This bulletin applies to NC Medicaid Managed Care.
In June 2023, North Carolina was selected as one of eight states to participate in a new Centers for Medicare & Medicaid Services (CMS) primary care payment model called Making Care Primary (MCP). MCP aims to strengthen primary care by driving multi-payer alignment across several priority areas including payment reform, quality measures and incentives, data sharing, and learning systems.
The Medicare portion of the model will begin for participating primary care practices in July 2024. Other payers, including Medicaid agencies, have additional flexibility on if, and when, to launch an explicitly aligned approach. In North Carolina, the Medicaid Advanced Medical Home (AMH) program already has significant alignment with Medicare’s MCP model, including emphasis on local care management, addressing health-related social needs, and increasing investments in primary care through payments beyond fee-for-service.
Throughout the Fall and Winter of 2023, NC Medicaid convened community partners, including providers, Prepaid Health Plans (PHPs), and Clinically Integrated Networks (CINs) to discuss further opportunities for alignment between the AMH model and the MCP Medicaid model.
Based on feedback received, along with analyses of the current state of primary care in North Carolina and value-based payment (VBP) arrangements from Medicaid PHPs, NC Medicaid is considering an update to the AMH program to further standardize VBP offerings to primary care providers and align further with Medicare MCP.
Background on the Medicare MCP Model
The Medicare MCP model will provide a pathway for primary care clinicians with varying levels of experience in value-based care to gradually shift away from fee-for-service payment in primary care, instead adopting population-based and quality-based payments informed by a focused set of measures. Practices will also build infrastructure to improve behavioral health and specialty integration and drive equitable access to care.
The 10.5-year model includes significant performance incentive payments and elements of prospective payment. The model will also improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health-related social needs (HRSNs) such as housing and nutrition.
Detailed information on the Medicare MCP model can be found on the CMS MCP website.
NC Medicaid Alignment with MCP: Community Partner Feedback
Key themes from community partner feedback provided in the Fall and Winter of 2023 included:
- Address administrative burden and increase provider flexibility. Community partners shared that the variability in VBP arrangements across the five PHPs leads to high administrative burden for providers which distract from providing the care members need. They were supportive of agency efforts to streamline and standardize requirements across health plans and increase provider flexibility in caring for members, while aligning with elements of the Medicare MCP model. In addition to the administrative burden caused by VBP arrangement variability, providers continued to express challenges with foundational components of the managed care model including member assignment and attribution, which could impact their participation in advanced VBP models.
- Build upon existing primary care reforms, including the AMH program. Community partners strongly supported efforts to align with MCP, using the existing primary care infrastructure in the Medicaid program, particularly the AMH program.
- Consider the unique features of the NC Medicaid program and population. Community partners noted that there are important differences between the Medicaid program and population with other payers, including Medicare. Some specific considerations include determining which performance metrics are best suited to a Medicaid population; how the churn in Medicaid enrollment and Medicaid expansion could impact a prospective payment model; and how practices with a disproportionate share of Medicaid members, such as pediatricians, may have less experience with and infrastructure to support value-based arrangements than commercial or Medicare focused practices.
- Invest in provider readiness and overall primary care payments when NC Medicaid considers prospective primary care payment. Community partners made clear that implementing a prospective payment model would be challenging without new investments in primary care payment and infrastructure. The Medicare MCP model includes upfront funding for providers with no VBP experience, as well as significant performance incentive opportunities, new codes to support specialist integration, and data sharing supports. The Medicare MCP model also includes significant prospective payment in Tracks 2 and 3. Taken together, CMS has indicated these payments are expected to result in higher total payment for primary care providers as compared to FFS Medicare.
Current State of Primary Care and Managed Care VBP Arrangements
In addition to convening community partners, NC Medicaid also conducted a landscape analysis of the current state of primary care in North Carolina and reviewed data from reports submitted by PHPs on their VBP arrangements. NC Medicaid has a strong primary care member engagement and network access; DHHS data from 2023 showed that approximately 90% of members saw a primary care provider in the past 24 months. Additionally, the AMH program lays a foundation for VBP tied to quality in the primary care program by requiring PHPs to offer performance incentive arrangements to most AMH practices.
However, analysis of PHP reports on VBP arrangements found there is wide variation in how AMH Performance Incentive Payments are structured, as well as the value of the incentives paid through these incentives to providers. This echoed feedback received from community partners regarding administrative burden caused by how PHPs structure their VBP models differently.
Proposed Approach: Aligning and Standardizing AMH Incentives
As NC Medicaid considers primary care reforms and potential future changes to the AMH program, it aims specifically to:
- Improve quality outcomes, equitably
- Maintain strong access to primary care and high member engagement
- Further integrate behavioral health and health-related resource needs in primary care
- Increase provider flexibility and transparency and lower administrative burden
- Support continued investments in primary care
These goals also align with Medicare MCP. To achieve these goals and to further deepen alignment with the Medicare MCP model, NC Medicaid is proposing to establish a standardized primary care performance incentive arrangement which all NC Medicaid Standard Plans and Tailored Plans must offer to AMH primary care practices.
Under this approach, NC Medicaid would specify and align the following features of the model regardless of health plan:
- One aligned, targeted and limited subset of key AMH measures across health plans
- An aligned approach across health plans for attributing members to providers for the purposes of calculating quality performance
- Consistent measure targets or benchmarks
- A consistent methodology for calculating incentives that is not contingent upon meeting total cost of care or shared savings benchmarks
NC Medicaid is also considering prescribing a standard and transparent minimum performance incentive dollar amount that providers would earn for achieving targets on each of the specified measures. However, this element of alignment may depend on funding availability.
Under this proposal, health plans would be required to permit all AMH Tier 2 and Tier 3 providers to participate in the standardized performance incentive arrangement. Providers may choose to participate in this standard arrangement and/or in other VBP arrangements offered by the health plan, as appropriate.
Next Steps and Request for Community Partner Feedback
NC Medicaid proposes launching a standardized AMH performance incentive model no sooner than July 2025. NC Medicaid will consider future primary care payment and care delivery reforms in alignment with the Medicare MCP model, including prospective payment, based on learnings from CMS, market readiness, and sufficient state capacity to implement more advanced VBP models.
The Department seeks community partner feedback on the proposed approach to primary care reforms, specifically:
- What initial reactions do you have to NC Medicaid’s approach to MCP alignment (starting with an aligned AMH incentives approach, with the potential of a future prospective payment model)?
- Primary care providers: would your practice be interested in participating in this aligned performance incentive model, or would you prefer to maintain the existing approach with a variety of performance incentive program designs across plans? Does your answer remain the same for more advanced VBP arrangements, such as prospective payment?
- Health plans and primary care providers: What challenges do you foresee with the implementation of a standardized performance incentive model across all Medicaid Standard and Tailored Plans? How would you recommend NC Medicaid address these challenges?
- What should NC Medicaid be considering as it designs an aligned AMH incentive model?
- What operational or administrative investments by the Department are needed to support this approach?
- What changes would most effectively reduce the burden on primary care providers relative to value-based contracting with Standard and Tailored Plans?
- How should NC Medicaid approach attribution for the purpose of measuring quality in an aligned incentive model?
NC Medicaid will continue to meet and collaborate with community partners and CMS in the consideration and design of this proposal.
We encourage community partners to provide feedback by emailing Medicaid.NCEngagement@dhhs.nc.gov (subject line “MCP Feedback”) by June 28, 2024.