Monday, July 5, 2010

CMS' Multi-payer Advance Primary Care Demonstration (MAPCP): How Was $10 Per Person Per Month Chosen?

So just how did the Medicare Multi-payer Advanced Primary Care Practice Demonstration (MAPCP) decide $10 per person per month (PPPM) was adequate reimbursement for the medical home? Was it a painstaking academic exercise using the brightest healthcare economists? Did they ask a representative sample primary care physicians about the costs of reengineering their practices? Did they take LeBron's lifetime projected salary potential and divide it by 100 million?

The Disease Management Care Blog investigates.

Recall that Medicare has historically paid physicians using "relative-value units" (RVUs). These are calculated based on provider 1) effort (time, skill and training), 2) practice expenses and 3) liability insurance costs. RVUs were the basis (look at page 10 of this document) of the Medicare Medical Home Demonstration's payment rate of $40 to $51 PPPM.

It would appear that the RVU methodology was completely jettisoned in the MAPCP Demonstration. Go to CMS' MAPCP homepage and look through the "Demonstration Q & As" document for the "How did CMS arrive at a $10 payment?" section. The answer is that the amount is based on the range of payments being used in the national medical home pilots as reported in this May 2010 publication in the Journal of General Internal Medicine. The article is by Harvard's Asap Bitton, Carina Martin and Bruce Landon and titled "A Nationwide Survey of Patient Centered Medical Home Demonstration Projects."

If this publication seems familiar to readers, it should. Long before it knew how CMS was going to misinterpret those data, the DMCB examined the article's review of the pilots' research methods. While the DMCB was fixed on outcomes methodology, the folks at CMS were focused on payment. The pilots' per person per month payments range from $.50 to $9.00. That PPPM payment is an additional yearly physician income ranging from $720 to about $91,000. The median is about $22,000.

So $10 PPPM is at the high range of what the market is paying, right?

Not exactly. The authors go on to say.....

"A majority of demonstrations use additional bonus payments as well, with most of those payments consisting of previously existing P4P programs, but others that include new P4P bonus systems specific to the pilot.....More than 40% of demonstrations also include additional payments outside of fixed monthly payment arrangements" (bolding DMCB).

So, are the smart folks at Medicare using the Bitton article as cover to underpay physicians with a commerical rate $10 PPPM while still getting credit for a demo? There's only one way to find out, and that's to play a version of National Public Radio's weekly chat/quiz show Wait Wait, Don't Tell Me.

Only this one is called...... OK OK, So Tell Me!

JOE BIDEN: From the DMCB World Headquarters, this is the CMS news quiz, OK, OK, So Tell Me!

(Soundbite of applause)

Here is your host…. Don Berwick!

(Soundbite of applause)

DON BERWICK: Thank you Joe! Now it’s time for OK, OK, So Tell Me, where we ask our panelists to amuse us with clever unscripted repartees over the wacky ways of America’s favorite deep-water fiscal leak, Medicare! This week’s topic is the Medical Home.

Whoever has the best answer will be rewarded by having Joe Biden defend the ongoing RAC audits at a physician staff meeting of your choosing, and, as an extra bonus, CMS' cracker jack web masters will make the DMCB your web browser's home page!

(Soundbite of applause, soundbite of laughter)

DON BERWICK: Are you ready panelists? As many listeners know, CMS recently unveiled another healthcare acronym, the MAPCP, which will test $10 PPPM for PCPs’ PCMHs. The question for our panelists: is the MAPCP DOA, MIA or FUBAR?

MS. SEBELIUS: Hey Don! Once we realized how much physicians detest RVUs, we thought we could cancel them and simultaneously end deficit spending by using Twinkies as the unit of payment. Those cream-filled yellow cakes are not only yummy, but docs can use them to barter! We're going to demo that but in the meantime, we thought $10 PPPM sounded good.

(Soundbite of laughter)

AMA PRESIDENT: Don Berwick, you rascal you. You left out the most important acronym of all: the SGR. [holding ears and humming “SGR, SGR, SGR….!]

(Soundbite of applause)

HEALTH INSURANCE EXEC: Well, Don, when we negotiate physician payment rates, our approach has been to propose a fee schedule based on Medicare, await the counter-offer and then compromise by imposing our original fee schedule proposal. We're glad to see Medicare is using the same playbook!

(Soundbite of laughter and applause)

MS. SEBELIUS: Oh, you insurance execs. CMS just loathes you!

(Soundbite of applause)

AMA PRESIDENT: [Holding ears and humming "SGR SGR..."]

HEALTH INSURANCE EXEC: Like we care? You're forcing everyone to buy our product!

DON BERWICK: There you have it folks. Join us next week when OK OK, So Tell Me looks at my nomination to head CMS and the proverbial snowball's chance!

(Soundbite of applause)

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