1. In the RFA on page 5, last paragraph, it states, “The CCM shall begin providing care management services by month six.” On page 1, fifth bullet point, it states applicants must have “been using EMR as its primary medical record solution at Meaningful Use Stage One for at least six months prior to the beginning of the Medical Home services.” Given the anticipated project start date of October 1, 2011, is it correct that (at the very latest) applicants must have been documented as using EMR at Stage One by October 1, 2011, and begin providing CCM/medical home services by April 1, 2012?

Response: For purposes of determining when practice responsibilities begin, “month one” is the month of the first learning session. For the St. Louis Learning Collaborative, month one is anticipated to be December 2011. Therefore, practices applying for the St. Louis Learning Collaborative must have been using an EMR since June 2011, and will be expected to have a Clinical Care Manager in place and begin providing care management services no later than June 2012.

Month one for the Mid-Missouri Learning Collaborative is anticipated to be March 2012. Therefore, EMRs must be in use by September 2011, and Clinical Care Managers in place and practices providing care management services by September 2012.

Please note that providing care management services represent only one component of Medical Home services that Medical Homes will be expected to provide.

2. Is the eligibility standard for Meaningful Use for the practice group, or each individual physician within a group (which might exclude new physicians who are arriving in Joplin now to join practices)?

Response: The Meaningful Use standard is for the practice group.

3. Do the CCM payments apply to patients regardless of whether the payer is the primary or secondary insurer? For example, will the $6.00 PMPM payment be made to patients age 65 and older who have Anthem or United insurance as primary insurance and as secondary insurance to Medicare?

Response: CCM payments will be the responsibility of payers who are providing primary insurance coverage.

4. Can you please define “third-next-available appointment”?

Response: “Third-next-available appointment” is a measure of accessibility. In order to determine third-next-available appointment, use the practice’s scheduling process, find the first available appointment starting on the day that the inquiry is being made. (For example, if the inquiry is being made on August 22, 2011, look for available appointments for that day and continue until the first available appointment is found.) Find the next available appointment (second-next-available appointment) and then the next available appointment after that one (third-next-available appointment). To meet the minimum standard, the number of days between the first available appointment and the third available appointment must be 30 days or less.

5. What is a substantial percentage of patients covered by payers?

Response: The Missouri Foundation for Health has not identified a specific percentage of patients that must be covered by the participating payers. The Foundation will be looking at the percentages reported in the application and giving greater weight to those practices with higher percentages than other practices with lower percentages that have applied.

6. What is required to meet the minimum access requirements of third-next-available appointment and same-day urgent care mean?

Response: See the response to question 4, above, for a discussion of third-next-available appointment.

Same-day urgent care means that a patient who needs urgent care can be seen in the doctor’s office the same day that the patient calls for an appointment.

7. If we are scheduled to go to EMR in February 2013 do we still qualify?

Response: Applying practices that do not have an EMR must agree to use an on-line patient registry and not implement an EMR for the first year or until its NCQA application is submitted, whichever occurs later. Month one starts with the month of the first learning session, which for St. Louis is anticipated to be December 2012 and for Mid-Missouri it is anticipated to be March 2012. One year for St. Louis practices would be December 2013 and Mid-Missouri would be March 2013.

8. Does the web-based registry need to be approved or on a list?

Response: The web-based registry must meet specific functional requirements. RMD meets those requirements.

9. Does the registry need to be set up for all insurance and all patients or just those with the participating payers?

Response: Participants are expected to transform their entire practice. Since using a patient registry is a foundational skill needed to perform population management, practices are expected to eventually include all their patients in the patient registry. The Learning Collaborative will initially focus on diabetes for adults and asthma for pediatricians. Participating practices must enter all their adult patients with diabetes and pediatric asthma patients into the patient registry during the pre-work period.

10. Does the CCM have to be a RN or can it be a LPN?

Response: The requirement is that the CCM be a licensed nurse. Experience in other Medical Home initiatives has indicated that an RN is best qualified for the position; however, we understand that RNs may not always be available and that some practices and that some practices may have LPNs who have gained a great deal of experience and expertise over time.

11. How often should the Pilot Care Team meet?

Response: Experience in other Medical Home initiatives has indicated that weekly Pilot Team meetings are effective. Participating practices will be required by a Participation Agreement to hold Pilot Care Team meetings no less frequently than every two weeks.

12. What is the definition of the “Spread Care Team”? How often should its members meet?

Response: The transformation model that is being implemented through the Learning Collaboratives is a train-the-trainer model. The Pilot Care Team will be attending the Learning Sessions, and testing and implementing new processes. The Pilot Care Team will then train other care teams in the new processes. The care teams that are learning from the Pilot Care Team are called Spread Care Teams. They should meet as frequently as the Pilot Team has found to be effective. In addition, large practices are expected to identify a Spread Team of high level administrators who will be responsible for overseeing the spread process to assure that it occurs in a timely and coordinated manner.

13. #2 on the application asks for provider numbers for primary care contracts.  Should we only put Anthem and UHC because they are the only two participating, or should we list all of our payers?  Also if we don’t have provider numbers and they go my tax ID or NPI do we just list those numbers?

Response: The instructions state: “include the provider number for any insurer with which the Practice Site has a primary care contract.”

If the provider number is your Tax ID or NPI, please list those.

14. Regarding #4 on the application, what does “defined panel of patients” mean?

Response: To participate in the Missouri Medical Home Collaborative, practices must have assigned individual patients to each primary care provider who is going to assume primary responsibility for the care of those patients. Clinicians with assigned responsibility are referred to as having a “panel of patients.” There may be some providers in the practice, such as PAs or RNs, who assist with care, but do not assume primary responsibility for the care of patients. Those providers should not be listed.

Our experience is that Nurse Practitioners may or may not assume primary responsibility for care of patients within a practice. If they do, they should be listed; if they do not but instead serve in a support role to the physician provider, they should not be listed.

15. Regarding #6 on the application and whether the hospital provides 24-hour notification of inpatient admission or ED visit, does this mean immediate notification or next day notification?

Response: It means notification within 24-hours of an inpatient admission or within 24-hours of an ED visit.

16. I was curious to see how this program relates to the one being done by MO HealthNet.  The application and program seems very similar to the one I filled out for that program and you state that you are working with them so I was just curious to how that collaboration was going to work?  Is it one learning collaborative or separate collaboratives?  Are the programs related at all?  Do you have to participate in one to be able to participate in the other?  Can you collect from both programs?  Any guidance you could provide on this matter would be greatly appreciated. 

Response: The Missouri Medical Home Collaborative and the MO HealthNet Health Home initiative are separate, but coordinated initiatives. A practice applying to MO HealthNet does not need to separately apply to MFH. Practices selected to participate either by MO HealthNet or by MFH will be participating in the same Learning Collaboratives.

17. Randolph County Health Department’s Primary Care Clinic is a Rural Health Center.  The majority of our patients have Medicaid and for those that are uninsured or underinsured they can be assessed on a sliding fee schedule (to help offset the cost of the visit).  In 2010 our providers saw 1538 clients, of that 3% was Medicare, 7% was Medicaid, 37% was other state-sponsored program (7.9% was Healthcare USA, 27% was Mo Care, 1% was Molina) and 53% were uninsured.  We are currently working to get contracts with private insurance companies, but at this time are only contracted with UnitedHealthcare. We just recently purchased an EHR system and are currently in the training phase (so we have not been working with the system for at least 6 months).  We would be interested in applying for this grant opportunity, but would like to know if we even meet the MINIMUN requirements for application. 

Response: Please see the answer to Question 1, above, regarding timing of EMR implementation. If you apply and are accepted, you would receive payments only from United Healthcare.

18. What is the length of time MFH will have this funding?

Response: The initiative is currently funded for two years.

19. Will AAAHC Patient Home Accreditation (AAAHCPCMH) be acceptable in lieu of NCQA?

Response: No.

20. Will there be future applications?’

Response: None are planned at this time.

21. As new physicians join our practice and other physicians’ transition onto our EHR, is the six (6) month counting period prior to beginning of the MFH medical home application or six (6) months prior to applying for AAAHCPCMH/NCQA accreditation?

Response: Please see the answer to Question 1, above.

22. How do you expect the shared savings program to be based? Will the savings be based upon what a patients’ cost was during a prior year? Or based on billed charges or reimbursed charges?

Response: Shared savings will be based on the reduction in PMPM inpatient acute care hospital costs and ED visit costs for each practice site’s attributed patients, relative to prior year experience. Savings will be calculated by payers based on paid claims. We anticipate that there will be adjustments for outliers and patient risk levels. All costs related to accident and injury will be excluded.

23. Where is the baseline number coming from? Will we be supplied with any reporting on our patient’s utilization from this base? (Place of service, diagnosis, date of service, billed, provider etc.)

Response: Baseline performance and savings will be calculated by payers based on paid claims.

24. What is the standard patient attribution algorithm?

Response: We anticipate that the patient attribution algorithm developed by UnitedHealthcare, which is a methodology being used in other multi-payer medical home initiatives across the U.S., will be used.

25. Are the plans participating with existing members within the physicians practices which would be with multiple clients or is this meant to be a new product? 

Response: The plans will be participating with existing members.  They are not introducing a new product, but rather are restructuring compensation with the expectation that the participating practices sites will engage in the learning collaborative and in practice transformation.

 

26. What is the attribution model in order to calculate the gain share and MLR numbers? 

Response: Please see the response to Question 24, above.

 

27. How is the MLR calculated? 

Response: There is no MLR calculation. 

 

28. We are a large physician organization with significant supervisory centralization of case management services (which do reside in the practices) we would like to submit our application as a medical group with a listing of certain practices who are either NCQA Level 1 or 3-recognized.  How many practices do you need to participate in the learning collaborative? 

Response: We will have 50 practice sites in a St. Louis-based learning collaborative.  Approximately 30 must be MO HealthNet participating sites, while the balance need not.  It would make sense for you to identify the specific sits that you wish to have selected.  MFH will be selecting sites, and not complete medical groups.

 

29. Our arrangement with one insurer is much more advantageous to providers (gain share is 100% instead of 40%).  I am not sure it is wise to have them participate in something that we would do worse in. 

Response: We have agreed with the payers that if they already have a risk agreement with a participating practice, that arrangement will prevail over that defined for the Missouri Medical Home Collaborative.

 

30. I applaud the effort so far but would point out that it is very “payer” friendly particularly with the gain share splits.  At 40% considering the lost revenue from the decreased utilization occurring as a byproduct of our better care management our health system goes broke.  My question is – the physician and health provide all the information systems through the EHR, provide all the care and access for the patients, provide all of the case management, build all of the infrastructure and thus taking all of the financial risk of the new model and for that the Insurance company takes 60% of the benefit from the improved utilization.  Doesn’t seem equitable does it? 

Response: This shared savings methodology may appear to be "payer friendly" in the first year, but please note that the payers are not netting out the PMPM payments they are committing to make, and are not considering potential increases in some costs (pharmacy, primary care) that could result from practice medical home transformation.

 

31. The application question states:  “In one page or less, describe and provide examples of how the Practice will involve patients, families and/or caregivers in the process of defining the elements of a “patient-centered practice.” What is MFH looking for in a response? 

Response: We are looking for examples of how the practice obtains and uses patient input in defining such patient centered elements of a medical home as: cultural sensitivity, enhanced access, and building self-management skills.

 

32. Could I please get some clarification on how this program collaborates with the Medicaid program? 

Response: Please see the answer to question number 16.

 

33. May a large organization submit more than one multi-site application? Example: one for St. Louis area practices, one for Rolla area practices and one for Joplin area practices. 

Response: The application is designed to allow more than one site to be included in the application. We would like multi-site practices to submit separate applications based on the location of the Learning Session the applying practices would attend; that is, please submit separate applications for the sites that would be attending the St. Louis-based Learning Collaborative and for those attending the Mid-Missouri Learning Collaborative.

 

34. Does the program apply to select plans within Anthem Blue Cross & Blue Shield and United Health Care, or all plans offered? 

Response: Please see the answer to Question 25.

 

35. Are additional plans expected to join the collaborative? 

Response: Not at this time.

 

36. The RFA indicates that at least 66% of selected practices must be MO HealthNet providers. Will MO HealthNet/Managed Medicaid plans also participate in the payment structure? 

Response: Practices recognized by MO HealthNet as Health Homes will receive payments for their eligible Medicaid patients, both FFS and MCO patients.  MO HealthNet is currently in discussion with MCOs around the possible development of a shared savings model.  The outcome of those discussions will not be known for some time.

 

37. Are licensed clinical social workers included as approved licensed providers to serve as Clinical Care Managers? 

Response: Only licensed nurses may be Clinical Care Managers.

