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.

The concept of the MAPCP is right on target: Medicare’s non-participation (to-date) in regional payer/provider collaboratives has been a rate limiting factor in achieving the critical mass that drives payer/provider participation. (see blog post #4 in this series for elaboration).

In 2009, five State governors recognized the problem and invited Medicare to participate in their regional medical home pilots. In response, HHS Secretary Kathleen Sebelius announced the creation of MAPCP that would “allow Medicare to join Medicaid and private insurers in State-based health reform initiatives.” Medicare to Participate in State Multi-payer Health Reform Efforts….” [MAPCP Fact Sheet — emphasis added.]

Numerous ensuing fact sheets and headlines conveyed an attitude of mutual respect, cooperation and partnership. 

2)  An Overview of the MAPCP Demo

Here’s the MAPCP in a nutshell: The demonstration is out to assess the effect of “advanced primary care practice,” when supported jointly by Medicare, Medicaid, and private health plans, on:

• The safety, effectiveness, timeliness, and efficiency of health care;
• Assuring access and appropriate utilization of services covered by Medicare, Medicaid, and private health plans, while lowering expenditures;
• The ability of beneficiaries to participate effectively in decisions concerning their care; and,
• The delivery of care consistent with evidence-based guidelines.

More info is available at the MAPCP homepage and this press release.

3) Our Main Takeaway: Emerging Reality Suggests Medicare Will Be a “Difficult” Partner

Once Medicare jumped into the sandbox, the cordiality ended. Medicare started kicking sand.

The 20 page MAPCP Demonstration Solicitation makes it clear who is in charge.  In fact, it’s not even about the PCMH anymore, but what Medicare has dubbed “advanced primary care practice.” As further evidence of Medicare’s intentions, we counted that the phrase “the application must” is used 68 times in the solicitation. Yikes.

Shifting metaphors for a moment — if this were a party, here’s how the conversation would play out:

States: Medicare, we’d like to invite you to our party.  We have some great ideas about how to include all payers in improving quality and reducing costs.

Medicare:  Yes, we’d like an invitation to your party.  We’ll set up a demonstration project that defines the buffet table, the size of the beverage cups and when the guests can dance.

For Example, the MAPCP Physician Payment Incentives are Way Too Low.

How much does Medicare plan to spend per beneficiary per month (PBPM) for this demo?  $10. That’s ten lousy dollars.

In contrast, the Medicare Medical Home Demonstration project (which, by the way is back on the table) announced weighted payment rates ranging from $40–52 per beneficiary per month. 

Yet, for MAPCP, CMS expects that the total CMS payment to participating practices, community support organizations and for shared administrative expenses will not exceed $10 PBPM. If States believe more is warranted, Medicare might magnanimously go along only if a “compelling” case can be made that shows why the higher payment is necessary and to the extent that all participating payers make a comparable expenditure.

We believe this is another example of Medicare forcing the States to cross-subsidize its perennially inadequate payment rates.

For Example, Deadline!

If you’re a participant in a State multipayer initiative and want Medicare in your sandbox, we suggest that when you stop reading this blog post, you get to work.  Letters of intent are required by the end of June and the full application is due at CMS on August 17.  And oh, six copies, one unbound copy and an electronic copy are required. And oh, Medicare requests that you don’t use USPS to send the copies.  Micromanagement extraordinaire.

For Example, Only One Payment Approach Allowed.

CMS generally expects that the application will identify only one payment arrangement to be used across all participating practices and by all participating payers. This payment arrangement may combine monthly care management fees, fee-for-service payments, and pay-for-performance incentives. We assume that if CMS can’t adapt to the proposed payment methodology, it won’t participate.

For Example, Can MAPCP Rely on Disease/Care Management Vendors?

It doesn’t appear so.

• $10 per beneficiary per month, leaves little for building care coordination infrastructure.
• The MAPCP anticipates that disease/care management will be structured mostly as “community based practice support”. We believe this relegates care coordination more to a public utility function than as a capability that can be effectively leveraged by through private vendors.
• The RFP requires that outside contractors/vendors must be identified in the applications, which doesn’t leave much time.

For Example: Mixed Financial Incentives but it’s up to the States – or else!

Our read of the solicitation is that States are being held accountable for budget neutrality. Yet, the incentives/penalties for physicians to lower overall medical costs are not at all clear. There are no provisions for physicians or states sharing Medicare savings physician or penalties for not meeting financial targets.  Medicare retains a “nuclear option” right to suspend any demo that isn’t achieving budget neutrality.

4) Conclusion: Think Twice Before Signing Up

We suggest States think twice, er, actually three times before signing up for this demo.

In order to participate, it appears the current multi-payer initiatives that are underway may have to be extensively re-tooled. CMS’ burdensome conditions combined with the threat of pulling the plug needs to be factored into the decision making. Payment rates seem low, deadlines are onerous, there’s a one size fits all reimbursement requirement, there is little role for legitimate outside vendors, it locks in Medicare’s view of the medical home and the Feds have little accountability in assuring budget neutrality. 

Medicare’s participation in the sandbox of the medical home is an important step forward.  Unfortunately, those steps may end up kicking too much sand.

Are we reading this wrong?  What do you think?  We invite your comments.