Leveraging Medicaid in a Multi-Payer Medical Home Program: Spotlight on Rhode Island's Chronic Care Sustainability Initiative
The CSI, which launched in 2008, had its origins in Rhode Island’s participation in a 2006 foundation-funded initiative that aimed to align public purchasers, private purchasers, and health plans in regional partnerships to more effectively leverage improvements in care for people with chronic conditions.1 Rhode Island has used this multi-payer strategy to support the PCMH model statewide.2 With strong leadership from the state’s health insurance commissioner, a multi-stakeholder group determined that the pilot program should align quality improvement and financial incentives among purchasers, health plans, and providers; improve chronic care in primary care settings; and make primary care a more attractive and viable specialty in Rhode Island.3 The idea was to use the leverage of the state’s large capitated health plans and Medicaid’s major role as a purchaser to drive the desired improvements.
Since the beginning, the CSI has included the two largest commercial health plans in the state – Blue Cross & Blue Shield of Rhode Island (BCBS) and UnitedHealth Care (UHC) – and the state’s one Medicaid health plan, Neighborhood Health Plan of Rhode Island (NHP). (UHC has many Medicaid as well as commercial members.) These payers provide practices that participate in the CSI with financial incentives and practice transformation resources to develop a sustainable model of patient-centered chronic care for adults.
Originally a voluntary pilot, the CSI was formalized in 2011 by state legislation, sponsored by the health insurance commissioner, mandating that all state-regulated (i.e., commercial) health plans participate. In 2012, Rhode Island required all commercial plans with Medicaid contracts to participate in the CSI. As a result, these plans are now required to pay supplemental care management fees to participating practices not just for their commercial enrollees, but also for their Medicaid enrollees if the practice serves at least 200 of them. Medicare began to participate in the initiative when CMS selected Rhode Island for the Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration in July 2011. Therefore, participating practices now receive supplemental payments for Medicare beneficiaries, Medicaid beneficiaries in managed care (about 60% of the total Medicaid population), and privately insured patients. Because the CSI does not include Medicaid patients who are enrolled in the state’s fee-for-service primary care case management (PCCM) program, the PCCM program was outside the scope of this study. However, we were told that, like CSI practices, primary care providers in the PCCM program receive supplemental fees to support nurse care managers, and that the state uses the same performance metrics in both programs. In addition, the Executive Office of Health and Human Services (EOHHS), where the Medicaid program resides organizationally, is a co-convener of the project with the Office of the Health Insurance Commissioner (OHIC) and has taken a more active role in the initiative in recent years. State Medicaid officials attend CSI meetings and the program provides non-financial support for the initiative.
Practices must be selected for the CSI in order to receive supplemental payments from plans. Initially, in 2008, five primary care practices identified as “champions” were selected to participate. Eight more practices were added in 2010, three were added in 2012, and consistent with the state’s strategic plan, 20 practices were added in 2013, including several multi-site practices. The initiative now includes 36 practices, 48 practice sites, and 297 physicians serving an estimated 250,000 Rhode Islanders, approximately 25% of the state’s total population. Under the strategic plan, another 20 practices will be added in each of the next four years and the initiative is slated to serve more than 500,000 patients. At the end of 2012, Medicaid managed care enrollees accounted for about 25% of patients in CSI practices, commercial enrollees constituted 51%, Medicare Advantage enrollees made up 9%, and Medicare fee-for-service beneficiaries made up 15%.4
The following elements are central to the multi-payer medical home initiative:
A common developmental contract, which all health plans use with participating practices.5 Appendix 1 outlines key elements of the developmental contract: supplemental payments, required practice improvements, performance metrics, and staging of the contract provisions as practices come on line.
A uniform per member per month (PMPM) fee for care coordination, which all plans pay participating practices, and which help finance the practice infrastructure needed to support a PCMH. Practices can also earn additional performance incentive payments.
Practice transformation investments, to support the addition of a nurse care manager, in particular. These investments also support the development and use of electronic health record (EHR)-based performance metrics, and participation in learning collaboratives.
A multi-stakeholder leadership group, which guides CSI policy development and practice transformation.
Governance, authority, and operational management
The health insurance commissioner’s leadership and Rhode Island’s small size and long history of collaboration among major stakeholders have had a defining influence on the CSI’s development and structure. All those interviewed considered the health insurance commissioner’s leadership to have been instrumental in engaging commercial insurers in the initiative and enabling them to develop a common contract. The fact that many of the key actors in the CSI go back years together has also been helpful. The medical directors from several health plans trained together, the health insurance commissioner was formerly the director of NHP, and the current Medicaid medical director was the original CSI project staff person.
