Patient-Centered Medical Home Initiative
Monica Picture
Early History of the Montana Medical Home Initiative
Fall 2009 March 2010 April 2010 May 2010 August 2010 September 2010November 2010March 2011
April 2011 May 2011June 2011July 2011August 2011September 2011

Fall 2009
Montana Medicaid at the Department of Health and Human Services (DPHHS) was awarded a technical assistance grant from the National Academy for State Health Policy (NASHP). This grant established a consortium of eight states who agreed to individually and collectively work with NASHP to advance medical homes for Medicaid and CHIP program participants. This advancement was to be driven by an improvement plan focused on five core elements: 1. Developing key partnerships, 2. Defining and recognizing medical homes, 3. Improving purchasing and reimbursement policies, 4. Supporting practice change, and 5. Measuring progress.

March 2010
NASHP staff facilitated a meeting to address a statewide, multi-payer medical home initiative with providers, major payers, provider associations, state programs, and other interested parties. The goal of the meeting was to define the medical home for Montana and begin to discuss how to collectively meet the needs of providers, payers and patients in a medical home setting.
The definition adopted at the meeting:

In Montana, a patient centered medical home is health care directed by primary care providers offering family centered, culturally effective care that is coordinated, comprehensive, continuous, and, when possible, in the patient's community and integrated across systems. Health care is characterized by enhanced access, an emphasis on prevention, and improved health outcomes and satisfaction. Primary care providers receive payment that recognizes the value of medical home services.

April 2010
Montana Medicaid hosted a webinar by the National Committee on Quality Assurance (NCQA) and invited the Office of the Commissioner of Securities and Insurance (CSI) to participate. Following the webinar, the stakeholder group recommended Montana adopt the NCQA standards and recognize practices that meet a Level 1 standard along with several additional standards. The group referred to the standard as Level 1 PLUS.

    NCQA Level 1 Must Pass Standards:
  1. PPC1A: Written standards for patient access and patient communication
  2. PPC1B: Use of data to show meeting this standard
  3. PPC2D: Use of paper or electronic-based charting tools to organize clinical information
  4. PPC2E: Use of data to identify important diagnoses and conditions in practice
  5. PPC3A: Adoption and implementation of evidence-based guidelines for three conditions
  6. PPC4B: Active support of patient self-management
  7. PPC6A: Tracking system for tests and identify abnormal results
  8. PPC7A: Tracking referrals with paper-based or electronic system
  9. PPC8A: Measurement of clinical and/or service performance
  10. PPC8C: Performance reporting by physician or across the practice

Additional Standards for a Montana Medical Home:

  1. Cultural Effectiveness:
    1. Practice has written policy to address the unique cultural needs of patient demographic which emphasizes American Indians and the frontier landscape of the state, where appropriate.
    2. Practice has a community resource list available to clients who demonstrate a need for services beyond the capability of the medical practice, but which may aid in the health or recovery of the patient.
  2. Continuous:
    1. Practice demonstrates a commitment to serving clients with acute and chronic conditions, from birth to end of life.
    2. Practice demonstrates a commitment to providing as many ancillary services as possible at the practice location.
    3. Each patient has a unique provider who they see as often as possible when they require care in the practice.
  3. Comprehensive:
    1. Referral follow-up.
    2. Patient appointment reminders.
    3. Mechanism in place to identify gaps in care for patients (especially preventive) which are utilized regardless of the reason for the visit.
  4. Family Centered: Practice is accessible and friendly to families and/or family members of patients.
  5. Patient Satisfaction: Practice monitors and/or measures patient satisfaction and has a process in place to address specific complaints or negative trends.

May 2010
Montana Medicaid hosted a visit by national Payment expert, Michael Bailit of Bailit Health Purchasing. Mr. Bailit discussed payment options, anti-trust laws, other state multi-payer initiatives and recognition processes. After the meeting with Mr. Bailit and further discussion with NASHP staff, it was clear that the stakeholders group should be convened by a neutral and authoritative entity other than Montana Medicaid.

August 2010
CSI agreed to serve as the convener for the Montana Medical Home Initiative.

