Issue Brief June 2020 Milbank Memorial Fund Using evidence to improve population health. Maryland’s Innovative Primary Care Program: Building a Foundation for Health and Well-Being By Chad Perman, MPP, Robert Patterson, MHS, MA, and Howard Haft, MD Policy Points ABSTRACT Maryland Primary Care Program is a statewide advanced primary care program > Built on an agreement with launched in January 2019 by the Maryland Department of Health in collaboration Medicare, the Maryland with the Center for Medicare and Medicaid Innovation. By creating a coordinated Primary Care Program system of primary care supported by multiple payers, with shared resources and an makes multiple systematic, information-sharing network, Maryland hopes to improve quality and lower costs—and coordinated primary care create a foundation for health and wellness. The program is also proving to be nimble investments to improve the in response to emergencies like the COVID-19 pandemic. In this brief, we describe the health of state residents. program’s evolution and core components, as well as its potential replicability in other states. > Shifting care from high-cost venues like hospitals to INTRODUCTION well-prepared, adequately Health care costs and expenditures throughout the United States are high, rising, resourced, lower-cost and unsustainable over the long-term. The highest costs for health care services primary care venues helps are predominantly found in the management of late-stage illness and hospital care to create a health care rather than in preventive, relationship-based primary care, which has been shown to delivery system focused on be effective with these populations. To lower costs while improving health outcomes, health and well-being. the Maryland Department of Health (MDH), in collaboration with the Center for Medicare and Medicaid Innovation (CMMI), launched the Maryland Primary Care Program (MDPCP) in 2019. The statewide program, designed to span at least eight years, aims to make strategic investments in primary care practices and build a resilient statewide infrastructure to prevent and manage chronic disease. Specific objectives in the MDPCP include: 1 • Reducing avoidable hospitalization and emergency a template on which to build the MDPCP. The MDPCP department (ED) visits was informed by lessons learned from CMMI’s Compre- hensive Primary Care (CPC) and Comprehensive Primary • Building a strong, effective primary care delivery Care Plus (CPC+) models. For example, evaluations of system to identify and respond to medical, behav- CPC found that, despite the prospective, per-person ioral, and social needs while contributing to lower payments, it was a challenge for small and medium-sized Maryland’s Medicare Part A and B expenditures by an practices to hire care managers, pharmacists, and other annual saving target of $300 million by 2023 staff. The evaluation also identified the value of being The MDPCP is operating in a unique health care delivery able to move from a standard to advanced program track environment by virtue of being in Maryland. To realize the and the fundamental need for an intensive education and state’s commitment to transform its health care system support program to help practices adopt the necessary and address care beyond hospital walls, the state of changes. Maryland and CMMI established the Maryland Total Cost Maryland facilitates MDPCP operations and practice of Care Model, which sets a target for total costs of care transformation through its Program Management Office reductions for Medicare. The contract for the Maryland (PMO) comprising both office-based and field staff. MD- Model, as it’s known, calls for improved population health PCP received over 700 applications in the program’s first outcomes supported by broad, innovative care redesign two years and has enrolled 476 primary care practices between hospital and non hospital partners across the that receive coaching and other outreach and organiza- state. The Maryland model includes the Hospital Payment tional assistance, as well as financial incentives. Program, in which all hospitals operate with global bud- gets; the Care Redesign Program, which enables hospi- Since the program’s launch, the PMO recruited health tals to make incentive payments to non hospital health care practices and practitioners to voluntarily enroll in care providers; and the MDPCP. the MDPCP to better serve their Medicare beneficiaries. Practices are required to provide comprehensive primary The MDPCP is a multipayer program designed to trans- care services. Services include expanding patients’ ac- form primary care practice for all patients, no matter cess to care; empaneling patients to providers; imple- the payer. Payers are required to submit an application menting data-driven, risk-stratified care management; to CMMI and are accepted based on their willingness to providing transitional care management; coordinating align with the program on non visit-based payments, care with specialists; hosting “Patient Family Advisory provider financial risk strategies, and quality measure- Councils”; integrating