Funding and Establishing Medical Home Care Coordination

Wednesday, July 8th, 2009
This post was written by Melanie Matthews

Experts on medical home models of care share their experiences in funding medical home transitions and care coordination fees.

Funding the Medical Home Transition

Question: How can a health plan fund the transition to a more chronic care medical home model?

Response: (Dr. George Rust, family practice physician for Physicians in Practice, head of the National Center for Primary Care at Morehouse School of Medicine) There are lots of different options. Capitate payments can sometimes offer the opportunity to have a more multidisciplinary team involved in care. If you’re in a purely fee-for-service (FFS) environment, broaden your teams so that nurse practitioners (NP), mental health professionals and behavioral healthcare specialists are all part of the team. In our state, we found that many of our community health centers believed that they could not have two visits by different providers billed on the same day out of the same facility. For example, they could not co-locate psychologists and primary care clinicians in the building on the same day. That turned out to not be true. Those types of visits would indeed be paid for.

Therefore, the first step would be determining how to broaden the team so that it isn’t just a doctor-centered model, but it includes individuals who currently may not be in the practice like NPs, psychologists and behaviorists. This is especially important in the high disparity or multi-cultural communities. Community health workers — people who are of the culture that you’re trying to serve — are important. They’re even more important if your own providers do not match that culture, since they can act as a cultural bridge or ambassador to the community to champion certain outcomes.

(Elizabeth Reardon, president of Reardon Consulting, National Council for Community Behavioral Healthcare Integrated Care Consulting Team) There are some current procedural terminology (CPT) evaluation and management codes that address care coordination and treatment planning. They even have some that involve telephone contact. Not all payors want to pay for that. However, it gives you some background. Also, the CPT behavioral management codes that Medicare pays can help. Some of them relate to care planning and some to practice teams getting together to address what they need to work on.

Establishing Care Management Fees

Question: Dartmouth-Hitchcock recommended a $4 per member per month (PMPM) care management fee, but could not operationalize that. What are you doing instead?

Response: (Barbara Walters, senior medical director of Dartmouth-Hitchcock Medical Center) There are some potential options on the table. There are G-codes that have been published. Medicare has chosen not to adopt them this year, but they are available for use by the commercial plans. If the commercial plans can program a care coordination CPT code into their systems, then we will negotiate a monthly or quarterly care coordination fee. That will allow us to get reimbursed for care coordination for the complex patient.

With CIGNA(R), we negotiated an increased regular FFS reimbursement rate on the E&M codes that are billed by our primary care departments. We hope this will cover the cost of care coordination, but because this pilot just started, we have to do a reconciliation at the end of the year to see if the amount of money we received trues up for the number of patients for whom we coordinated care.

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