Medical Home Reimbursement Pilot

People used to go to their family doctor if they had a health problem. Now, according to a study published in Health Affairs, only 42 percent of the 354 million annual visits for newly arising health problems are made to a primary care physician. Hospital emergency rooms, specialists and outpatient departments are handling the rest.

Emergency room visits are much more expensive than a primary care visit—and evidence shows that as much as half of emergency room visits could have been potentially avoided if people had a strong relationship with their primary care provider and had been seen in a primary care practice earlier.

The Multi-Payer Medical Home Reimbursement Pilot is testing one way to reduce potentially avoidable emergency room and hospital admissions by paying primary care practices in a way that rewards positive outcomes.

The pilot is anticipated to launch during the first quarter of 2011 and last three years.  It is being led by the Health Care Authority and is co-sponsored by the State Medicaid program and Health Alliance. All eight major health plans in the state are participating, including Aetna, CIGNA, Community Health Plan, Group Health, Molina, Premera Blue Cross, Regence BlueShield, and United Healthcare.

What is a Medical Home?

A patient-centered medical home – sometimes called a “health home” – is not a building, house, or hospital, but rather an approach to providing advanced primary health care. In a medical home, patients are encouraged to be active participants in their own health and well-being. They are cared for by a provider who leads a health team that coordinates all aspects of preventive, acute and chronic care using the best available evidence and appropriate technology. Through this partnership, the team can help the patient access and coordinate specialty care, out-of-home care, family support, and other community services important to the patient’s overall health.   

Designed to Give Patients More Timely and Coordinated Care

The current fee-for-service payment system, which compensates providers each time they provide a service or see a patient, is ineffective in rewarding quality and value. The kinds of changes that would improve the quality of patient care takes time and resources that are not fully provided for within the current reimbursement system.

The Multi-Payer Medical Home Reimbursement Pilot is testing alternative reimbursement approaches that compensate providers more if they achieve specific, targeted outcomes. It is designed to give patients more timely and coordinated care through advanced primary care.   

How the Pilot Rewards Providers for Value, Not Volume.

In this pilot, primary care practices may receive an additional monthly fee per patient to support work that normally does not get reimbursed in a fee-for-service payment model, such as care coordination, increasing flexible access to care, tracking and monitoring chronic conditions and doing preventive outreach or follow up planning.

Primary care practices that participate in the pilot will share savings if they can reduce preventable ER and hospital admissions while maintaining or improving quality care in a number of areas such as care for chronic conditions like diabetes, heart disease and depression.

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