Various payment innovations have been testing ways to support primary care innovation and PCMH for many years. Depending on the region and the provider arrangement (e.g., a solo or small practice, an Independent Practice Association or Accountable Care Organization (ACO), or an employed provider as part of a health system), some practices that were once paid fee-for-service only, are now receiving additional per member per month payments (PMPM). Others are receiving payment incentives tied to performance metrics that measure quality, cost, or patient engagement. Medicare has been piloting various types of payment reform — ranging from pay-for-reporting to bundled payment — but the scale and spread of delivery models that tie payment to quality for all Medicare benefi ciaries is more recent.
As part of the Affordable Care Act, the Centers for Medicare and Medicaid Innovation (CMMI) is spearheading one of the most aggressive efforts in recent history to address delivery system reform. Recent passage of MACRA can help bring these efforts to scale across the entire Medicare program, and subsequently impact the broader commercial marketplace.
Because fee-for-service does not reimburse for key PCMH features — such as facilitating information sharing and care coordination with sub-specialists and hospitals, managing web-portals and personal health records, email communication and telephone visits, developing connections to community-based organizations, and integrating behavioral health — it often fails to compensate for the complete scope of services offered by a PCMH. Smaller practices with little reserve capacity are especially challenged in offering PCMH-level care without adequate financial support.
Numerous alternative payment models (APMs) are poised to support PCMH implementation and sustainability. Significant experimentation and testing of alternative payment arrangements is well underway, ranging from accountable care, to episode-based payment initiatives, to up-front payments that support primary care practice transformation, to initiatives that focus on specific populations, such as Medicaid, CHIP, or individuals dually eligible for Medicaid and Medicare.
For more information, please access our 2014-2015 PCMH evidence report.
Title | Date | Source | |
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Aligning Incentives & Systems:Promoting Synergy Between Value-Based Insurance Design (VBID) and the Medical Home | January 2010 | Patient-Centered Primary Care Collaborative | |
The Triple Aim: Care, Health, And Cost | May 2008 | Health Affairs | |
Patient Health Questionnaire - Mental Health Tools | January 1996 | Patient Health Questionnaire (PHQ) Screeners |
Title | Source | Date |
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Study Demonstrates Value of Practice Supports During PCMH Transition Process | AAFP News | April 24, 2013 |
Idaho Embraces Medical Home Model:Statewide Programs Seek to Facilitate Innovative Care Transitions | AAFP News | December 10, 2014 |
States Build on Primary Care Models to Expand Access | AAFP News | October 17, 2017 |
Illinois Medicaid Program Achieved Savings While Boosting Quality of Care | AAFP News | October 1, 2014 |
Researchers Ask: Is ACO Payment Worth the Time, Effort? | AAFP News | August 12, 2015 |
100+ Medical Organizations Urge Changes to Proposed Rule | AAFP News | July 1, 2016 |
Summit Focuses on Lower Health Care Costs, Success of New Models | AAFP News | June 17, 2013 |
Payment Reform Must Emphasize Primary Care | AAFP News | March 6, 2017 |
AAFP Declares Victory for FPs as Senate Fully Repeals SGR | AAFP News | April 15, 2015 |
Report Highlights Role of Health IT in Managing Patient Population Health | AAFP News | November 6, 2013 |