The Centers for Medicare and Medicaid Services (CMS) recently extended its novel “all payer” hospital model for an additional year (through 2019), while the state seeks approval for a similar plan for outpatient providers. The State intends to expand its per-capita global budgets beyond the hospital setting and apply them statewide, accompanied by robust CMS investment in primary care via the Maryland Primary Care Program (MDPCP), which will begin next January. This is a welcome change, and one in which we have worked closely with state officials and other stakeholders to craft a viable path for independent primary care physicians.

As proposed, the MDPCP emulates the Comprehensive Primary Care Plus (CPC+) program launched by the Centers for Medicare and Medicaid Innovation (CMMI) in 2017. CPC+ is a national advanced primary care medical home model that aims to strengthen primary care through multi-payer payment reform and care delivery transformation. It builds on a predecessor program and offers selected practices additional financial resources and the flexibility to make investments in primary care to reduce unnecessary services. More information can be found here

Maryland proposes one key difference, namely the Care Transformation Organization (CTO). This coordinating entity serves as a partner to practices to guide, expand and support the intended program aims. CTOs will provide care management resources, infrastructure, behavioral health support (in Track 2) and technical assistance to practices who participate in the MDPCP.

In our opinion, this is a vital and welcome addition. Aledade has written extensively on CPC+ (see here and here), and is actively engaged with practices who participate in the program in Arkansas, Louisiana, Michigan, Pennsylvania and New Jersey. CPC+, though laudable in its aims and generous in its funding, has created complications in its implementation that can create misalignment with other value-based efforts.

The CTO construct solves many of these problems by providing physician practices with a partner who can guide resource allocation and leverage these resources with additional wrap-around services. Indeed, the CTO framework – as proposed – closely mirrors the role that Aledade already plays with its independent physician-led ACOs: we partner with independent physicians to deliver expanded primary care access; risk-stratified care management and care transitions; specialist utilization management and coordination; and real-time population health analytics. We also augment practices’ existing capabilities with the direct support of an integrated behavioral health program and a suite of medication management initiatives, led, respectively, by our Mental Health Director, Dr. Josh Israel, and our lead pharmacist, Megan Cancilla, PharmD.

It is important to note that, as proposed, not all CTOs will be created equal. There will likely be three formal levels: the first, for large practices that wish to participate directly, essentially serving as their own CTO; the second, for CTOs that function to support practice-provided services; and a the third level in which the CTO provides some direct services while also supporting the practice in their efforts. Many different organizations will come forward as CTOs, including hospitals. Some organizations may view this program as a way to support their continued efforts to deepen fee-for-service. Others may create local networks. Still others will combine this work with existing ACO work.

There will undoubtedly be various CTO options from which practices can pick. The work, especially in Track 2, is complex and time consuming; the right CTO will alleviate this burden and enhance a practice’s ability to improve patient outcomes.

A few guiding thoughts for the independent physicians:

  • Be selective. CTOs will offer a variety of services and structures. We advise practices to be selective and seek a partner with similar aims and structures that enhance their sustained, long-term independence.
  • Not all ACOs = CTOs. If you’re in an ACO, ask if your ACO partner can truly offer the services required for your practice to meet the MDPCP program requirements.
  • Beware of unintended hospital integration. Hospitals will likely present themselves as the logical CTO for surrounding practices. This may initially make sense for the practice, but could also lead to unintended consequences of curtailed autonomy.
  • Explore the CTO’s capabilities. Ensure that the group has the capacity to meet the demands of the program, especially if you choose to pursue Track 2 (integrated behavioral health).
  • Seek integration with other value-based models. Done properly, MDPCP aligns incredibly well with the aims of the Medicare Shared Savings Program, CareFirst Patient Centered Medical Home, and various other value-based payment models. Aligning models creates efficiencies that boost practice success.

Aledade is working closely with its existing and prospective physician partners in Maryland to align current efforts with the anticipated announcement of MDPCP. We are excited to expand our work in Maryland in a way that supports high-quality patient care and sustained physician independence.