That's were the DMCB found some insightful market intelligence on the actual reimbursement levels for PCMHs:
Maryland's multipayer initiative will pay clinics a PMPM ('per member per month' payment) that ranges from a low of $3.51 to a high of $6.01, depending on the practice size (less than 10,000, between 10 and 20,000 and more than 20,000 patients) and PCMH recognition. A PCP on-line payment estimator is here.
Minneosta's multipayer initiative will pay based on a complex grid that counts that number of "major condition groups" and, depending on the number of groups (1 to 3, 4 to 6, 7 to 9, >10) creates patient "tiers" that range from 1 to 4. Tier payments can range from $10.14 to $60.81.
New York's EmblemHealth pays $2.50 PMPM for care management and up to $2.50 in additional pay for performance
Pennsylvania's Chronic Care Initiative pays $1.50 PMPM for practice support and PMPMs that range from $0.60 to $7.00 PMPM, depending on age.
To put things in context, recall that CMS was planning in its original Medical Home Demonstration to pay between $27.12 and $100.35 PMPM. That demo was shelved in May of 2010 in favor of the Multipayer Advanced Primary Care Practice Demo. In contrast to the Medical Demo, the new Advance Practice demo has planned on paying no more than $10 PMPM, unless it "justified by compelling evidence of a commensurate improvement in performance" (see page 12 here). The illogic of this has been previously examined by the DMCB and its colleague, Vince Kuraitis here.
Which leads to three DMCB's impressions:
Race to the Bottom: Everytime the DMCB looks, the amount of money being committed to medical homes seems to be going down, not up. The DMCB has generally found, in contrast to the mostly single digit amounts described above, that the commercial market PMPMs for care management programs are considerably higher. Keep in mind that those are also programs that rely on "light touch" and periodic telephonic patient outreach. The cost of higher touch "medical home" style patient education and care coordination typically exceeds $10 PMPM. The amount charged is even higher.
No new money: Beware, says the DMCB: when providers see additional payments in the low single digit range, that's usually an indication that the insurer is merely shifting money from elsewhere. That elsewhere is usually from their scheduled adjustments in the regular fee schedule, which are therefore correspondingly less. The DMCB suspects the insurers are moving money from the providers' left pocket and putting in their right pocket.
Payment for Extra Work or for Infrastructure? The DMCB went to that handy Maryland calculator linked above and, assuming 1500 patients, Level 2 recognition, a majority of Medicare patients with only 5% uninsured and found the yearly payment will amount to approximately $34,000 per year. That doesn't come close to supporting the non-physician FTEs necessary really support a fully functional PCMH team infrastructure.
Two other observations:
Some States are using their own recognition criteria that shadow NCQA PCC-PCMH recognition program. Check out what Maryland and Minnesota are up to.
Just because you're investing in a PCMH doesn't mean that disease management also isn't important. Just ask Capital District Health Plan.