North Carolina Primary Care Providers: Here's Why You Should Be Paying Attention to the Advanced Medical Home (Part I)
This article is the first in a two-part primer on the new Medicaid Advanced Medical Home model, detailing what it is and what primary care providers need to know in order to make informed, strategic decisions regarding their practice.
In this segment, we address the big picture of the AMH model, outlining the evidence and rationale behind the model and explaining how it represents an opportunity for primary care providers to practice medicine the way they were trained and to be more fairly compensated while doing so.
Medicaid’s transition towards Managed Care is complex and represents a fundamental shift in how care to beneficiaries is both delivered and paid for in North Carolina (NC). However, you do not have to digest all 700+ pages of the State’s recent request for proposal to understand how this transition will affect NC primary care providers (PCP). There is a handy shortcut that provides the essential principles and parameters guiding health care delivery under Managed Care: The Advanced Medical Home (AMH).
What is the AMH and Where Did It Come From?
The AMH is the linchpin of Medicaid Transformation in NC today. It is also the 2.0 model of the Patient Centered Medical Home (PCMH) infrastructure on which NC’s Medicaid system currently operates, as represented by the ACCESS I and II PCMH program.
The PCMH model was developed and promoted in the early 2000s when health researchers and practitioners recognized that lack of coordination and communication across providers and caregivers leads to avoidable outcomes, errors, and wasted dollars. The PCMH was intended to close this gap, while simultaneously placing the patient and his or her primary care provider at the center of all communications and coordination of care.
As outlined by the Agency for Healthcare Research and Quality (AHRQ), the PCMH has five key attributes:
The PCMH is equipped to meet the majority of a patient’s physical and mental health care needs across the continuum of care.
In addition to providing comprehensive care across the care continuum for patients, the PCMH adopts a tailored, holistic approach towards each patient. Care delivered reflects and is informed by the unique needs, preferences, and values of the individual patient.
Coordination of Services
The PCMH is responsible for coordination of care across health systems and for overseeing safe and efficient care transitions.
The PCMH has enhanced standards to make primary care more accessible to patients. This includes extended office hours, after-hours access, and alternative methods of contact (telephone and/or email).
A focus on Quality and Safety
PCMH participants consciously engage in continuous quality evaluation and improvement. A system-level commitment to quality improvement requires quality data exchange and clinical decision-support tools, shared decision-making and routinized performance measurement.
Taking Care Management under Managed Care One Step Further
The key difference between the PCMH model of the early 2000s and the new AMH model is the formal addition of care management. While this may seem like a natural and logical progression from the care coordination and needs identification of the PCMH, it is hard to overstate the importance of this additional component, particularly in the context of Managed Care.
More specifically, effective Care Management is the core of the business model for Managed Care. This capitated business model works when contracted payers are able to deliver care across a population at a lower cost while meeting specific coverage and quality standards. This is dependent on (1) the identification of high-risk or high-need patients, (2) their accurate stratification; and (3) delivery of tailored, effective interventions to avoid escalation in utilization. This is a big lift, and those responsible for that lift necessarily enjoy a great deal of leverage across a system. It is therefore significant that, under the State’s model, PCPs are not only the “primary vehicle for delivery of care management services,” but that as a Tier 3 AMH, they also exercise a great deal of autonomy and control over how those services are delivered.
What PCPs Should Know about the AMH Opportunity
This brings us to the bottom line: this intentional allocation of care management authority (with reimbursement) represents a significant opportunity for primary care providers to regain greater control, professional satisfaction and predictability in their practice. More specifically, there are two big takeaways for PCP’s about the AMH model:
First, the AMH model (and particularly Tier 3 AMH) centers clinical and administrative authority within the PCP’s practice. It does this by identifying PCPs as the primary vehicles for care management services. This is a significant and deliberate shift on the State’s part.
Previously, care management has too often been viewed as an administrative service external to clinical care. In the many cases where this service has been “outsourced” and not effectively integrated with clinical providers, it has impeded the impact care management can have on outcomes and utilizations. This is detrimental, as effective care management is the crux of comprehensive, patient-centered care delivery.
Having PCPs at the center of care management is also effective and efficient. Recent studies have demonstrated the crucial importance of clinically integrated and provider directed care management on medical costs across a population, particularly for patients with complex diagnoses or chronic disease. One analysis by Price-Waterhouse Cooper even estimated that effective primary care oriented interventions and care management is associated with $1.2 million dollars in savings over a population of 10,000 patients.
Second, and perhaps more importantly, this is not an unfunded mandate. Primary Care Providers have been expected to be all things, to all patients, at all times and (too often) at a reimbursement rate that is not reflective of their impact on patient outcomes and utilization. The AMH model seeks to address this disconnect and outlines an enhanced, capitated (per member per month) rate for practices that assume care management responsibilities.
Over the past twenty to thirty years, health care has often been described as a battle between health care providers and administrators, one in which providers have experienced an erosion of autonomy and the time they are able to dedicate to patients. This is particularly true for primary care providers. As the designated, recompensed leaders of care management for their patients, this is a significant step towards addressing this imbalance in power and re-center the locus of clinical control at the primary care provider. In short, this is a significant opportunity.
Next week we will examine the requirements associated with being a Tier 1, 2 and (especially) 3 AMH and detail the attestation process to become an AMH. Emtiro Health has over twenty years’ experience supporting providers to achieve improved outcomes for themselves and their patients. For more information about our full menu of services available, please contact us at (336) 978-6542 or firstname.lastname@example.org
 AHRQ. “5 Key Functions of the Patient-Centered Medical Home.” Visited on October 5, 2018. https://pcmh.ahrq.gov/page/5-key-functions-medical-home.
 See e.g. Alexandar JA, Markovitz AR, Paustian ML, et al. Implementation of patient-centered medical homes in adult primary care practices. Med Care Res Rev. 2015;72(4):438-467.
 PwC Health Research Insitute. ROI for primary care: Building the dream team. October 2016. https://www.pwc.com/us/en/health-industries/health-research-institute/weekly-regulatory-legislative-news/pdf/pwc-hri-primary-care-roi.pdf