The medical home model: What physicians need to know

Posted by Continuum on Nov 1, 2016 1:08:19 PM

The concept of a “medical home” has evolved over the years, starting in the 1960s as the center iStock_81378855_LARGE (1).jpgof medical records for a child with special healthcare needs. Today, that definition is greatly expanded: A medical home is a partnership between the patient, family and primary care provider, in cooperation with specialists and community supports, according to the U.S. Department of Health and Human Services. It can encompass children and adults, regardless of their healthcare needs.

The medical home model will also play a key role in Medicare’s new reporting and reimbursement regulations, which will be phased in starting January 1, 2017. Physicians who participate in certain medical home models will have financial advantages under the Medicare Access & CHIP Reauthorization Act (MACRA) of 2015.

Under MACRA, physicians must choose a reporting path: either the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (Advanced APM). The Advanced APM track brings greater potential rewards as well as additional requirements over MIPS, including assumption of financial risk tied to spending benchmarks.

The medical home model provides distinct advantages for each track:

  • MIPS track: Medical home participants can receive the maximum score in the MIPS “Improvement Activities” category, which accounts for 15% of a physician’s total MIPS score. Higher MIPS scores result in greater financial rewards for doctors.
  • Advanced APM track: Medical home participants have a lower financial risk criterion to qualify as an Advanced APM. For instance, medical home models that are “expanded” under CMS Innovation Center Authority satisfy the risk criteria. And medical home models that are not expanded will have different financial risk standards than those for other APMs. 

All medical home models must have the following features, according to the Centers for Medicare & Medicaid Services (CMS):

  • Participants include primary-care practices or multispecialty practices that have primary-care physicians and practitioners and offer primary-care services.
  • Empanelment of each patient to a primary clinician.
  • Payment arrangements in addition to, or substituting for, fee-for-service payments.
  • At least four of the following:
    • Planned coordination of chronic and preventive care.
    • Patient access and continuity of care.
    • Risk-stratified care management.
    • Coordination of care across the medical neighborhood.
    • Patient and caregiver engagement.
    • Shared decision-making.

Ultimately, an effective medical home model should benefit both patients and doctors by improving quality of care, reducing overall costs of care, and enhancing patient satisfaction. Moreover, physicians can receive well-deserved monetary rewards for participating in such models.   

For more information on MACRA, MIPS and APMs, download one of our 2016 white papers:

Topics: Value-Based Healthcare, MIPS, APMs

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