V

I also agree that the demo process is problematic. This is huge undertaking being presided over by a corner of CMS that critics have charged is underfunded and undermanned. Me thinks that when all you have is the hammer of a demo, all Medicare benefit design issues look like the nail of prospectively conducted trials. Both issues could be solved by a time-honored approach used in State and commercial programs: outsource it. Surely the States would be willing to take that on?

On your first point about rates, we agree that $10 per beneficiary per month is way too low.

A main point here is simply to suggest that Medicare has right arm/left arm problems. In structuring the Medicare Medical Home Demo (MMHD), Medicare did extensive analysis in coming up with the $40-52 range. (of course, many disagreed with the methodology).

For the MAPCP demo, Medicare relied on a recent survey of PCMH rates. There is no reference to all the extensive work and machinations for MMHD pricing.

The beast is forgetful.

What’s the right amount? We really don’t know… I’ve discussed benchmarks in a previous blog post at http://e-caremanagement.com/the-medical-home-confusion-over-care-management-fees/. On the higher side, a Deloitte study suggests $150 PBPM is required to make the medical home work.

In previous discussions we’ve had, yes, I’ve expressed concerns about the methodology of the Medicare Medical Home Demonstration project — that it’s structured for failure http://www.thecollaborativeforum.com/24/medicalhomemodel/the-medicare-medical-home-demonstration-mmhd-between-a-rock-and-a-hard-place/

My concern really isn’t that $40-50 isn’t too much — actually, it’s probably still too low to entice physicians to participate in large numbers). My concern is that we structure demos correctly out-of-the-box so they have potential to be successful.

As to your second point about needing a more collaborative approach — yes! Medicare’s rigidity is showing in every line of the RFP for the MAPCP.

Actually, this whole demo process is being done backwards. The states ought to being issuing RFPs asking Medicare to submit a proposal to participate in their multipayer demos. The states are on the leading edge of innovation here, not Medicare.

A couple of points:
I agree with you that the per person-per month rate, if around $10= is going to be far too low for practices to DO anything sufficiently differently so as to impact health outcomes and Medicare spending. I can’t help but observe, though, that last time I spoke with Vince, he was on the opposite tack — that the proposed Medicare payment of $40-$50 per person per month was too big and that practices would never be able to save that much money and so make the demo cost neutral.

Second and more important – I think this solicitation shows the fundamental mistake we have been making in this process – trying to do everything in a competitive contracting/grant making mode. Surely, when working at the state level, it would be more reasonable for CMS to convene and work closely with those states who think that they might like to participate and educate, negotiate, and develop the approach together rather than this rigid approach. I think it would be less harmful to the public good to have angry loosing states sue about the process, than build in approach that is virtually certain to be futile.