behavioral health; screening for ment. This multipayer alignment of payment approaches social needs; and using health information technology and reporting requirements reduces the administrative tools to continuously improve quality. burden for practices. In exchange for implementing these changes and In the first year of the program, Medicare was the only services, participating practices receive prospective, payer. CareFirst BlueCross BlueShield, the state’s largest nonvisit-based payments per attributed Medicare patient commercial payer, joined in 2020. In an effort to extend known as care management fees (CMF). Practices also the program to more practices serving vulnerable popu- have the option to receive operational and administrative lations, Maryland’s federally qualified health centers will support from the PMO and Care Transformation Organi- be allowed to apply in 2020 for participation beginning in zations (CTOs). An extension of the practices, CTOs are January 2021. It’s anticipated that Medicaid and addition- private entities that hire and manage the interdisciplin- al commercial payers will join over time. ary care management teams that provide care coor- dination services at the direction of the participating MDPCP STRUCTURE AND OPERATIONS practices. CTOs also offer support for care transitions, Fortunately for Maryland, predecessor primary care standardized beneficiary screening, data tools and infor- transformation models supported by CMMI gave the state matics, and practice transformation. Milbank Memorial Fund • www.milbank.org 2 Small and medium-sized practices can therefore include Thanks to broad statewide participation serving patients team members who they would otherwise have difficulty in every Maryland county, MDPCP is reaching a substan- acquiring on their own such as pharmacists, licensed tial portion of the state’s population. MDPCP officially clinical social workers, community health workers, and serves more than 340,000 Medicare fee-for-service data analysts. CTOs are funded by a share of the practic- beneficiaries (under direct attribution), over 49,000 es’ care management fees; they may also receive perfor- dual-eligible beneficiaries, and approximately 3 million mance bonuses based on the aggregate performance of Marylanders overall.1 the practices they serve. Twenty-four CTOs are support- ing 77% of the practices as of mid-2020. PROGRAM CORE COMPONENTS MDPCP, similar to CPC+, has two levels of practices When the Maryland Model was announced in 2018, Mary- known as track 1, the standard track, and track 2, in land committed to addressing broader population health which all advanced primary care requirements are met. issues, including diabetes, substance use disorders, and All participating Maryland practices are required to other major drivers of poor health outcomes in the state. achieve track 2 status by the end of the third year of The MDPCP was enlisted to meet this commitment. participation. Requiring a transition to fully advanced The PMO is currently working with partners at MDH and primary care is driven by the expectation that through CMMI to incorporate these goals into MDPCP. The PMO is this program the state will have an organized, identifi- setting up technical assistance webinars with the MDH’s able, and fully operational advanced primary care work- chronic disease office, and CMMI and the PMO are con- force functioning independently but under the guidance sidering adding performance measures on prediabetes of the MDH. More than one-quarter of practices have and substance use disorders. The state has also begun a already achieved advanced status (Figure 1). pilot that allows practices to make electronic referrals Figure 1: Practice Status in MDPCP as of January 2020 Practice Status in MDPCP as of January 2020 Practice Tracks Practices Partnered with a Care Transformation Organization (CTO) 15.76% 25.84% 7.35% 74.16% 76.89% n Track 1 n Track 2 n Non-CTO n CTO-Like Groups n CTO Note: CTO-Like Groups are entities that provide services to practices similar to CTOs but are not formal CTO participants in the MDPCP. Milbank Memorial Fund • www.milbank.org 3 The primary care workforce, coordinated and supported by the Maryland Department of Health through the Program Management Office, has become a critical part of the public health response to the COVID-19 pandemic. The Maryland Primary Care Program providers have mounted a coordinated telemedicine response, shared best practices, and reached out to at-risk patients. to diabetes prevention programs, nutrition services, tive analytics, and a bidirectional community-based and other self-management partners. In addition, organization electronic referral system. Claims data the PMO hired a contractor in 2019 to help practices are refreshed monthly, allowing practices to track their implement substance use screening at no charge to hospital and ED utilization compared to peers and the MDPCP practices. state overall, as well as identify high-cost patients and high-volume, high-cost specialists. This is an attempt to To help realize the broader state goals, MDPCP