A look at Providence Family Medicine Center’s proposal for Medicaid Coordinated Care

At the beginning of June, Alaska Department of Health and Social Services (DHSS) posted its Notice of Intent to award the Provider-Based Reform (PBR) contract to Providence Family Medicine Center as part of the Medicaid Coordinated Care Demonstration Project.

PeaceHealth Ketchikan Medical Center and Pinnacle Integrated Medicine also submitted offers but were not selected. I read through Providence Family Medicine Center’s proposal to see how the project will take shape.

Providence Family Medicine Center (PFMC) is an integrated clinic in Anchorage and an ambulatory care site for Providence Alaska Medical Center. PFMC currently serves approximately 11,000 patients with 4,800 Medicaid enrollees and 700 dual eligible patients. PFMC has an average of 38,000 primary care provider encounters and an average 6,000 IDCT encounters per year.

Under the Coordinated Care Demonstration Project, PFMC will provide care to patients from the Anchorage area, the Mat-Su Valley and Kenai Peninsula.

PFMC currently uses a Patient-Centered Medical Home (PCMH) model, the cornerstone of which is the Integrated Direct Care Team (IDCT). The IDCT includes behavioral health, social work, nurse case management, home visits and pharmacy. The IDCT works with the patient’s primary care physician to “increase access, decrease inappropriate utilization, and improve patient outcomes.”

According to PFMC’s proposal:

“Our proposal is for Provider-Based Reform (PBR) that will allow us to make our IDCT services available to all Medicaid enrollees seen in our clinic, based on level of need. We propose a blended payment model that continues FFS payments for physician services and adds a capitated (PMPM) fee for care coordination. Financial support for the work accomplished outside the traditional doctor/patient office visit, by care team members whose services are not currently billable, is essential to support the care of Medicaid enrollees and to improve the health of our community.”

PFMC proposed a per-member per-month (PMPM) fee of $5.00 for each Medicaid enrollee who receives primary care at the clinic. Pinnacle Integrated Medicine proposed a PMPM fee of $8.00.

As another point of comparison, under CMS’ Chronic Care Management for Medicare patients, providers can bill:

  • Between $44 – $209 for an initiating visit
  • $64 as an add-on to the initiating visit for the billing practitioner’s time and effort personally providing extensive comprehensive assessment and chronic care management care planning to patients outside of the usual effort described by the initiating visit code
  • $43 for 20 minutes of more of clinical staff time spent on non-complex chronic care management
  • $94 for 60 minutes of clinical staff time spent on complex chronic care management
  • $47 for each additional 30 minutes of clinical staff time spent on complex chronic care management

PFMC projects savings within the first year of the project, however these projections were made in 2016 with the understanding the project would begin on January 1, 2018 based on the original timeline in the RFP.

The proposal had to include three out of nine elements included in the RFP. PFMC’s project aligns with seven of the nine elements.

  1. Comprehensive primary care-based management for medical assistance services, including behavioral health services and coordination of long-term services and support
  2. Care Coordination, including the assignment of a primary care provider located in the local geographic area of the recipient, to the extent practical
  3. Health Promotion
  4. Comprehensive transitional care and follow-up care after inpatient treatment
  5. Referral to community and social support services, including career and education training services
  6. Sustainability and the ability to achieve similar results in other regions of the state
  7. An innovative payment process, including bundled payments or global payments

PFMC’s proposal does not align with integration and coordination of benefits, services, and utilization management, or local accountability for health and resource allocation.

Under the PCMH model, patient needs are evaluated based on six domains, and then patients are referred to the appropriate IDCT member. IDCT members then develop a care plan for that patient.

To validate the PCMH model and IDCT, PFMC will also focus on five subgroups during this demonstration. These five subgroups will receive focused care coordination.

PFMC’s four objectives under this project are

1. Improve Health through full Medicaid patient engagement in our PCMH and IDCT care model.
2. Optimize Access through extended hours and services for Medicaid enrollees to achieve effective whole-person care.
3. Increase Value of care through monitoring and improving health outcomes within the Medicaid patient population.
4. Contain Costs through health promotion and reduction of unnecessary utilization by providing the right intervention in the right setting at the right time.

PFMC intends to reduce utilization for inpatient admissions, inpatient days, outpatient emergency department visits, and professional visits.