Mid-Atlantic Health Law TOPICS

The Maryland Primary Care Program (MDPCP) is part of the new Maryland Total Cost of Care Model that has just been agreed to by the State of Maryland and the Centers for Medicare and Medicaid Services (CMS).  The MDPCP is aimed at reducing overall spending for Medicare beneficiaries in Maryland by offering care coordination to keep patients healthier and out of the hospital.

This is a voluntary program, but presents a unique opportunity for primary care providers to partner with larger organizations, with both groups earning financial incentives. For purposes of the MDPCP, primary care providers include those in general practice, family medicine, internal medicine, obstetrics and gynecology, pediatrics, geriatrics and co-located psychiatry.

The program will run from January 1, 2019 through December 31, 2026. While the deadline for the first round of applications for providers to participate ended on August 31, 2018, those that met that deadline and additional providers will be able to participate in subsequent years.

A.  CTOs

This past July, CMS also accepted applications for the first year of the MDPCP from Care Transformation Organizations (CTOs), which are entities that provide management services to participating providers.

Many different types of organizations may qualify as a CTO, including hospitals, Accountable Care Organizations, and managed service organizations (MSOs). The CTO, even if it is a part of an existing organization, must have separate financial accounting, and the ability to establish a clinically-driven governing board comprised of affiliated participating providers.

The CTO’s services may vary, and could include pharmacy services, nutrition counseling, behavioral health, and referrals to social services or other community health programs. Though each CTO may deploy different services, the CTO must be able to provide five key functions: (1) care coordination; (2) care transitions; (3) standardized beneficiary screening; (4) data tools and informatics; and (5) practice transformation assistance.

B.  Care Management Fees

The MDPCP financially benefits both CTOs and the participating providers via care management fees, paid prospectively by CMS on a quarterly basis. The fees generally range from $17 to $28 dollars per patient per month, with more money for patients with complex needs.

Fees are allocated in two ways. Under the first option, the CTO must deploy one full-time employee to serve as the Lead Care Manager for every 1,000 Medicare fee for service beneficiaries attributed to a participating practice. The Lead Care Manager is dedicated to overseeing and supporting care management functions in that practice. In this scenario, the CTO receives 50% of the fee and the participating practice receives the remaining 50%.

In the second option, the participating practice employs its own Lead Care Manager while the CTO still provides access to other services.  In this option, the CTO receives 30% of the fee and the participating practice receives the remaining 70%.

C. Performance-Based Payment

In addition to a portion of the care management fee, CTOs may also receive a performance-based incentive per-beneficiary per month payment, paid prospectively by CMS, based on utilization and quality measures of all practices with which a CTO partners. If beneficiaries fail to meet the applicable utilization and quality targets, the CTO must repay the performance fee to CMS.

To support all of these initiatives, the MDPCP will provide support to CTOs through learning sessions and a web-based platform, MDPCP Connect, that will include curriculum, discussion, and strategies.

Alexandria K. Montanio
410-576-4278 • amontanio@gfrlaw.com