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.

PCMH and Healthcare Reform: Avoiding Drowning in an Ocean of Opportunity

This article appears in the April 2010 issue of Medical Home News.

First, the good news: There are a lot of pilot and demonstration projects potentially involving the Patient Centered Medical Home (PCMH) in newly enacted Federal health care reform legislation – the Patient Protection and Affordable Care Act (PPACA).

Then, the bad news: There are a lot of pilot and demonstration projects potentially involving the PCMH in the PPACA.

…so many that the PCMH risks being drowned in an ocean of opportunity.

I’d like to make a few simple points in this essay:

  1. The number of authorized pilots and demos in the PPACA is staggering
  2. This creates both opportunities and challenges
  3. PCMH focus will be required to navigate the ocean

The Real Secret Sauce of Medicare’s Participation in Regional Collaboratives — Network Effects

Last week I asked whether Medicare’s Biggest Change in 40 Years is on the horizon. That post described and discussed implications of Medicare’s new direction for the medical home — the shelving of Medicare Medical Home Demonstration (MMHD) and the refocusing on the recently announced Multi-Payer Advanced Primary Care Initiative (MAPCI).

In that post I touched briefly on the potential for MAPCI to create effective networks at multiple levels — contracting networks, health IT networks, social and collaborative care networks.  I’d like to expand a bit today…

So, why is Medicare’s participation in MAPCI  and other regional collaboratives such a big deal? Here’s my hypothesis:

Medicare’s non-participation (to-date) in regional payer/provider collaboratives has been a rate limiting factor in the potential to achieve high levels of network effects that drive adoption.

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.

 

 

Medicare’s Biggest Change in 40 Years on the Horizon?

Earlier this week CMS issued a typically cryptic Announcement indicating that they were shelving the Medicare Medical Home Demonstration (MMHD) and instead would focus on the recently announced Multi-Payer Advanced Primary Care Initiative (MAPCI). My blog post from Tuesday provides details and asks the question “What does all this mean?”

Today’s blog post will tackle:

  • Medicare’s biggest change in 40 years?
  • The rise of MAPCI
  • The fall of MMHD
  • Implications/discussion

Medicare’s Biggest Change in 40 Years?

ExPt

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

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

Complimentary Issue — Medical Home News

MHN

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.

Medicare Health Support: 8 Takeaways on Building Better Bridges

by Thomas Wilson, PhD, DrPH and Vince Kuraitis

Engineer

What’s the right metaphor for Medicare Health Support (MHS), CMS’ major experiment with disease management for Medicare beneficiaries?  We prefer to look it as a bridge failure that presents an opportunity to improve future engineering and design.

We’ve now had the time to read, reread, and reread again the very recent report from Research Triangle Institute (RTI) — Evaluation of Phase I of the Medicare Health Support Pilot Program Under Traditional Fee-for-Service Medicare: 18-Month Interim Analysis .  Here’s a listing of our 8 key takeaway points:

  1. There’s Sufficient Evidence to Conclude "MHS Didn’t Work As Expected"
  2. Some Quality Measures in MHS Improved, Yet Outcomes Didn’t. Why?
  3. MHS Suffered Execution Nightmares
  4. Ronald Reagan Was Right — “Trust, But Verify”
  5. MHS Has Implications for the Medicare Medical Home Demo (MMHD)
  6. Be Wary of Claims from Pre-Post Studies
  7. Differences Between Medicare and Commercial DM are Dramatic
  8. The Guaranteed Savings Model is a Two Edged Sword

Let’s examine these at these one at a time.