September 26, 2019

This article was originally produced in the Alabama Medicine Magazine, Volume 5, Number 3, Summer 2019 issue.

The Alabama Medicaid Agency (“Medicaid” or the “Agency”) will complete its pivot from the Regional Care Organization program in October with the implementation of the Alabama Coordinated Health Network (“ACHN”) program. The ACHN program is intended to continue the push to improve health outcomes and reduce costs in the Medicaid program through integration and coordination of primary care for Medicaid beneficiaries. This will ultimately result in some big changes for Medicaid-enrolled primary care providers, with changes being phased in over the next few years.

An Overview of the Alabama Coordinated Health Network

Where Medicaid’s care coordination services are currently spread across 6 health homes, 12 maternity program contractors, and Alabama Department of Public Health employees in 67 counties, the ACHN program will integrate the care coordination between the Agency’s Health Home, Maternity, and Plan First programs into the single ACHN program.¹ The ACHN program is divided into 7 regions based on existing care patterns, access to care, and financial viability, with each region being served by a single Primary Care Case Management Entity (“PCCM Entity”). These PCCM Entities will be charged with implementing a care coordination delivery system for the region they serve and will be incentivized, along with regional primary care providers,² to achieve better health outcomes and provide a higher volume of care coordination services.

Paying for Value

Currently, certain primary care physicians³ are eligible for a primary care “Bump” which increases the reimbursement for the services they provide. Physicians who choose not to participate in the ACHN program will continue to receive “Bump” payments, but physicians and groups that participate in the ACHN program will be eligible for a higher baseline ACHN payment⁴ and will also be eligible for bonuses for achieving quality, cost-effectiveness, and Patient-Centered Medical Home (“PCMH”)⁵ recognition metrics.

The Agency will make quality and cost-effectiveness performance payments based on attribution of Medicaid recipients to a particular physician group. Medicaid recipients will be attributed quarterly to the physician group with the highest scores for the recipient. Quality performance measures include: well-child visits (children ages 3-6), adolescent well-care visits, immunization status (children and adolescents), antidepressant medication management, HbA1c test for diabetic patients, follow-up after ER visits related to alcohol or other drugs, and Chlamydia screening for women. Quality performance payments will be guaranteed for participating physician groups for at least four quarters after ACHN implementation.

The Agency will begin to make payments based on actual performance as soon as the previous calendar year’s performance has been calculated (likely 6 months after the start of the second contract year, or May 2021). By contrast, quality performance metrics for maternity care focus on reductions in infant mortality, treatment of substance use disorders, and prevention of childhood obesity. Quality bonuses of $100 (per each of the following visits) are available for Delivering Health Care Providers (“DHCPs”)⁶ who provide a prenatal visit (during the first trimester) and postpartum visit (between 21 and 56 days after delivery).

The Agency will measure cost effectiveness using a two-year lookback of medical claims, a one-year lookback for maintenance medications claims history, and peer-to-peer review of costs per beneficiary. Somewhat similar to the Medicare Shared Savings Program ACO concept, the Agency will compare the physician group’s actual per-member-per-month (“PMPM”) cost to a risk-adjusted expected PMPM cost. Groups at or below the median efficiency score will receive cost-effectiveness payments. Cost-effectiveness bonus payments will be guaranteed for participating physician groups during the first four quarters after ACHN implementation (October 2019-September 2020) and will be calculated by the Agency based on actual performance thereafter.

Physician groups are eligible for PCMH recognition payments based on achieving PCMH recognition by a nationally-recognized organization⁷ or documented progress toward attaining such recognition. PCMH recognition payments will be distributed to physician groups based on the number of Medicaid recipients attributed to the physician group for the prior quarterly period. Physicians must demonstrate PCMH recognition (or progress toward PCMH recognition) through attestation to the Agency. The Agency will review the attestation on the last business day of the month prior to the first quarterly PCMH recognition payment of the ensuing year.

Notably, performance bonus payments and payments for services actually rendered are not paid by the PCCM entity to providers, but are paid directly from the Agency.

Requirements for Participation

To participate in the ACHN program, physician groups must:

(1) Actively work with the ACHN to review recipient care plans;

(2) Participate (as needed) in the ACHN multidisciplinary care team;

(3) Participate in ACHN quality measure initiatives;

(4) Participate in at least two quarterly Medical Management Meetings of the PCCM Entity⁸; and

(5) Review data provided by the ACHN to help achieve regional and state Medicaid goals; and

(6) Participate in the DHCP selection and referral process (for maternity care providers). Physician groups must have an Alabama Medicaid Provider Agreement, an Alabama Medicaid Primary Care Physician Group Agreement, and an ACHN participation Agreement. Physician groups only need one ACHN agreement, but they may participate within any ACHN region.

On a more granular level, participating physician groups must provide for 24-hour availability by phone in order for Medicaid recipients and other providers to contact the physician group for instructions regarding patient care and/or referrals. This requirement is met if the group provides an after-hours telephone number connecting the recipient to the group, or an after-hours answering service through which the group or an authorized practitioner gives the recipient a call back within one hour of the recipient’s initial contact.

Physician groups must also have either admitting privileges, or an admitting agreement with a hospitalist or other physician group, at a hospital within a 45-minute drive from the group’s practice location. In addition, physician groups should consider providing comprehensive Early and Periodic Detection, Screening, and Treatment (“EPSDT”) screenings, or in the alternative, have an agreement with another provider to perform such screenings.

More Details to Come

The previous is no more than a broad overview of the structure of the ACHN program that will be implemented in October of this year. More details will likely become available as part of the Medicaid Administrative Code and Provider Manual and will continue to be updated on the Agency’s website. Ultimately, all health care providers should recognize the ACHN program as a small, but meaningful, step closer to value-based care in the Alabama Medicaid program. 

This Insight is intended only to provide an overview of the matters addressed herein and does not constitute legal advice.  If you have any questions regarding a specific arrangement with a physician or other health care provider, please seek appropriate legal counsel.

[1] The information contained in this article is derived from materials published by the Alabama Medicaid Agency, including the Alabama Medicaid Agency State Plan Under Title XIX of the Social Security Act (the “Medicaid State Plan”) and ACHN-specific materials on the Agency’s ACHN page at https://www.medicaid.alabama.gov/content /2.0_Newsroom/2.7_Special_Initiatives/2.7.6_ACHN.aspx.

[2] This article focuses on primary care providers, including primary care physicians and maternity providers, but specialty providers must be aware of applicable policies for referrals for specialty care.

[3] This includes those physicians who are Board certified with a specialty or subspecialty designation in family medicine, general internal medicine, or pediatrics and those non-Board certified physicians who practice in family medicine, general internal medicine, or pediatrics and who attest that 60% of their paid Medicaid procedures are for specified E&M codes and vaccines for children.

[4] A list of eligible primary care services comparing the “Bump” rate to the ACHN payment rate is available on the Agency’s website at https://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.7_Special_Initiatives/2.7.6_ACHN/2.7.6_ACHN_Participation_Rates_ Bump_Rates_6-27-19.pdf.

[5] A PCMH is a primary care model focused on comprehensive, patient-centered, and coordinated care, accessible services, and quality and safety. Defining the PCMH, AHRQ: PCMH Resource Center (July 6, 2019), https://pcmh.ahrq.gov/page/defining-pcmh.

[6] DCHPs include OB/GYNs, nurse midwives, and other physicians providing maternity care.

[7] The National Committee for Quality Assurance (“NCQA”) is the only national organization specifically recognized in the Medicaid State Plan.

[8] Nurse Practitioners and/or Physician Assistants may attend the Medical Management Meetings on behalf of their physician groups.