The Advanced Medical Home: What Primary Care Providers Need to Know (Part II)
Last week we reviewed some of the governing principles and objectives of North Carolina’s Advanced Medical Home (AMH) model.
This week we will dive into the mechanics and the application (attestation process) to become an AMH.
As a brief refresher, the AMH represents both the crux of Medicaid Transformation in North Carolina and a progressive iteration of the current Medicaid medical home model. To the latter point, Primary Care Providers (PCPs) prepared to become a Tier 3 AMH will undertake responsibility for the care management of their patients. For this, they will receive reimbursement negotiated with the Prepaid Health Plans (PHPs) in addition to the medical home payment that practices already receive under the Carolina ACCESS I and II program. The AMH Tier 3 represents a significant opportunity to PCPs to improve patient care and regain greater control in their practice.
With that introduction, we turn to the requirements needed to become an AMH.
As noted above, the AMH model is based on the PCMH model as represented by the Carolina ACCESS program. The Carolina ACCESS Program operates on two levels, ACCESS I and II. To be ACCESS level I, a practice must meet certain enhanced access and preventive service requirements. This includes after-hours availability, availability of interpretation services, hours of operation, and offering certain preventive or ancillary services. In exchange, ACCESS I practices receive a $1.00 per member per month (PMPM) payment in addition to the Medicaid fee schedule for services.
In addition to all the requirements of ACCESS I, ACCESS II requires the practice to contract with the local Community Care of North Carolina (CCNC) network to provide care management and quality improvement services, such as Emtiro’s parent organizations, Partnership for Community Care and Northwest Community Care. For meeting these criteria, practices receive a payment of $2.50 per member per month (PMPM) for most Medicaid beneficiaries enrolled (and a higher rate of $5.00 for beneficiaries who are aged, blind, or disabled (ABD)).
The AMH is initially designed as a three-tiered program. Tiers 1 and 2 intentionally overlap and align with the existing ACCESS I and II models. The intention is to provide continuity and reduce unnecessary administrative disruption for practices already engaged in this model. The three tiers, and how the ACCESS I and II models transition to the tiers, are outlined below:
Tier 1: ACCESS I practices will be automatically grandfathered in as a Tier 1 AMH. ONLY ACCESS I practices are eligible to participate as a TIER 1 AMH. ACCESS I practices can also apply for AMH Tier 2 status. There will not be an option for new practices to enter AMH Tier 1.
Tier 2: ACCESS II practices will automatically be grandfathered in as a Tier 2 AMH. Existing ACCESS I practices can apply for AMH Tier 2 certification by indicating their intent in NCTracks. New practices may also register to participate in Carolina ACCESS and will automatically be entered as a Tier 2 AMH. While there are no additional steps required for Tier 2 AMH certifications, practices are “expected to demonstrate capabilities similar” to those of the current ACCESS program.
Tier 3: While any enrolled practice may apply to be certified as Tier 3, Tier 3 practices must attest that they are “adequately equipped” (individually or through an agreement with another entity) to assume care management responsibilities. (more on this to follow)
These pathways are also illustrated in the figure below.
As outlined above, current ACCESS participants will, absent any actions, be assigned to the corresponding tier in the AMH model.
Because there is not a corresponding ACCESS level for AMH Tier 3, practices that wish to become a Tier 3 AMH must follow a different process, which is described below.
Becoming a Tier 3 Advanced Medical Home
In the AMH model, a practice seeking Tier 3 certification must attest and then demonstrate to both the state’s Medicaid program and PHPs that they are independently capable of, or have business partners capable of, managing their empaneled patient population. These key capabilities include care management and care coordination, risk stratification of high need and high-risk patient populations, monitoring Admission, Discharge, and Transfer (ADT) feeds for hospital utilization by their patients and providing transitional care for patients who have had hospital encounters.
These functions require data aggregation and analytics capabilities, requirements that a practice can meet independently or through a partnership with an external entity, such as Emtiro Health.
Negotiations with PHPs
Once a practice has successfully attested to and demonstrated their capacity to meet these requirements, the State will certify them as a Tier 3 AMH. The practice will then negotiate with the PHPs operating in their region for care management fees on top of the baseline AMH medical home fee of $2.50 PMPM ($5.00 for ABD beneficiaries). Each PHP is required to contract with at least 80% of the Tier 3 AMHs in their region. In addition, PHPs have monitoring and oversight responsibility of AMHs to assure that the AMH is meeting the requirements for the appropriate tier.
The attestation application process began earlier this month (October 1st) and runs through January 2019. While this is a short timeline for practices to plan out their future strategic and operational goals, it is an opportunity that should not be overlooked. Becoming certified before February 2019 assures a practice is included on the list of AMHs that State will provide to PHPs. The practices included on this list are the ones that PHPs must engage with when forming their provider networks prior to the launch of managed care.
Practices that wish to pursue AMH Tier 3 must attest to the current or future ability to meet 22 key elements, plus 8 supplemental questions. These requirements fall within specific categories including:
Risk stratification of the patient population
Provide care management to high needs patients
Document a care plan for high needs patients
Provide transitional care management
Use data to support care management interventions
Emtiro Health stands ready to support providers through the attestation process from beginning to end, assuring that your practice not only completes the process but that you can truly provide whole-person care management services along the continuum of care. With over 20 years’ experience in care management within your community, we have the expertise and commitment to tee your practice up for success and tailor your roadmap according to your individual practice’s priorities and objectives.