September 2010
CSI convened the Working Group whose members drafted a work plan with a goal of starting a pilot medical home project. The group decided progress on reimbursement reform could not move forward until the recognition standards were in place and anti-trust laws fully considered. A smaller recognition subgroup was established and CSI agreed to research anti-trust issues.

November 2010
Recognition workgroup members were surveyed concerning their thoughts on the draft standards.

March 2011
The working group reconvened, the work plan was revisited and revised, the definition revisited and affirmed, the NCQA 2011 standards examined and a webpage developed. CSI agreed to host a series of at least 8 weekly calls.

April 2011
Weekly calls continued with expert guests, discussion about other state's projects, discussion of the 2011 NCQA recognition standards, conversation with TransforMED—a consulting firm that helps practices achieve medical home recognition, and discussion on BCBS of MT pilot project for chronic disease management. A list serve was established.

May 2011
Commissioner Lindeen met with major domestic health insurance carriers to discuss the PCMH Initiative and ask for their continued involvement. The recognition subgroup convened to discuss NCQA PCMH 2011 recognition standards. They recognized that the 2011 updates were more comprehensive than the 2008 standards and were inclusive of the additional standards identified in April 2010. The subgroup recommended practices meet the 2011 level 1 standard for recognition as part of Montana's initiative.

June 2011
The Working Group met with HealthShare Montana to discuss the state's Health Information Exchange and the potential use of the system as the data repository to support PCMH. The working group agreed it was important to focus on adopting a single platform statewide for medical homes. Group members participated in webinars highlighting the capacity of several systems. Commissioner Lindeen forwarded a recommendation to the Working Group to adopt the NCQA PCMH 2011 standards for recognition of medical homes. During a comment period, discussion concerned those practices that were already recognized under 2008 standards and how they would be grandfathered or transitioned into the on-going project. The group recommended the following recognition standards to the Commissioner:

Montana will use standards accepted by NCQA PCMH to recognize a primary care clinic as eligible for the pilot project as a medical home and potentially to receive enhanced reimbursement. Pilot sites will commit to moving along the NCQA tiered recognition process. Those recognized as Level 1 under NCQA PCMH 2008 standards must reach 2008 Level 2 or higher, or 2011 Level 1 or higher by January 1, 2013. Once anti-trust issues are resolved, progression may be encouraged with enhanced reimbursement rates based on the level of recognition achieved.

Initial discussion about performance measurements for medical homes began and a draft document was developed for comment.

July 2011
Working Group adopted a set of measures for provider performance, and outlined a process for setting goals and benchmarks for improved performance which may eventually be tied to enhanced reimbursement. Anti-trust issues are being explored by CSI legal department. The group examined a crosswalk between NCQA and Meaningful Use. The group continued evaluating technology platforms for potential use by a PCMH project. Commissioner Lindeen accepted the proposed recognition standards from the Working Group on July 12 after a public comment period.

August 2011
With input from CSI legal staff, the Working Group discussed ways to avoid anti-trust violations while working on payment models for PCMH. They concluded there was much that could be done in the way of the structure of PCMH without confronting anti-trust issues, and that legislation was likely needed to establish a state action declaring Montana's intent to displace competition for the purpose of PCMH. They agreed to explore if it could be accomplished by executive authority, but agreed to explore a legislative bill to accomplish this purpose.

Performance benchmarks continued to be refined. Commissioner Lindeen announced her intention to form an official Advisory Council made up of the active members of the working group.

September 2011
The PCMH Advisory Council was formed on September 9th and held its first meeting on the 14th. The purpose of the Council as set forth by the Commissioner was to furnish advice on setting up a working model for a state-wide system of patient-centered medical homes in Montana. She asked the Council to gather information on other PCMH projects across the country homes and assess which have the most value to Montana efforts; to recommend procedures and policies for launching a pilot project in Montana; and to recommend a legal structure, governance model, and funding mechanism for an on-going program to support patient-centered medical homes.

The Advisory Council was not authorized to administer a program or set policy.

The on-going work of the advisory council is being recorded in official minutes and is available here.