for that fiction, North Carolina’s Community Care program, turns out to cost state taxpayers probably $400 million a year, rather than save them $300 million, as the state’s self-serving and blatantly incorrect analysis claimed.    A more extensive analysis is available for review, and any state is welcome to the backup data as well.

Here’s a press release with more details.

Highlights of the head-scratching implausibilities claimed would be as follows:

Medicare Medical Home Demo (MMHD) is in BIG Trouble

Between the time the MMHD was authorized in 2006 and now, we’ve learned a lot about what works and what doesn’t work in Medicare care coordination programs. The MMHD is between a rock and a hard place — conflicted by two “must achieve” objectives that are diametrically opposed:

  • As a political matter, the MMHD must save money
  • As currently structured, the MMHD cannot save money

Please read my guest post

The Medicare Medical Home Demonstration (MMHD): Between a Rock and a Hard Place

over at Pharos Innovations new blog: The Collaborative Forum.

Is there a way out from between the rock and the hard place?  In Part II of this series, Dr. Randy Williams will discuss options.

Disclosure: Pharos Innovations is a client of Better Health Technologies, LLC.

Table of contents for the series--Medicare Medical Home Demo Challenges

  1. Medicare Medical Home Demo (MMHD) is in BIG Trouble
  2. Part II — The Medicare Medical Home Demonstration: Crawling Out From Under the Rock

HITECH Overlap: Medical Home, Telehealth, Health IT/Exchange

What’s the commonality among Medical Home, Telehealth, and Health IT/Information Exchange initiatives?

They all relate to care coordination.  As shown in the diagram below from the Kansas Health Policy Authority (KHPA), there’s a lot of overlap.


A larger copy of the slide is available in this March 2 PowerPoint presentation by Marcia Neilsen , Executive Director, KHPA.

What are some of the implications?

Medical Home “Model” Transmogrifies to: The Medical Home Movement



Part Medical Home 101,  part strategy session to rescue primary care, part revival meeting — the National Medical Home Summit held earlier this week in Philadelphia was an amazing event.

The optimism, energy, and dogged persistence of attendees and presenters was pervasive. The event was standing room only with another 200 people tuning in to a live Internet video cast.

Dr. Joseph Scherger captured the mood of the day when he proclaimed:

The Medical Home “model” has become the Medical Home Movement !

For those of you unable to attend, here are some key links and publicly available PowerPoint presentations:

Complimentary Issue — Medical Home News


Would you like to receive a complimentary issue of a new publication — Medical Home News ?  Click on the link and then on “Sample Issue” in the upper left corner.

Here’s a preview of the first issue:

  • Introducing Medical Home News
  • An Annotated Guide to the Medicare Medical Home Demonstration (MMHD)
  • Subscriber’s Corner
  • Johns Hopkins Lipitz Center to Assist Practices in Medical Home Demo
  • National Medical Home Summit to be Held March 2nd – 3rd 2009
  • Thought Leader’s Corner
  • Industry News
  • Catching Up With… Paul Grundy, MD

I’m honored to have been asked to serve on the Editorial Advisory Board of Medical Home News.

JAMA Article Asks: What About “The Other Medical Home”?

New_American_Gothic Dr. Steven H. Landers writes a thoughtful article in today’s JAMA .  He asks why the term Medical Home doesn’t include the patient’s home:

“…the Medical Home initiative, as currently articulated, ironically fails to emphasize the complex chronically ill patient’s actual home. This represents a failure to recognize the profile of the highest-risk beneficiaries driving much of the high Medicare costs—that is those with or more chronic conditions and activity limitations…

“A promising way to strengthen and broaden the Medical Home initiative for high-risk Medicare beneficiaries may be to make their actual homes the central venue of primary health care. This could be accomplished through another reform agenda that specifically empowers family caregivers, home health and hospice nurses, social workers, therapists, and personal care aides. This agenda places primary care physicians, advanced practice nurses, and physician assistants as partners and advisors to ongoing multidisciplinary care teams in the patient’s home.”

Dr. Landers provides some examples of reforms to consider for pilot testing: