Patient-Centered Primary Care Homes are clinics that are recognized for their commitment to quality, coordinated care. Aligning payment to move away from fee-for-service to incentive payments provides additional supports to recognized primary care homes, allowing them to focus on prevention, wellness, and better management of chronic conditions.
The program is working toward incentive options that encompass all Oregon Health Authority programs including the Oregon Health Plan, Public Employees Benefit Board, Oregon Educators Benefit Board, and the Office of Private Health Partnerships, in order to provide supplemental financial support to recognized clinics for their OHA-covered patients. The program is also working with private payers to align payment methods to support the primary care home model.
Current Incentive Payment Opportunities
Last Updated 4/1/2013
Commercial Health Plan Enhanced Payments and Incentives
Aetna Launches PCPCH Payment Program
Aetna is proud to be the first non-Oregon Health Authority contracted plan to offer per-member-per-month payment incentives using the PCPCH tiers. Starting on April 1, 2013, Aetna’s Patient Centered Medical Home (PCMH) recognition program will be available to physician practices in Oregon that meet certain criteria: Directly contracted with Aetna; Received recognition by the NCQA or by the State of Oregon Patient Centered Primary Care Home program as a PCPCH; Have 10 or more attributed Aetna members; and be reimbursed at 100% of the Aetna Market Fee Schedule (AMFS). Clinics that have questions can contact Dan Seaverns, Aetna Senior Network Manager at SeavernsD@Aetna.com or Denise Casner, Network Manager, at 503-937-0621 or by email at CasnerD@aetna.com.
Public Employees’ Benefit Board
Beginning in January 2013, the Public Employee’s Benefit Board (PEBB) provides an age-adjusted, per-member-per-month incentive payment to Tier 2 or Tier 3 recognized primary care homes in the PEBB Statewide plan, administered by Providence Health & Services. In addition, PEBB members in the PEBB Statewide plan will have lower cost share for primary care services when they access care through a recognized primary care home – from 15 to 10 percent.
Affordable Care Act Section 2703 payments
Recognized patient-centered primary care homes are eligible for supplemental per-member-per-month (PMPM) Medicaid payments to support the comprehensive care they provide to Medicaid patients (both FFS and MCO/CCO) who have certain chronic conditions. These payments are $10-$24 based on the practice’s tier of recognition and are intended to support services such as care coordination and health promotion that are typically non-billable. Payments are available through September 2013.
Click here to read more: Medicaid Health Home Enhanced Payments
Comprehensive Primary Care Initiative
Oregon is one of seven markets selected to participate in this four year, multi-payer federal initiative to strengthen primary care capacity by testing a model of comprehensive, accountable primary care supported by multiple payers.
In 2012, after a call for applications from the CMS Center for Innovation (CMMI), nearly 70 Oregon primary care practices in Oregon were selected to participate in the initiative. Each practice is required to be recognized by the state as a patient-centered primary care home and to achieve certain CMS milestones over the four years. The Comprehensive Primary Care Initiative (CPCI) is expected to impact over 145,000 Oregonians including 49,000 Medicare beneficiaries.
Enhanced payments to the selected practices began in November 2012 from CMS and five Oregon payers including Regence Blue Cross, Providence Health Plan, CareOregon, Tuality and OHA (Medicaid FFS).
CMS is paying participating practices a risk adjusted, monthly care management fee for their Medicare FFS beneficiaries. The fee will be approximately $20 per member, per month during the first two years and then reduced to $15 per member, per month in the final two years. Bonus payments and shared savings in Medicare FFS will also be available to practices that better coordinate care for their patients. The other payers have differing payment schedules with the practices.
Visit the Comprehensive Primary Care Initiative webpage for more information.
Other Federal Payment Initiatives for Primary Care
The Affordable Care Act (Section 5501(a)) created the Primary Care Incentive Payment (PCIP) program to offer an incentive payment to qualifying primary care physicians and non-physician practitioners who furnish primary care services to Medicare patients. To be eligible for the incentive payment, qualifying services must be rendered between January 1, 2011, and December 31, 2015. Providers in Oregon received approximately $4.3 million under this program in 2011.
The Affordable Care Act also directs a temporary increase for primary care physicians who see Medicaid patients in 2013 and 2014. The increase in payments will bring Medicaid primary care service fees in line with those paid by Medicare. The extra payments are intended to encourage primary care physicians to provide more checkups, preventive screenings, vaccines and other care for Medicaid beneficiaries. States will receive 100 percent federal matching funds for the increase in payments.
Resources and Technical Assistance to Practices
The Oregon Health Authority and the Northwest Health Foundation, in partnership with the Oregon Health Care Quality Corporation launched the Patient-Centered Primary Care Institute in September 2012 to support primary care practice transformation in Oregon. A broad array of resources will be available over the coming year, including the first PCPCH Learning Collaborative. The website and resources are available now at www.PCPCI.org