offers its focus attention on the relative costs between specialists CTOs and practices enhancements and supports that are and to have providers engage specialists in conversa- creating a holistic, comprehensive primary care system. tions and cooperative agreements about creating value. Core components of MDPCP that differentiate it from other primary care models include: Finally, the state engaged a contractor to help practices optimize their electronic medical records. Under this • A robust health information system, including data engagement, practices have upgraded their systems infrastructure, care coordination tools, and analytics and developed integrations with other systems including • A tool to reduce avoidable health services use CRISP. • Partners to help address behavioral health and social needs A Tool to Reduce Avoidable Health Services Utilization • Supportive state leadership and dedicated Recognizing the challenges that prior programs have practice coaching experienced in avoiding unnecessary hospital and ED uti- lization, Maryland contracted with The Hilltop Institute at Health Information System the University of Maryland, Baltimore County to create a The MDPCP requires all practices to participate in the user-friendly tool to identify patients at risk for avoidable state-designated health information exchange known hospitalization (AH) or ED visits. The “Pre-AH” tool uses as the Chesapeake Regional Information System for Our artificial intelligence to analyze claims, demographics, Patients (CRISP). CRISP provides all practices with a diagnoses, and pharmacy and environmental/social data package of health information technology tools including sets to predict AH and ED events (Figure 2). Primary care a nearly real-time event notification system, clinical que- providers can then target their resources to help prevent ries, care alerts and patient summaries, and prescription ED visits or AH. The tool is available to all practices free drug monitoring program. Practices and CTOs can also of charge on their CRISP dashboards and is updated use a suite of tools that includes a quality data upload monthly. portal, utilization and cost data visualizations, predic- Milbank Memorial Fund • www.milbank.org 4 Figure 2: Likelihood of Avoidable Hospital Events Report Partners to Address Behavioral Health their patients’ social needs. To facilitate linkages to and Social Needs community-based organizations to meet social needs, Unmet behavioral health and social needs can lead to the state developed a bidirectional referral tool available significant morbidity, mortality, and avoidable hospital through the CRISP platform. The referral tool provides and ED use.2 The MDPCP provides practices with a easy, secure referrals to organizations to meet food menu of evidence-based methods of behavioral health insecurity, housing, and other needs. MDPCP has begun integration. For example, to help practices combat collaborating with Meals on Wheels, community self-help Maryland’s statewide opioid epidemic, the state engaged programs, the State Department of Housing, diabetes a contractor experienced in integrating into primary prevention programs, and Catholic Charities. It plans to care the evidence-based protocol for substance use continue to build relationships with other government known as Screening, Brief Intervention, and Referral to and nongovernment organizations to address patients’ Treatment. By the end of 2019, 115 Maryland practices had social needs. fully implemented this process. In fact, 95% of practices reported having integrated behavioral health into their State Leadership and Dedicated practice workflows. Many practices have also implement- Practice Coaching ed the Psychiatric Collaborative Care Model and the be- MDPCP leadership, operations, and staff are all housed havioral health co-location model. The Collaborative Care operationally within the PMO, and its physician execu- Model focuses on defined patient populations tracked in tive director reports directly to the Secretary of Health. a registry, measurement-based practice, and treatment This unique reporting arrangement allows primary care to target. Primary care providers and behavioral health practices to identify a single source of leadership for the professionals provide evidence-based medication or state that offers both clinical guidance and the power of psychosocial treatment supported by regular psychiatric state government. case consultation and treatment adjustment for patients To provide hands-on support to practice leaders who are not improving as expected. and staff, the PMO began even before the start of the Acknowledging the significant impact of nonmedical program providing technical assistance and guidance factors such as housing and food insecurity on health, with practice coaches who work directly and daily with MDPCP practices are required to screen for and address practices. At the same time, the PMO offers regular Milbank Memorial Fund • www.milbank.org 5 webinars focused on areas of implementation such COVID-19 webinars cover topics such as provider, staff, as