Lowell

I agree that there are major implications to CMS’s decision to structure the demo this way. I also agree that we will not know the real deal until the RFP is issued. But in the meantime, and in view of the criticism appearing suggesting that the RUC’s payment recommendations are inadequate, it is important for people to understand that the RUC recommendations are based on a broader and shallower payment approach than what they are used to thinking about.

IMHO that changes scope of project significantly from what is implied by “high need population” wording in the enabling legislation….still mulling over implications.

Let’s see what the actual RFP looks like…hopefully soon.

“CMS has indicated that it will rely on beneficiary eligibility criteria for the demonstration project that will expand inclusion to 86% of all beneficiaries based on the Hwang criteria.”

Also on page 3:

“If 86% were eligible for the demonstration (per CMS current criteria), 245 patients per family physician would be eligible.”

The 86% figure is also referred to in the cover letter to Kerry Weems.

The document emphasizes that the recommendations are based on a particular set of assumptions, and that different assumptions (such as eligibility criteria that would limit enrollment to 15% of Medicare beneficiaries) would change substanitally the recommended payment levels.

Alan, you raise excellent points. The precise math will depend on interpretations by CMS, and we’ll have to wait to see the MMHD RFP to clarify some issues.

The MMHD legislation states that the project will take place with “high-need populations”, defined as “individuals with multiple chronic illnesses that require regular medical monitoring, advising, or treatment.”

This is still pretty fuzzy wording.

Alan, you quote CMS as stating that 86% of Medicare patients will be eligible for enrollment. Can you reference a source? I’ve never seen anything this specific from CMS. 86% seems to stretch the definition of “high need population”.

Nonetheless, you’re absolutely right in asking about the population to which the PPPM fee should be applied, and $50 PPPM of a broad base of Medicare patients could be better than $150 PPPM of a frail, elderly population.

It’s unfortunate that we’re trying to do the math under such opaque conditions.

1. What is the monthly payment?
2. For which patients will the physician receive payment? (i.e., which patients may enroll in the medical home?)

The RUC recommendations are about $50 pmpm for the level 3 PCMH. CMS estimates that 86% of the Medicare population will be eligible for enrollment.

The Deloitte paper does not explicitly define these critical elements, but if I understand it, it envisions 15% of the Medicare population being eligible.

From page 12 of the Deloitte report:

“• Health coaching and increased effectiveness in patient enrollment in
disease management programs is a major driver for care coordination.
• Currently, disease management organizations are typically
enrolling 10-15 percent of eligible patients for their programs.
The Center’s model assumes 15 percent.”

Deloitte recommends at least$150 PMPM

Now, which method generates more revenue for the physician? $150 pmpm for 15% of your Medicare population. Or $50 PMPM for 85% of your Medicare population?

The Deloitte paper also proposes that a doc will take of of 1000 patients “who need care management”. If this means 1000 of the sickest and most complex 15% of Medicare beneficiaries, this is totally unrealistic. Too many patients.