Governance. Governance of the CSI was structured to be collaborative and participatory.6 A large Steering Committee and a smaller Executive Committee set strategic direction for the CSI and are responsible for its overall governance; they include representation from the three major stakeholder groups – providers, payers, and purchasers (i.e., employers and Medicaid). The Steering Committee develops consensus on major issues, such as chronic conditions to be targeted, metrics, and payment strategies. While not required to do so, the Executive Committee also operates by consensus. Appendix 2 shows the governance structure, which, besides the Steering Committee and an Executive Committee, includes Working Committees on data and evaluation; practice training support and transformation; practice reporting; payment reform/contracting; and service expansion and integration. The purpose and scope of these Working Committees are outlined in Appendix 3.
The governance structure has remained largely unchanged, although it is now being refined and more formally constituted. In 2013, a Patient Advisory Subcommittee is being introduced to serve as the voice of patients and families and provide advice and input to the Steering and Executive Committees.7 In addition, a new Marketing and Communications Subcommittee is charged with increasing awareness of PCMH among employers and labor unions, increasing patient participation in PCMH practices; supporting the Patient Advisory Subcommittee, and conducting liaison with other community agencies.
Authority. A broader goal of the health insurance commissioner’s is to increase the role of primary care in health care delivery. Operationally, his strategy is to shift Rhode Island’s “primary care spend” from 8% of total health care spending currently, to 30%. To move in this direction, he has required state-regulated insurers to increase the share of their premiums spent on primary care by 1 percentage point per year over the period 2010-2014. Insurer investments in the CSI (e.g., their supplemental payments to participating practices) count toward this required annual increase. The health insurance commissioner has also interpreted his authority to allow him to require plans to contribute to the overhead costs of the data and related infrastructure for the CSI; these costs have grown recently because the federal Beacon Community Program, which provided grants for health information technology and other infrastructure, has ended. Insurer expenditures on these costs also count toward the primary care spend goal.
Operational management. The OHIC, with the support of a staff person then at the state’s Quality Improvement Organization (and now the state’s Medicaid medical director), was responsible for appointing the original Steering Committee and managing CSI’s day-to-day operations. At that time, staffing for the initiative was minimal— just two full-time staff funded by a foundation grant and the health plans. The Rhode Island Foundation, the state’s only community foundation, later served as a vehicle for accepting and handling external funding support for the CSI, and also provided office space for the program. When the original staff left in 2011, the state issued a competitive solicitation for project direction and project management support, and the contract was awarded to Commonwealth Medicine, the medical school at the University of Massachusetts.
Infrastructure. Substantial infrastructure is needed for the CSI to work. Essential components include:
- Support (staff and facilities) for governance, coordination, and convening;
- Technical support to assist practices in constructing all-payer, EHR-based clinical metrics and using them to improve performance;
- Development of interim all-payer, claims-based metrics (e.g., all-cause hospitalizations; ED use) until a permanent, consistent data base that integrates EHR clinical data can be developed;
- Coaching in practice transformation, particularly for practices newly entering the PCMH; and
- An annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey of patients in CSI practices.
For part of the CSI’s history, the Beacon grant provided crucial financing to the Rhode Island Quality Institute (RIQI) for some of these infrastructure costs (except for the first item).89 With Beacon’s expiration, the costs are now being transferred to the CSI itself and payers are being asked to cover more of them. (The RIQI will continue to do portions of the work related to data collection and analysis, but practice transformation services are no longer procured through the RIQI.) As the CSI expands to include more practices, the needs for infrastructure development and funding will grow. In 2013, the annual cost of administering CSI will be $2.2 million, up from about $0.5 million for its first contract, which started in December 2011.10 About half of the total budget will go to organizations providing support to the RIQI for work previously funded under the Beacon grant.11 In early 2013, Rhode Island received a federal grant for up to $1.6 million under the Center for Medicare and Medicaid Innovation (CMMI) State Innovation Models (SIM) initiative, which is designed to foster state-based models for multi-payer payment and health care delivery system transformation.12 Interviewees expressed hope that the award will allow the CSI to develop a more permanent operating model suitable to a broad-based permanent program.