CMS Steps Up With the Multi-Payer Advanced Primary Care Practice Demonstration on the Patient Centered Medical Home (PCMH) at $10 PMPM

Readers have questioned the Disease Management Care Blog about its Facebook and the other glow-pink eyed portraits in the right side of the page. It's been told that it conveys a buffoonishness that is inconsistent with the DMCB reputation of sober erudition and morose skepticism. What's more, it's been asked: just what are those lights?

Well, the pic is not long for this blog, but that doesn't mean it doesn't hold a special place in the DMCB Galaxy. Those are, by the way, pink flamingo tree lights, surreptitiously added to the cart by DMCB after being invited by the spouse to accompany her on a holiday shopping errand months ago. Despite the DMCB's merry participation, it was pointedly warned during check-out that this was the "last time" it would "ever" etc. etc. It seems it turned left in the aisles when it was supposed to go right, touched things it shouldn't have and said things that weren't helpful. While the lights were disappointingly never tasked to their original celebratory purpose, the DMCB has discovered - despite occasional attempts at spousal sabotage - that they are suitable for year-round display in the Executive Suite of DMCB World Headquarters.

And the States with Patient Centered Medical Home (PCMH) pilots may gain a special appreciation for the DMCB spouse's travails after they're done checking out just how CMS intends to merrily participate in their programs. The Feds have just released their "solicitation" for their "Multi-payer Advance Primary Care Practice Demonstration." This is **THE** three year demo designed to test the PCMH across multiple insurers, including Medicare fee-for-service (FFS).

Recall that one big problem encountered by the current bevy of pilots is that they're typically sponsored by just one or a few insurers. As a result, it's been difficult to ask primary care practices to reengineer their daily workflows to offer the "Cadillac" PCMH to patients with one type of insurance and "Chevy" usual care to patients with another type of insurance. Up until now, Medicare has relegated its patients to the Chevy.

Can the Cadillac PCMH pay off in Medicare FFS? To find out, CMS is inviting up to six States with ongoing multi-payer pilots to submit applications by August 3, 2010.

CMS' requirements are considerable. It wants (in "40 pages or less"):

1) a State agency to lead it,

2) enlistment of multiple group/individual private payers (that together enroll ">50% of State residents") as well as its Medicaid program,

3) the State to"demonstrate [the] commitment" of majority of its PCPs,

4) identification of and a way to certify PCMHs that also have links to State/community, public health, wellness and prevention resources,

5) to have the provider payment mechanisms in place,

6) CMS's uniform payments for the clinics/coordination/CMS' share of the administrative expenses (plus not to exceed $10 PMPM) all set up,

7) a way to figure out how to "attribute" a beneficiary to a PCMH (for example, by "designation"),

8) the State to line up any necessary waivers,

9) the creation of an adequate monitoring system,

10) State agreement to participate in an independent evaluation by an entity of CMS's choosing,

11) a reasonable assurance that the demo will be "revenue neutral" ("describe the anticipated effect of the State initiative on aggregate or global expenditures under the Medicare program for all covered services combined"), and

12) be ready to go by the end of 2010.

The DMCB's first reaction is that these requirements to the States and their physicians will be, er.... daunting. It is going through the other documents on the CMS web site and will be pondering them over the appropriate beverages this weekend. Look for lots more on the topic here.