NJ Health Plans Selected in National Pilot to Improve Primary Care

Beth Fitzgerald | June 19, 2012 | Health Care
Practices will be selected next to receive the extra financial support to provide enhanced services

The federal government has chosen five health plans to join Medicare in a four-year pilot program that will channel new financial support to 75 primary care practices in New Jersey.

The goal is to help these practices, which will be chosen over the next few weeks, coordinate patient care, concentrate on the sickest patients, and reduce healthcare spending.

The federal Centers for Medicare and Medicaid Services has chosen an application from New Jersey health plans as one of seven winners nationwide in the competitive CMS program created under the Affordable Care Act to improve primary care. The five health plans are Horizon Blue Cross Blue Shield of New Jersey, AmeriHealth New Jersey, UnitedHealthcare, the Teamsters multi-employer healthcare fund, and Amerigroup.

“Under this new, first-of-its-kind program in New Jersey, primary care practitioners will receive multiple streams of financial support from health plans and CMS,” said Robert A. Marino, chief executive of Horizon.

CMS will select the 75 primary care practices. All the health plans, including Medicare, will start making additional per patient, per month, payments to each practice. These payments will be in addition to the claims dollars paid by Medicare and the other plan pay when patients get medical care from the practices.

In the first two years of the pilot, the per-patient monthly payments by CMS will average $20 per patient. The payments made by the other providers have been negotiated with CMS and are confidential. Primary care practices have until July 20 to apply to CMS to be one of the 75 in the program, which will launch in November.

The practices will be required to use the extra money to provide enhanced services to their patients. These include offering longer and more flexible hours. Practices will use electronic medical records, focus on preventive care, coordinate care, and provide more intensive care to patients with multiple chronic diseases. Patients will also be encouraged to manage their own care.

“The practices will be given other valuable resources, such as timely, population-based data, to help them deliver more effective and efficient care to their patients,” Marino said.

Amerigroup is a Medicaid managed care company, one of four in New Jersey that delivers Medicaid services under contract with the state. Medicaid, which is funded 50/50 by the state and federal government, provides healthcare to 1.3 million low-income New Jersey adults and children.

Judith L Roman, chief executive of AmeriHealth NJ, said “We are anxious to get started and are confident this pilot will enable New Jersey to successfully achieve better health, better care and lower healthcare costs for the residents of this state.”

Dr. Rick Cohen, medical director of Amerigroup New Jersey, said the company decided to participate in the CMS pilot because “we are very much committed to providing quality care for our members, but we are also committed to controlling our costs for the taxpayers of New Jersey. We really feel that the best way to do that is through supporting our primary care physicians and by giving them the resources and the tools so that we would see improved care.”

The partnership, Cohen said, will give the primary care doctors “adequate financial resources and additional tools to really provide better care and at the same time, work to control costs.”

The primary care practices will engage in the care delivery system improvements associated with “patient centered medical homes” (PCMH) that achieve designation from the National Committee on Quality Assurance (NCQA). The 75 practices don’t have to become NCQA patient homes, but it’s expected that if the pilot is successful they will be operating along the lines of a PCMH. One of the central missions of the PCMH is care coordination, including keeping tabs on whether patients have had regular exams, if their chronic diseases are under control, and if they are managing their medical conditions in order to avoid unnecessary hospital visits.

Cohen said a number of Amerigroup’s New Jersey practices have already achieved NCQA patient home status and through the pilot “we will be working with the other practices to bring them along.”

Cohen, an internist, said the initiative gives physicians the tools to provide a high level of medical care. The primary care doctor “really wants to be the person who can diagnose and cure a problem, to help a patient understand what their problems are,” he said. “You want to be able to guide them to appropriate specialists and tests. And you need the time and the office resources to do all that.” With the additional revenue, primary care practices will be able to add staff to coordinate care.

“The primary care doctors who are selected will really have the resources and tools to work with the individual patients, engage them, help guide them through the system, help manage their chronic conditions — and make sure patients population are getting the preventive services they need,” Cohen said.

Michael McGuire, UnitedHealthcare chief executive for New Jersey, said the CMS primary care initiative “is trying to raise quality, raise patient satisfaction and lower overall costs.” The pilot seeks to reserve a well-documented shortage of primary care: “It is a problem today and it will be a bigger problem going forward. This is a good program and a good opportunity to improve primary care,” he said.