by Sam Starbuck
Maryland is a trailblazer when it comes to healthcare. Since the 1970s, Maryland has eschewed the other 49 states’ approach by adopting an all-payer system for hospital services. This unorthodox move effectively eliminated cost-shifting between hospitals. Then, in 2014, the state pivoted once again to a model that emphasized quality-care delivery, population health strategies, and per capita — as opposed to fee-for-service — expenditures. Just this past June, Governor Larry Hogan signed a contract to assume full risk of Medicare beneficiaries that is projected to save the state $1 billion over the next five years.
This innovation and forward-thinking experimentation doesn’t end at the political level. Rather, it permeates throughout Maryland’s healthcare system, from politicians to physicians to patients. Now Maryland’s independent primary care physicians (PCPs) have an opportunity to help their practices and patients through the recently announced Maryland Primary Care Program (MDPCP).
By launching this program, the state of Maryland and the Centers for Medicare and Medicaid Services (CMS) are committing to improving patient care and reigning in unnecessary medical costs across the state. In this program, PCPs will finally be financially rewarded for their part in making these goals a reality. From our perspective, the development of MDPCP is a great step in emphasizing the vital role PCPs play in keeping Marylanders healthy.
There are substantial benefits to patients and physicians who participate in the program. If you’re a PCP in Maryland weighing whether or not to participate, here are five things you should know.
#1 – 2019 Applications are due August 31, 2018.
The countdown has begun! Participant Practice applications became available on August 1 and are due by August 31. You can check out CMS’s timeline here.
#2 – You may make more money and improve your patient care.
MDPCP is an avenue to increase the capacity to provide comprehensive and continuous primary care. The program’s goal is to improve the health of Medicare beneficiaries while reducing and managing overutilized services in higher cost settings.
The program rewards PCPs for meeting quality and utilization targets while also paying the physicians prospective care management fees to support the build of the comprehensive primary care infrastructure (explained below). This approach can yield significant rewards.
According to CMS, “The MDPCP also offers all Participant Practices a combination of prospective per-beneficiary per-month (PBPM) care management fees and at-risk PBPM performance-based incentive payments, which Participant Practices may use to fund investments in care management staff and activities not directly payable under the existing [fee-for-service] payment system.”
Indeed, this program is a game changer for Maryland Medicare beneficiaries and PCPs. For years, PCPs have been asked to continually lower costs and improve outcomes. However, the financial incentives for doing so have been slow to catch up with programmatic expectations. This new opportunity seeks to correct that.
#3 – Your practice must meet five primary care functions.
MDPCP payments are based on practices meeting requirements of the five “Comprehensive Primary Care Functions of Advanced Primary Care.” These five functions are:
Access and Continuity – Includes patient-to-provider assignments, dedicated care teams, appropriate access to care, and 24/7 access to care.
Care Management – Includes longitudinal and episodic care management, risk stratification, goal-directed care plans, and integrated behavioral health.
Comprehensive Care and Coordination – Includes care transitions, practice transformation, referral management, and social needs assessments.
Patient and Caregiver Experience – Includes patient and family advisory council (PFAC), patient satisfaction surveys, and patient engagement.
Planned Care for Health Outcomes – Includes preventive care, addressing gaps in care, health IT, use of data to make informed decisions on patient needs, as well as quality, utilization, and performance reporting.
#4 – Key Players: Participant Practices and Care Transformation Organizations
The MDPCP comprises two main players: Participant Practices and Care Transformation Organizations (CTOs).
Participant Practices must have a location within the state of Maryland with one or more providers billing under a common tax identification number. Provider groups with multiple locations are seen as multiple “practices” for the purpose of MDPCP and must submit separate applications. In addition, each participating practice must maintain a minimum of 125 attributed Medicare patients.
In terms of reporting, Participant Practices “report quarterly to CMS their progress towards meeting the care transformation requirements.”
CTOs are state-approved entities designed to support participating practices in the MDPCP. CTOs could be formed by accountable care organizations, management services organizations, health plans, hospitals, and clinically integrated networks. It’s important to note that CTOs can control the overall capacity they serve, but they cannot choose the specific participating practices they support; in other words, no cherry picking.
A CTO must demonstrate the ability to support practices to perform the care transformation activities outlined in point #2. CTOs are designed to allow practices of any size to have some of the resources necessary to support the care management requirements.
According to CMS, “Practices and CTOs will be selected for participation in two separate rounds. CMS will first review CTO applications and select CTOs to participate in the MDPCP. Next, CMS will review practice applications and select Participant Practices. As part of their application, practice applicants may choose the CTO with which they would like to partner, if any.” The CTO applicants have already been accepted. You can find the full list for 2019 here.
#5 – Two tracks are available with varied expectations and payments.
MDPCP has two tracks of participation that provide varying levels of risk, payments, and expectations. There is a standard track (Track 1) and an advanced track (Track 2).
The two tracks have their own care transformation requirements and corresponding payment options. Track 2 requires more comprehensive practice transformation and provides Participant Practices increased payment amounts, relative to Track 1.
It is important to note that a practice can only stay in Track 1 for a max of three years. According to CMS, “A practice that applies during the 2018 application period and is accepted to participate in Track 1 will participate in the MDPCP from January 1, 2019, until December 31, 2026. A practice selected to participate in Track 1 beginning in Performance Year 2019 must transition to Track 2 no later than the start of Performance Year 2022.”
The state of Maryland and CMS have come together to create an opportunity for all PCPs to successfully fulfill the tenets of comprehensive primary care, no matter their size or sophistication.
There are big incentives for those who successfully navigate the requirements of the MDPCP, and we’re enthusiastic that this program will lead to better outcomes for Medicare beneficiaries. However, it can be an overwhelming administrative task to go through the bureaucracy and “acronym soup” of a program like this alone.
We’d be happy to walk you through these nuances and provide ideas for your practice. Click here to send us an email and schedule a consultation!