Medicare Medical Home Demonstration Project
On October 26, 2009, CMS made the following announcement about the status of this demonstration project:
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.
Background
The Medicare Medical Home Demonstration project was authorized in Section 204 of the Tax Relief and Health Care Act of 2006
and attempts to redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family–centered care by a personal physician practicing in a medical home to Medicare beneficiaries with qualifying chronic conditions (see complete list of qualifying chronic conditions).
The 3-year demonstration project will provide reimbursement in the form of a care management fee to physician practices for the services of a “personal physician.” The legislation directed CMS to use the relative values scale update committee (RUC) process to establish the care management fee codes for care management fees. The RUC made its recommendations to CMS for the Medicare Medical Home Demonstration in April 2008.
.
Demonstration Design
CMS contracted with Mathematica Policy Research (MPR) to prepare option papers pertaining to defining a medical home and patient eligibility, among other topics.
CMS shared those papers with ACP and the American Academy of Family Physicians, the American Academy of Pediatrics, the American Osteopathic Association, the American Medical Association, and others for comment.
These option papers were then used to develop a draft demonstration design paper. The Medicare Medical Home Demonstration design was also presented in a Special Open Door Forum on October 28, 2008.
.
Physician Eligibility
Physician practices:
Including internal medicine, family practice, geriatrics, general practice, specialty and sub-specialty practices (except where specifically excluded).
Excluding radiology, pathology, anesthesiology, dermatology, ophthalmology, emergency medicine, chiropractic, psychiatry, and surgery.
.
Definition of a Medical Home
The CMS Medicare Medical Home Demonstration project has defined a two-tier medical home model with increasing levels of capability:
Achieving medical home status at either of the tiers represents an expectation that the practice has the capability and the intention to provide a certain level of care management and coordination services to patients in the demonstration.
Six general domains and up to 28 specific core capabilities.
Tier 1 or “typical” medical home must have 17 basic medical home capabilities, such as:
- Uses health assessment plan
- Uses integrated care plan
- Tracks tests and provider follow-up
- Reviews all medications
- Tracks referrals
Note: Although the scoring of the PPC-PCMH-CMS is different from the PPC-PCMH being used in the commercial market, Tier 1, as defined by CMS, tracks more closely with level 2 recognition for the commercial PPC-PCMH.
Tier 2 or “enhanced” medical home must meet Tier 1 requirements plus 2 additional capabilities (electronic medical record and coordination of care including follow-up of inpatient and outpatient care), plus three of nine optional capabilities.
Practices will qualify for medical home status on the basis of documentation submitted using the Physicians Practice Connections/Patient-Centered Medical Home instrument (developed and owned by NCQA), modified as necessary for the Medicare demonstration.
NCQA has licensed to CMS without cost for use in the demonstration, including instructions for submission.
Can be submitted electronically or on paper.
Note: Although the scoring of the PPC-PCMH-CMS is different from the PPC-PCMH being used in the commercial market, Tier 2, as defined by CMS, tracks more closely with level 3 recognition for the commercial PPC-PCMH.
Practices that qualify for Tier 1 may later move up to Tier 2 by submitting documentation of their additional qualifications.
Resources for Further Information on the CMS Medical Home Definition:
- Detailed PPC-PCMH-CMS Standards
- Crosswalk of PPC-PCMH-CMS Standards to Medical Home Capabilities
by Tier - CMS Medical Home Tier Qualifications – Information for Patients
.
Patient Eligibility
Coverage eligibility:
- Medicare Part A & B, fee-for-service
- Medicare as primary coverage
Disease eligibility:
Other eligibility:
- Patients who enter nursing home while participating in demonstration (as long as the patient continues to receive primary care services from the medical home)
- Patients who “recover” from a qualifying chronic condition while participating in medical home
Exclusions:
- Enrolled in a Medicare Advantage Plan
- Current hospice patients
- Current nursing home patients
- Participating in other Medicare demonstrations
.
Monthly Medical Home Fees
Proposed Medical Home Demonstration Per Patient Per Month Payment Rates, Overall and By Patient Heirarchal Condition Code (HCC) Score
| Medical Home Tier | Per Member Per Month Payments | Patients with HCC Score < 1.6 | Patients with HCC Score = 1.6 |
| Tier 1 | $40.40 | $27.12 | $80.25 |
| Tier 2 | $51.70 | $35.48 | $100.35 |
- Fees are adjusted using the Hierarchal Condition Code (HCC) scores to reflect severity and burden to the physician.