behavioral health and other topics. Additionally, and patient safety; identifying high-risk patients; and contractors offer staff training programs, webinars, communicating with patients. The webinars have recent- and provider leadership academies in locations across ly shifted to allow practices the opportunity to speak to the state (see Table 1). their peers and share their experiences. Approaches on Table 1: State Contributions to the MDPCP Program CTOs CRISP Contractors State Coaches • Furnish care coordination •C entral place to report • I mplement provider lead- • Facilitate escalation process services quality measures to CMMI ership academy and state to the Centers for Medicare training academies and Medicaid Services • Support care transitions •H as portal to access claims data reports •P rovide educational mate- • Offer strategies to reduce • Provide data and analytics rials on complex program administrative burden •P rovides social determinants issues • Assist with practice of health screening tools and • Deliver hands-on, in-person transformation resource directories •D evelop and conduct assistance and support behavioral health integration •O ffers prescription drug webinar series • Encourage quality monitoring programs, query improvement portal, secure messaging, •O ffer Screening, Brief ENS services Intervention, and Referral • Assist with health to Treatment assistance information exchange •H as preventable hospital tool implementation utilization tool integrated •H elp to optimize electronic into claims reports medical records •P rovide billing and coding guidance MDPCP POISED TO RESPOND issues such as how best to triage patients in parking QUICKLY TO COVID-19 lots and outdoor environments have been honed by The primary care workforce, coordinated and supported the practices during these virtual events. (See our by the MDH through the PMO, has become a critical part companion feature article for more on MDPCP’s response of the public health response to the COVID-19 pandemic. to COVID-19.) MDPCP providers have mounted a coordinated telemedi- cine response, shared best practices, and reached out to Importance, Scaling, and General at-risk patients. Applicability Maryland is an active proving ground for the concept Since March, the vast majority of practices in Maryland of increasing primary care investment to improve health have implemented or expanded their telemedicine while reducing the costs of care. It’s anticipated that MD- offerings. Based on a recent survey of practices, more PCP clinical quality, consumer satisfaction, and utiliza- than 472 practices are offering virtual care; others have tion data for performance year one (2019) will be available stayed open using telephone and limited in-person visits by late summer 2020. As the health of the population to care for their patients. improves and the rate of avoidable utilization of health The PMO held its first COVID-19 informational webinar services declines, Maryland intends to reduce overall for practices on March 12, when Maryland had 12 virus- spending with a focus on avoidable and unnecessary infected individuals. Since then, MDPCP has hosted high-cost utilization. COVID-19 update webinars three to five times a week If successful in Maryland, the MDPCP could be scaled and led by the PMO executive director and attended by 200 replicated elsewhere. Admittedly, Maryland is unique in to 300 primary care practice providers and staff. The its ability to directly regulate hospital spending under Milbank Memorial Fund • www.milbank.org 6 the Health Services Cost Review Commission and its global budget system. The investments in the MDPCP are included in the total cost of care spending calculations and, under the hospital global budgets, reductions in utilization financially benefit hospitals. Maryland’s currently unique regulatory system, however, could be expanded to other states if those states intro- duce global hospital budgeting or similar mechanisms to reduce unnecessary utilization. Rhode Island, Colorado, and Vermont have all introduced policies, statutes, and regulations that establish “affordability” caps on ele- ments of health care premium spending, for example, that can also lead to lower costs and higher quality. Even in a fee-for-service environment, reductions in unnecessary utilization in high-cost hospital venues may lower costs. The high cost of health care services in the United States drive the high health care insurance premiums and con- tribute to Americans’ inability to afford and access health care. There is no quick or simple solution to this problem, which has resulted from policy and program decisions made at many levels over the past 50 years. However, shifting care from high-cost venues like hospitals to well-prepared, adequately resourced, lower-cost primary care venues can be a foundation for creating a health care delivery system focused on health and well-being. To that end, Maryland will continue moving forward with its innovative and timely MDPCP. Milbank Memorial Fund • www.milbank.org 7 NOTES 1. ltschuler J, Margolius D, Bodenheimer T, Grumbach K. Estimating a reasonable patient panel size for primary A care physicians with team-based task delegation. Ann Fam Med. 2012;10(5):396-400. doi:10.1370/afm.1400. 