Tina Simpson, JD, MSPH
Principal
Last week, the North Carolina Division of Health Benefits (Medicaid) launched its Advanced Medical Home (AMH) Webinar series with North Carolina Area Health Education Centers (NC AHEC) to support providers in the transition to Medicaid Managed Care. At this kick off meeting, Kelly Crosbie, Director of Quality and Population Health for NC Medicaid, Krystal Hilton, Associate Director of Quality and Population Health for NC Medicaid, and Carol Stanly, Manager of Medicaid Transformation for NC AHEC, outlined recently finalized changes to the AMH program, the cornerstone of the State’s 1115 Medicaid waiver.
A number of these changes follow feedback DHB received over the past year from providers, particularly as it relates to the investment required to adapt to the AMH Tier 3 model. Explaining the “big conceptual changes” to the program, Director Crosbie referenced the feedback collected from stakeholders following the suspension of Medicaid Transformation in November 2019. She also discussed the shift in circumstance and priorities as a result of the COVID-19 public health emergency as the impetus for this change in DHB’s model and oversight strategy.
The purpose of this article is to briefly summarize the four “big conceptual changes” to the AMH Tier 3 model as well as highlight the operational details (as far as they are known at this point). So, let’s get started.
(1) “STREAMLINED” REPORTING
DHB has simplified reporting requirements for PHPs. Simplification of reporting requirements come in two flavors. First, DHB is restricting what it is measuring and what it will hold PHPs accountable for. This is in contrast to the original AMH model wherein PHPs had multiple reporting requirements related to care management processes as well as penalties for failure to meet deadlines associated with those processes (such as failure to engage with the patient within a specific timeframe or complete an assessment or care plan). Now, DHB is focused exclusively on overall penetration and no penalties will be assessed associated with previous “process” metrics.
Secondly, DHB is standardizing reporting templates. DHB is in the process of creating two reporting templates: A Risk List, which the PHP is required to circulate to participating AMHs and the Care Management Report, which is the reporting template that the AMHs then report back to the PHPs. These templates are expected to be published by DHB in January.
(2) “GUARANTEED” CARE MANAGEMENT RATES AND INCENTIVE PAYMENTS
Care management rates cannot be tied to performance or include any risk-based calculation. Now, “guaranteed” does not include any guaranteed amount – rate negotiations are entirely left to individual negotiation. However, the care management rates cannot be put “at risk.” Additionally, PHPs will be required to provide incentive payments to Tier 3 AMHs that meet performance standards based on AMH measures, which may include total cost of care.
(3) SEED FUNDING THROUGH THE PRE-LAUNCH GLIDE PATH
Incentive payments in the amount of $8.51 per member per month (PMPM) payment based on existing Medicaid patient panels are available to qualifying AMH Tier 3 practices for three months in advance of the go live on July 1. Payments will be made directly from DHB and are made in response to feedback from providers citing the investment cost associated with conforming to Tier 3 requirements as a barrier to participation. To qualify for incentive payments, you must meet three criteria:
- Be an attested Tier 3 practice;
- Who has contracted with at least two PHPs; and,
- successfully completed data testing with those PHPs.
(4) PHP DISCRETION TO DOWNGRADE AMH TIER 3 PRACTICES
DHB has removed the 90-day grace period during which PHPs were prohibited from downgrading any AMH Tier 3 practices following go-live. The rationale here is that the three month “glide path” serves the same function as a grace period. Now PHPs may downgrade at their discretion – or rather, in conformity with the terms outlined in their contract with the individual practice. DHB expects a 30-day remediation period and all contracts must include an appeal process to the PHPs. Practices will have no ability to appeal to the Department.
THE TAKEAWAY: EFFECTIVE CONTRACT NEGOTIATION IS CRITICAL TO SUCCESS (AND CONTINUED PARTICIPATION AS AN AMH TIER 3 PROVIDER.)
DHB is in the process of reviewing all PHP contract templates (again) for conformity with these changes.
It is critical that providers understand the contract is not just about payment rates; it will also determine your ability to continue to participate at the AMH Tier 3 level by stipulating the bases for demotion, notice requirements, ability to remediate, and appeal rights. While PHPs are now required to contract with ALL AMH Tier 3 practices in their respective regions, failure to negotiate balanced terms as they relate to performance and downgrading will mean that PHPs don’t have to contract with those practices for long.
In conclusion, modifications to PHP and AMH reporting and contracting requirements represent a substantive change to the structure and priorities of the AMH program. This includes increased delegation to PHPs as to the oversight of operations, with DHB exercising a lighter touch, and relying increasingly on the individual contracting arrangements between providers and the PHPs. The influx of additional resources, including “seed funding” through the glide path in advance of the launch as well as required incentive payments for practices that meet individually negotiated performance standards (based on AMH standards), also represent a model that is likely to be more attractive to many. Perhaps the question, as raised by one participant in last week’s webinar, is whether enough time remains for practices to take advantage of and prepare for this AMH Tier 3 redux model.
For more information, we encourage you to visit the Department’s Advanced Medical Home webpage or refer to the recently released AMH Provider Manual.
And if you are a provider, we are experts in the NC Medicaid space and would be happy to work with you to develop your own contracting strategy in preparation for the change. Start by checking out our recent webinar on the topic, then reach out to us directly here.