The growth of multipayer patient centered medical home (PCMH) reform across the country, accelerated by the Affordable Care Act, offers the opportunity to widely transform the primary care delivery system. Recent Health Affairs research noted 17 multipayer PCMH initiatives had been launched since 2008; and with State Innovation Model (SIM) grants awarded to 39 states and territories, these numbers will grow — multipayer payment reform is a core requirement of SIM funding.

States have played a dominant role in multipayer PCMH initiatives with Medicaid agencies overwhelmingly providing the infrastructure and support, but there are other state departments and agencies that can be leveraged. This blog post will discuss how state insurance departments, State Employee Benefits, and Public Health departments and agencies in collaboration with Medicaid, private payers, and other stakeholders have undertaken significant roles to strengthen multipayer PCMH efforts.

Insurance Departments As Both Regulators And Conveners

The role of a convener is to bring payers, providers, and stakeholders together, get agreement on the parameters of the initiative and then keep stakeholders actively engaged. Although state insurance departments regulate health plans offered within their state, they are typically not involved in leading delivery or payment system reforms.

Montana’s Insurance Commissioner advocated for a lead role in the state’s multipayer PCMH program. As a result, the Montana legislature authorized the Commissioner of Securities and Insurance to convene as well as regulate the Montana PCMH program. Montana is the only state in the nation in which an Insurance Commissioner has such authority. Medicaid initially convened the Montana Multipayer PCMH initiative in 2010, but then advocated for the Commissioner to take over this role. With the Commissioner’s support, the Montana legislature passed the 2013 PCMH Act providing the Office of the Commissioner of Securities and Insurance with the responsibility to work with stakeholders to create PCMH standards for both health care providers and payers, qualify both providers and insurers to participate, and promote the initiative statewide.

Over a one-year period, the Commissioner along with the multi-stakeholder PCMH Council that included Medicaid, developed and adopted the program standards around qualification of PCMHs, health care quality, performance, and prevention measures. To date Montana has certified over 60 practices as PCMHs because the providers met national PCMH standards. These practices can receive enhanced payments from three commercial health plans and Medicaid that have agreed to the state’s PCMH initiative. The exact payments vary by plan, but typically includes additional per member per month (PMPM) payment to the practices.

State Employee Health Programs As Purchasers

Adding the purchasing power of state or public employee programs can greatly increase the scope of reform. State public employee programs constitute about 10 percent of the workforce, and their health care costs account for the second largest state expenditure, yet just seven of the 17 multipayer PCMH initiatives launched since 2008 included state employee plans.

In Maine, the State Employee Health Commission (SEHC), which has authority over the state employee health plan, including benefit design, has been involved in the Maine multipayer PCMH initiative since it was first convened in 2010 by the Dirigo Health Agency’s Maine Quality Forum (MQF), Maine Quality Counts, and the Maine Health Management Coalition. The SEHC’s participation in the pilot adds significantly to the reach of the multipayer, non-profit collaborative.

The SEHC offers participating PCMH practices an upfront PMPM care management fee, continued fee-for-service payment, and payment that recognizes enhanced performance by the practice, whenever possible. An estimated 19,000 of 33,000 state employees now receive care through a Maine PCMH.

The SEHC supported the initiative because it sees primary care as the cornerstone of integrated care. Like other payers and purchasers in multipayer pilots, the SEHC has had to exercise patience in giving the Maine PCMH pilot time to make progress on meeting cost and quality outcomes, but sees this initiative as an important part of restoring the primary care foundation.

Public Health Departments As Both Purchasers And Providers

Public health departments can serve as purchasers and providers to enhance statewide multipayer PCMH initiatives. In Vermont, its statewide, universal vaccine purchasing programs have enhanced PCMH providers’ ability to meet immunization goals regardless of payer.

Many state public health departments operate vaccines for children’s programs, which buy and distribute vaccines for Medicaid and low-income uninsured children, but the Vermont Department of Health serves as the universal purchaser (across all payers) for both adult and child vaccines throughout the state. Commercial payers and Medicaid then pay the Vermont Vaccine Purchasing Program a quarterly assessment on covered lives. According to the Commissioner of the Department of Health, this is a cost efficient system for purchasing and distributing vaccinations resulting in excellent vaccine access and increased immunization coverage through the PCMHs.

The Department of Health also spearheaded work to integrate specialty opiate treatment with the state’s multipayer PCMH program. This opiate treatment program known as the “Hub and Spoke” program was initially launched through the Affordable Care Act as a Medicaid Health Home program in 2013. The program’s “hubs” are regional specialty opioid treatment centers that are responsible for coordinating the care and services of patients who have complex addictions, co-occurring substance abuse, and mental health conditions. The spokes are the PCMHs that are provided with an enhanced payment to support care management and additional counseling needs for patients with less complex needs. The program began with Medicaid financing, but now all commercial payers are providing monthly bundled payments for patient access to specialty opiate treatment services.

Multipayer payment reform is complex and requires collaboration between numerous stakeholders to ensure success. States are playing critical roles in multipayer initiatives that go beyond Medicaid acting as a payer. It’s important for stakeholders, especially those involved in the 39 SIM initiatives, to understand how to leverage other state agencies or departments in collaboration with Medicaid to ensure the success and sustain the momentum of multipayer payment reforms.

Authors’ Note

The authors’ work on this topic is supported through a grant by Kaiser Permanente.