Medical Home
Over the past several years, an increasing number of states have been working to promote medical homes. While many of these efforts focus on adults, several states have been pioneers in promoting medical homes for children. For the purposes of this document, we do not include primary care case management programs (PCCM) as medical homes for children with special health care needs unless there are explicit processes, such as medical home certifications, scores on a medical home index, commitment to quality improvement activities, and/or involvement of families as partners, above and beyond the traditional PCCM contract. Many of the medical home projects are time-limited and financed by grants. Below we describe more long-term financing models that rely on reimbursement from payers rather than grant funding.
Colorado was one of the early adopters of the medical home concept. The state passed a law in 2007 to ensure that all children covered by Medicaid and CHIP have access to a medical home, and over 230,000 children are now enrolled in certified medical homes. The certification process uses the Medical Home Index developed by Dr. Carl Cooley and colleagues at the Center for Medical Home Improvement, rather than NCQA certification, which is costly and required physicians to have electronic medical records. The Colorado certification does require medical homes to conduct quality improvement projects based on the Index. Medicaid reimburses practices for primary care coordination if they use the Medical Home Index and provides an enhanced payment for EPSDT well-child visits if the practice has a quality improvement plan. Colorado state policy staff is working with their counterparts in Montana, North Dakota, and Michigan to set up medical home models in those states.
Oklahoma Medicaid pays primary care physicians a monthly case management fee for providing medical home services. The amount of the payment is dependent on the age of the enrollee, the age mix of the practice, and what tier of medical home is offered. There are three tiers of medical home based on level of medical home services provided. The requirements for the three tiers can be accessed at http://www.okhca.org/providers.aspx?id=8470&menu=74&parts=8482_10165. In addition, the state has created a Health Access Network to serve as the infrastructure for medical homes. Physicians can join the network and then each time the physician enrolls a patient in his or her medical home, the network receives a small payment in addition to the physician. The network uses funds to work on quality improvement, access to care, coordination of care, and other activities that an individual physician might not have the capacity to handle. This is similar to the PCCM model in North Carolina, which also functions as a medical home.
New Hampshire has a medical home pilot project for privately insured children which involves the Center for Medical Home Improvement. Practices engaged in the pilot can receive reimbursement for care plan oversight if they demonstrate the existence of a care plan to one of the three health insurance companies that participates in the program. This payment is made annually. New Jersey has several medical home pilot projects with two hospitals and related practices with funding from the Department of Health and Human Services to support medical home training, collaboration with the parent network, and linkage to care coordination.
The Texas Department of State Health Services is providing $10,000 in seed money for a limited number of pediatric or family physician practices to create medical homes for children. In addition, physicians who attest to be medical homes can be authorized to bill on a fee-for-service basis for a variety of clinician-directed care coordination procedures codes. Rhode Island is working to build medical homes through their Pediatric Practice Enhancement Program (PPEP), which is described under the Care Coordination section.