2. erkowitz SA, Hulberg AC, Hong C, et al. Addressing basic resource needs to improve primary care quality: a B community collaboration programme. BMJ Qual Saf. 2016;25(3):164-172. doi:10.1136/bmjqs-2015-004521. Milbank Memorial Fund • www.milbank.org 8 AUTHORS Chad Perman, MPP, program director for the Maryland Primary Care Program’s Program Management Office, co-de- signed and now manages Maryland’s partnership and daily operations. Mr. Perman is a key advisor to the Maryland Department of Health on health transformation and population health initiatives. He previously served as the director of health systems transformation within the department’s Office of Population Health Improvement. Before working for the state, Mr. Perman served as a consultant with Health Management Associates. He conducted health policy analyses and provided consulting services to public and private-sector clients focused on publicly financed health care. Mr. Perman has also presented at a variety of state and national meetings. His abstract, “Innovative Payment Mechanisms in Maryland Hospitals,” was selected for “The Best of the 2014 Academy Health Research Meeting.” He leverages additional expertise in the areas of public policy analysis, consumer engagement, econometrics, and per- formance measurement through a variety of engagements with federal agencies, universities, and policy institutes. Mr. Perman serves on a variety of workgroups and boards including the Herschel S. Horowitz Center for Health Litera- cy (University of Maryland) Advisory Board. Robert Patterson, MHS, MA, has worked for 30 years in the global health and development sector as an organizational leader, technical expert, and technical writer for multinational agencies, governments, nongovernmental organiza- tions, foundations, and the private sector. He is a strategic thinker with experience across 25 countries and is fluent in English, French, and Italian. Mr. Patterson holds graduate degrees from the Johns Hopkins University’s Bloomberg School of Public Health and Nitze School of Advanced International Studies, as well as an undergraduate degree from Dartmouth College. Howard M. Haft, MD, was appointed by Governor Larry Hogan to serve as deputy secretary for public health services in the Maryland Department of Health in 2015. Since then he has also served as the interim executive director of the Maryland Health Benefit Exchange and most recently as the executive director of the Maryland Primary Care Program. Dr. Haft was the founder and chief medical officer of Conmed Healthcare Management, a publicly traded company. He served as the president of Maryland Healthcare, a multispecialty clinic in Southern Maryland; as president of the Maryland Foundation for Quality Healthcare; and as medical director of Health Partners, Inc. Dr. Haft has also served as chief executive officer of the Ellis Medical Group in New York. He provided emergency medical care for disasters, including Hurricane Katrina and the Haitian earthquake, and in remote Caribbean locations. Dr. Haft received his undergraduate degree at the University of Rhode Island, attended medical school at Pennsylvania State University, and completed post graduate internship and residencies at Brown University. He has a master’s degree from Tu- lane University School of Public Health and Tropical Medicine. He is recognized by the American Board of Physician Executives as a Certified Physician Executive and as a Fellow of the ACPE. He served as an adjunct professor in the McDonough Graduate School of Business and as assistant clinical professor of medicine at Georgetown University School of Medicine. Milbank Memorial Fund • www.milbank.org 9 About the Milbank Memorial Fund The Milbank Memorial Fund is an endowed operating foundation that works to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience. Founded in 1905, the Fund engages in nonpartisan analysis, collaboration, and communication on significant issues in health policy. It does this work by publishing high-quality, evidence-based reports, books, and The Milbank Quarterly, a peer-reviewed journal of population health and health policy; convening state health policy decision makers on issues they identify as import- ant to population health; and building communities of health policymakers to enhance their effectiveness. The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. In the Fund’s own publications, in reports, films, or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect opinions or factual determinations of the Fund. © 2020 Milbank Memorial Fund. All rights reserved. This publication may be redistributed digitally for noncommercial purposes only as long as it remains wholly intact, including this copyright notice and disclaimer. Milbank Memorial Fund 645 Madison Avenue New York, NY 10022 www.milbank.org Milbank Memorial Fund Using evidence to improve population health. Milbank Memorial Fund • www.milbank.org 10