 

38. What will be the methodology to determine the population or cohort of patients for a practice and/or provider? 

Response: Please see the answers to Questions 24 and 27.

 

39. When and where will information be made available regarding the selected quality measures and peer groups/benchmarks for the Shared Savings methodology that will be used for comparison? 

Response: We anticipate that the shared savings methodology will be

 

40. What will be the methodology to determine savings under the Shared Savings methodology? 

Response: Please see the answer to Questions 24 and 26, and 27.

 

41. Will all participating plans follow the same methodology? 

Response: We are working towards the payers following a shared methodology.

 

42. Are practices that have already attained medical home certification eligible (NCQA 2008 Level 1 or Level 3) to participate? 

Response: Yes. The application provides the following guidance with regard to practices recognized under the 2008 standards: “If the Practice has already achieved NCQA recognition at the time of application, the Practice must submit documentation that it has achieved the following additional requirements:

 

If recognition was achieved under 2008 standards: the Practice must demonstrate achievement of at least 75% on Standard 3C, 100% on Standards 3(D) and 40% on Standard 4B.”


 

43. Can a Rural Health Clinic apply?  If so, what impact or implication might that have on the Rural Health Clinic if recruited to be a Medical Home Collaborative practice?

    
    

    Response:  Yes, RHCs may apply.  If they apply through the Missouri Foundation for Health’s applications process, they will receive supplemental reimbursement only for select eligible patients who are receiving health insurance through either Anthem or UnitedHealthcare.  Eligible patients are those who are covered by policies purchased by fully insured employers or by self-insured employers who have agreed to participate in the initiative.

    
    

    If the RHC has applied through the separate MO HealthNet application process, the RHC, if accepted by MO HealthNet, will receive supplemental reimbursement for every MO HealthNet beneficiary who qualifies for Health Home services, in addition to the supplemental payments from Anthem and United for eligible patients.  Eligible patients are those who are covered by policies purchased by fully insured employers or by self-insured employers who have agreed to participate in the initiative. 

    
    

44. Is the PMPM only for Anthem and UnitedHealthcare patients?  When will this reimbursement be finalized?  How is this funded?  Is the determination of patients covered under this reimbursement based upon our reporting or reporting from outside entities?

    
    

    Response:  Practices sites that apply through MFH will only receive supplemental reimbursement for eligible Anthem and United Healthcare patients.  Currently Anthem and United will provide reimbursement for all their fully insured patients and potentially for some, but not likely all, self-insured patients.  We expect the total reimbursement methodology to be finalized within the next four to six weeks.

    
    

    Practice sites that have previously applied and are accepted into the MO HealthNet Health Home initiative will be receiving supplemental MO HealthNet payments for patients who qualify for Health Home services.  These practice sites will also receive supplemental reimbursement from Anthem and United for eligible patients if selected by MFH for Learning Collaborative participation.

    Determination of patients eligible for reimbursement will involve the following steps:

    United and Anthem will be “matching” patients to practices using a patient attribution methodology (for PPO, HMO and POS products);

    The payers will remove from the lists members who are covered by non-participating self-insured employers and will send patient lists to the practice;  

 

45. If this includes ASO members will the PMPM funding be by the plans and won’t the ASO customers need to agree to gain sharing?

     

    Response:  The carriers differ in terms of how they will handle this based on the terms of their ASO contracts.  At a minimum, both Anthem and United have agreed to ask their ASO clients to participate. 

 

46. Our arrangement with one insurer is much more advantageous to providers (gain share is 100% instead of 40%).  I am not sure it is wise to have them participate in something that we would do worse in. 

Response: We have agreed with the payers that if they already have a risk agreement with a participating practice, that arrangement will prevail over that defined for the Missouri Medical Home Collaborative.

 

47. Will all Anthem and United HealthCare follow the same patient attribution methodology?

    
    

    Response:  Both Anthem and United will use a patient attribution methodology that matches patients to primary care physicians based on evaluation and management CPT codes.  While the two methodologies are very similar, they may not be identical. 

    
    

48. When and where will information be made available regarding the selected quality measures and peer groups/benchmarks for the Shared Savings methodology that will be used for comparison?

    
    

    Response:  We anticipate that the shared savings methodology will be available in next 4-6 weeks.