Medicare joins with insurers to test paying for care management

Payers will provide up to $40 per patient per month, but primary care physicians in eight selected states have only a month to apply.

By Charles Fiegl amednews staff — Posted June 18, 2012

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Dozens of private and public insurers have joined a Medicare-led initiative to offer primary care practices in seven markets monthly care management fees and the opportunity to share savings for keeping patient costs low.

Primary care physicians in eight states have until July 20 to apply for the four-year program known as the comprehensive primary care initiative, the Centers for Medicare & Medicaid Services announced on June 6. Interested doctors are encouraged to complete a series of online screening questions to determine their eligibility and then formally apply for the program. CMS will select about 75 practices to participate in each market.

“We know that when we support primary care, we get healthier patients and lower costs,” said acting CMS Administrator Marilyn Tavenner. “This initiative shows that the public and private sectors can come together to meet the critical need for these services.”

Physician organizations said they were pleased by the response from insurers, including Medicaid agencies in several participating states. The support from a wide range of payers will help physician efforts to coordinate patient care, said American Medical Association President Peter W. Carmel, MD. “Cooperation between Medicare and private insurers is critical to the success of innovations by allowing physicians to improve care delivery for all patients.”

Maximizing the effort's reach

In May, CMS sponsored a meeting with insurers to discuss details of the program and encourage them to agree to terms. Each interested participant emerged with a memorandum of understanding for how its market would operate. The markets include the entire states of Arkansas, Colorado, New Jersey and Oregon. Select counties in New York and Oklahoma and a joint state area of counties in Kentucky and Ohio also will participate.

UnitedHealthcare will participate in three of the markets — Colorado, counties in Kentucky and Ohio, and New Jersey. The insurer already operates patient-centered medical home programs in Colorado and Ohio, said Michael McGuire, CEO of UnitedHealthcare for New Jersey.

The Medicare-led initiative offered another way to work with physicians to boost quality of care, improve patient outcomes and keep costs low, he said. Insurers will identify the enrolled patients who already are assigned to physicians selected for the initiative. Practices then will receive monthly care management fees for each patient, which can be used to hire care coordinators, monitor care plans and manage chronic diseases.

The exact fee amounts are kept confidential between the payer and physician, but CMS estimates that doctors will receive an average of $20 per patient each month. Fees will be adjusted based on risk factors and will range from $8 to $40.

Each market will operate differently, but all of the programs will have quality measurement tools and a basic payment structure in place, said Bruce Bagley, MD, medical director for quality improvement at the American Academy of Family Physicians. The initiative's success is designed by ensuring that a large enough chunk of a practice's patient base is part of an innovative model that supports primary care.

“We have seen pilot projects galore,” Dr. Bagley said. “One payer has a great idea in a market and state, but if it makes up a small percentage of a practice, it is not going to get much attention.”

Doctors must move quickly

Interested physicians in any of the seven markets should complete a five-question prescreening application on the CMS Center for Medicare and Medicaid Innovation website, said Shari Erickson, director of regulatory and insurer affairs at the American College of Physicians. Practices that meet initial screening criteria will be prompted to submit points of contact and email addresses to receive more information about applying.

The program is intended for practices that have been recognized as patient-centered medical homes or that are moving in that direction, Erickson said. For instance, physicians must have an electronic health records system and have achieved or are on their way to achieving stage 1 of the federal meaningful use initiative by the end of the first year of the primary care program.

Physicians also can determine eligibility by evaluating their insurance payer mix to see if enough of their patient panel — 60% — is covered by participating payers. The practice then can estimate how much support it would receive in the form of monthly management fees. Doctors will receive higher payments for patients with multiple chronic and complex conditions.

Practices without all the necessary components of a medical home will have to show CMS they will have care coordinators and other necessary staff in place. “They need to show they are investing the money back into the practice,” Erickson said.

After the first year, practices would be eligible to share part of any savings generated to the payers, including Medicare. If a practice is not meeting participation requirements, it could be asked to leave the project, but practices would not be required to give back management fees, Erickson said. CMS planned to release more details and expectations for the program later in June.

Other primary care practices that are not eligible for the program still can learn from the experiment, Dr. Bagley said. If the program is a success, it might be implemented in additional markets and states.

“The law says that if the HHS secretary decides this is working well, the secretary can declare that this is the way to pay for primary care across the country,” he said.

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Who is eligible for the initiative?

Primary care practices that pass prescreening criteria for the Medicare-led care management project will be asked to submit formal applications. The total number of practices chosen will be capped at about 75 per each of the seven markets selected for participation. The agency is looking for practices that:

  • Treat at least 150 Medicare patients.
  • Generate at least 60% of their revenue from payers participating in the initiative.
  • Have achieved or are in the process of achieving stage 1 meaningful use of an electronic health records system.
  • Have started transforming their practice model to obtain a state-based medical home designation or have completed a national recognition program.
  • Have participated in practice transformation activities during the past three years.

Source: Prescreening tool for comprehensive primary care initiative, CMS Center for Medicare and Medicaid Innovation (link)

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What other payers are in the initiative?

The care management pilot is limited to physician practices who generate most of their revenue from Medicare and payers in seven markets.


Arkansas Blue Cross and Blue Shield
Arkansas Medicaid
QualChoice of Arkansas


Anthem Blue Cross Blue Shield of Colorado
Colorado Access
Colorado Choice Health Plans
Colorado Medicaid
Rocky Mountain Health Plans
Teamsters Multi-Employer Taft Hartley Funds

New Jersey

AmeriHealth New Jersey
Horizon Blue Cross Blue Shield of New Jersey
Teamsters Multi-Employer Taft Hartley Funds

New York (12 counties)

Capital District Physicians' Health Plan
Empire Blue Cross
Hudson Health Plan
MVP Health Care
Teamsters Multi-Employer Taft Hartley Funds

Ohio (14 counties) and Kentucky (4 counties)

Amerigroup (Ohio only)
Anthem Blue Cross Blue Shield of Ohio
CareSource (Ohio only)
Medical Mutual
Centene Corp. (Ohio only)
Ohio Medicaid

Oklahoma (25 counties)

Blue Cross and Blue Shield of Oklahoma
Oklahoma Health Care Authority


ODS Health Plan
Oregon Health Authority
Providence Health Plans
Teamsters Multi-Employer Taft Hartley Funds
Tuality Health Alliance

Source: “Comprehensive Primary Care Initiative,” CMS Center for Medicare and Medicaid Innovation (link)

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External links

Prescreening tool for comprehensive primary care initiative, CMS Center for Medicare and Medicaid Innovation (link)

“Comprehensive Primary Care Initiative,” CMS Center for Medicare and Medicaid Innovation (link)

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