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Interview: Elizabeth Mitchell, CEO of the Maine Health Management Coalition, Talks About Her State’s Patient-Centered Medical Home Demonstration Project

When the Centers for Medicare and Medicaid Services launched its new Innovation Center in November 2010, it did so with a degree of flair uncharacteristic of most government agencies, concurrently handing out tens of millions of dollars to support worthy innovations. Consistent with the Center's charter, the innovations are projects that seek to upend the status quo and develop better, more efficient ways to deliver and pay for health care. But that doesn't mean starting from scratch: among the Center's first acts was to allocate over $20 million to support a one-year-old patient-centered medical home pilot in Maine. Purchasing High Performance talked to Elizabeth Mitchell, CEO of the Maine Health Management Coalition (a coalition of employers, hospitals, health plans and doctors), about the project.

PHP: How did you get selected for the Innovation Center demonstration project?

IMPORTED: __media_1935528441E34E1F93100E608AADF4A4_w_120_h_120_as_1.png EM: We were already doing what they wanted to fund. Starting in 2009, the Maine Health Management Coalition, Quality Counts (a regional health care collaborative), and the Maine Forum (a group which advocates for high quality care) set up a patient-centered medical home pilot project with the support of area employers and a good cross-section of the health care community. Nobody was expecting federal money at that time because there wasn't any. It was just the right thing to do. Over the first year of our pilot, we saw early positive results in terms of both quality improvement and cost control but it was slated to end in 2012. The Innovation Center funding means we can potentially expand to include more practices, build community health teams, and continue the effort for an additional two years.

PHP: How do you spend $20 million?

EM: Well, let's just be clear that this is not a grant and the money doesn't go to the Maine Health Management Coalition, Quality Counts, or the Maine Quality Forum. Not a penny. We're the conduits through which the money follows 100,000 or so enrolled patients and gets passed on to doctors and practices. All $20 million will ultimately go to participating primary care practices in Maine to compensate for the added work involved in operating as a medical home. There's nothing set aside for administration.

PHP: What happens after the $20 million in federal money runs out?

EM: We think about that question all the time, but the answer is probably pretty simple. We're in the proof-of-concept stage right now and either this works and people get on board and it becomes a part of the new normal, or it doesn't and the whole thing goes away. I'm optimistic that over the course of the roughly three years for which we're now funded, we'll show some real results that will allow us to move beyond the $3 per-member per-month model we have now. That money is nice, but it's not enough to sustain the approach. We need practices and plans that are willing to engage in shared-savings arrangements and employers that see the value in paying for it. I think we'll get there. Employer interest in the medical home model, at least in Maine, is incredibly strong.

PHP: There must be a fair amount of work involved in administering a $20 million demonstration project.

EM: There is! Some thought really does need to be given to funding an "innovation infrastructure." What's happening in Maine only works because the infrastructure was already there, courtesy in large part to employer support. In fact, the Innovation Center made private purchasers support a prerequisite for selection, really emphasizing the need for multistakeholder collaboration for system transformation. Fortunately, Maine has several organizations like the Coalition leading multistakeholder work. But that's not always true in other states and you don't want to limit innovation to places where innovation is already happening.

PHP: What is required of practices that participate in the effort?

EM: The front door to the program is earning recognition under the National Committee for Quality Assurance's (NCQA's) patient-centered medical home program. But earning NCQA recognition does not a medical home make. Practices have to show they have fairly sophisticated registries for tracking patient populations. In addition, they are required to sign agreements on referral patterns. Once a practice is in the program, they participate in quarterly learning sessions, which are great opportunities to share lessons and compare notes on what works in different settings. Reporting is required, as well. We collect and share regular data on care and services consumed and turn that into reports for each practice so they can see how they stack up with their peers.

PHP: What have the challenges been to date?

EM: The biggest one is getting good, timely data. We don't have great systems to distribute timely data in Maine and this is a state with an all-payer database. We pull some utilization and financial data from that, but it's incomplete without integrated clinical data. Providers need data on costs, utilization, and patterns of illness if they are going to accept any significant financial risk when treating patients and managing population health. The Maine Health Management Coalition is stepping in to expedite timely data distribution to sustain the efforts by providers and purchasers to transform care. It's not fair to ask them to do so without it. We have several accountable care organization pilots emerging around our patient-centered medical home pilots, and financial risk will be a growing part of these arrangements.

PHP: Some medical home pilots target only high-needs or high-risk patients. Is that true of the Maine effort?

EM: No. We're just the opposite; we target everyone. I know the jury is still out on whether the medical home model is cost-effective for all populations, but our assumption is that what's good for people who are sick is also good for people who may become sick, which is everyone. I think a lot of people are going to be looking at this question over the next few years.

PHP: How much do participating practices get paid?

EM: Less than you'd probably think. The practices get an approximately $3 per-patient per-month enhanced fee as their only real incentive. For that, they revamp the way they practice medicine. It's really amazing, actually, and it's obviously not the money that's motivating them. We talked about doing a shared-savings model, where practices would also get a bonus based on their ability to keep people healthy and avoid costs over the course of a year, but area health plans weren't willing to do it. They don't have the data systems to support it yet.

PHP: So why do practices participate if the upside is only that modest monthly fee?

EM: Practices are actually excited about participating—not all, but a lot. We've had to turn some interested practices away. We're planning to expand from the original 26 practices to 46 practices and we don't anticipate any difficulty recruiting them. There are a lot of factors driving interest. Some practices want experience with the medical home model, which I think everyone sees as a possible model for the future. Others look at it as a way to improve the quality of care they deliver, while others might be looking ahead to the day when being a leading medical home will mean higher revenues and more income for doctors. Very few people see the current system as sustainable.

PHP: Do practitioners seem to like the medical home model?

EM: Yes. Doctors and nurses really like to practice in a medical home setting. Across the 26 practices in our original cohort, each one has been somewhere between happy and extremely happy with their experience thus far. In one practice, staff turnover went from 30 percent per year to essentially zero (not counting the staffer who got activated by the National Guard).

PHP: Do you think the pilot has led to real change in the way doctors practice medicine in Maine?

EM: I've talked to doctors about this and the answer is a clear yes. What I hear a lot is that it's changed the conversation from "Who is my next patient?" to "Who do we really need to see this week? Who missed what and how can we get them back on track?" That's a huge difference. It's more proactive and it's better medicine.

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