More state health policy in New Orleans

Yesterday, I finished up at the NASHP conference hearing the latest from VT’s Blueprint for Health and a panel on how FQHCs are stepping up to provide coordinated care and patient-centered medical homes (PCMHs). VT is planning to expand their Blueprint PCMH program to the entire state in three years. Primary care practices certified as PCMHs by NCQA are paid a flat per member per month fee based on their level of certification; the Blueprint does not include a quality or performance based payment provision. The pmpm rates vary from just $1.39 to just over $2, far below CT’s $7.50 pmpm in our PCCM program. Preliminary results are very promising both for savings and improving health status. The program also includes community health teams with a team of clinicians for each community; the team offers more intensive care coordination services to any patient in the community regardless of payer or insurance status. The clinicians on the team and services offered are locally based, no remote disease management, and are based on an assessment of local population needs. Each team serving about 20,000 people costs $350,000/year. All four private insurers in the state contribute to the community health teams. Because of the health teams two insurers have been able to cancel their expensive disease management contracts with outside companies. It is not clear yet if premiums to consumers will be reduced to reflect the savings.

The panel on FQHCs and PCMHs highlighted the natural fit between the two models of care and the cost advantages of linking the two. Iowa had a bare bones coverage program with limited provider participation, similar in many respects to Charter Oak. Also like Charter Oak, IowaCare quickly began sinking under its own weight from adverse selection and administrative issues soon after it was implemented in 2005. Iowa wisely decided to transition the program to a PCMH model based on their FQHCs. IowaCare Medical Homes are paid a monthly care management fee as well as performance payments.

Building on their successful PCCM program, Montana also created a flexible, locally controlled PCMH program through their FQHCs. Patients are referred to the program by a prospective payment risk assessment system or by referral from primary care providers; many PCPs state that they can tell which of their patients are at risk of incurring high medical costs before they would be picked up by a claims based system. Primary care providers hire the care managers, who meet patients where they are – in their homes, in their cars, at the grocery store, at a laundromat, etc. Care managers must become certified within three months of hire. They engage in a conversation with patients and their families to see “what the problem is and find a way to fix it.” That may mean arranging reliable transportation to appointments, pulling out carpet, cleaning drapes, or finding a vacuum cleaner for someone with asthma whose cleaner broke a year ago and hasn’t been able to replace it. Since care managers are local residents connected to their communities, they can identify informal resources and donations. The switch from using outside disease management companies to local community programming has expanded benefits and reduced costs for patients in the program. The total number of care management FTEs has increased from 4 to 25 now and soon will be 45 at a lower cost to the state.
Ellen Andrews