- HCC scores < 1.6 represent beneficiaries who are less ill and require less physician effort to manage. Those with scores > 1.6 are considered more ill and require more physician effort to manage the patient.
The monthly medical home fees listed above are based on recommendations made by the Relative Value Scale Update Committee (RUC).
.
Payment Process
CMS has contracted with Palmetto Government Benefits Administrator (Palmetto GBA) to make monthly payments for each eligible, enrolled beneficiary to the Medical Home practice that they have agreed to provide their Medical Home care. This payment is made automatically each month in addition to any covered Medicare services the beneficiary receives during that time.
Palmetto GBA will verify beneficiary eligibility each month prior to making payments. Beneficiaries who choose not to participate, or become ineligible due to changes in coverage or death will be deleted from their Medical Home’s patient roster. Adjustments will be made for all monthly payments made to practices while the beneficiary was not eligible.
.
Site Selection
CMS expects to announce site selection in 2009 and anticipates the demonstration will be implemented in all or parts of 8 States. More detailed site selection criteria are listed below.
Site Selection Criteria:
Section 204 of the Tax Relief and Health Care Act of 2006 specifies that the Medical Home Demonstration will be conducted in no more than 8 states. Locations are to include urban, rural and underserved areas.
CMS anticipates soliciting 50 practices in each of 8 sites for a total of 400 practices.
CMS will choose sites that will provide good geographic distribution across the country and do not have other CMS demonstration projects in which contamination of comparison groups could occur.
Sites must have a sufficiently large Medicare fee-for-service population with both Part A and Part B coverage and not enrolled in Medicare Advantage.
Sites must provide a sufficient physician-based practice pool from which to recruit 400 practices.
CMS expects to include 2,000 physicians from all practices participating in the demonstration.
CMS would prefer sites that are high Medicare cost areas because there is greater potential for better care management of chronically ill beneficiaries to produce savings.
CMS would prefer sites that have private payer Medical Home demonstrations occurring as it is expected to help in recruiting physician practices.
.
Implementation Schedule (as of January 2009)
CMS has contracted with Thomson/Reuters (Healthcare) Inc. to assist in implementing the recruitment, application, qualification, and patient enrollment activities.
CMS will begin soliciting practices to participate in the demonstration immediately following approval to conduct the demonstration.
Applications from interested practices will be accepted for at least a 3-month period.
Eligible practices will be notified to submit their qualification (recognition) survey and documentation and be evaluated as Medical Homes by NCQA. Applicants will be notified of their evaluation status immediately following the Medical Home qualification review.
Practices can begin enrolling qualified beneficiaries and submit Acceptance/Agreement forms immediately upon being qualified as a Medical Home.
Payment of the monthly Medical Home fee to qualified practices will begin January 2010 and continue through December 2012.
.
Additional Information and Resources
- CMS Medicare Medical Home Fact Sheet – this document summarizes much of the information included on this page in one printable document
- CMS Medicare Medical Home Demonstration Questions & Answers
- CMS Medicare Medical Home Demonstration Project Website
- MedHomeInfo: A resource for physicians and practices that want to participate in the Medicare Medical Home Demonstration (MMHD). This resource is being provided though a grant from the John A. Hartford Foundation to the Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health
Acrobat PDF format.
Download Acrobat Reader
software for free from Adobe.
Problems with PDFs?
Do You Need Help Becoming a Patient Centered Medical Home?
Learn about how this product can help and watch a video tour (3 min, no sound).
MKSAP 15 Discount 10% Off
Get ready for the New Year with the newest edition of MKSAP. Enjoy a 10% discount off MKSAP 15 for a limited time. You must order by December 11, 2009 and use priority code E9048 to get the discount.
Holiday Gift offer - 10% off
A great gift for a colleague or yourself - Landmark Papers in Internal Medicine: The First 80 Years of Annals of Internal Medicine. Enjoy a 10% discount when you order by December 11, 2009 and use priority code E9049.