Robert Master, MD, has been trying to create a primary care model for poor, elderly and disabled patients in greater Boston since the late 1970s, and in 2003 he co-founded the not-for-profit Commonwealth Care Alliance, a delivery system for Medicaid-Medicare dual eligible, developmentally and physically disabled patients.
With several state and federal contracts in Massachusetts, the Commonwealth Care Alliance is one of dozens of healthcare organizations participating in federal dual eligible demonstrations, after decades of the nation's poorest and frailest populations receiving fragmented care, at a cost of about $300 billion a year to both Medicaid and Medicare.
Master says the Commonwealth Care Alliance and others have shaped some working models for cost-effective, high-quality integrated care that emphasizes independent living, with interdisciplinary clinical teams, nurse practitioners that can provide care in the home, clinical access 24-hours a day, internet-based electronic medical records and contracted networks of specialists, agencies and vendors as chosen by beneficiaries.
Master, CEO of Commonwealth Care Alliance, talked with Healthcare Payer News about how he developed his model.
HPN: How did you get started on developing a primary care model for these complex patients?
Master: Commonwealth Care Alliance really came to be because of a realization that nothing else seemed to work for these populations. Fee-for-service, obviously, was not the answer; there was no accountable entity. All of the kind of typical managed care toolbox solutions -- payer-based efforts at care coordination, care management, utilization management, disease management and the like -- none of that was relevant or made any difference. The question was: What did work? There were similar questions around the country -- the PACE program -- many demonstrations were testing and evaluating different things.
HPN: What have you found?
Master: We're really testing out these models in kind of experimental pre-paid capitated approaches, going back to the early nineties, on a small scale -- a few hundred people here, tested against what would be the cost of service, use and experience in a fee-for-service Medicaid program.
We developed models for frail elders that were either homebound or in nursing homes, young populations with very involved physical and developmental disabilities and with often concurrent, very serious mental illness, another for Medicaid and dual populations that are seen in community health centers with the more complex array of chronic illnesses and substance abuses.
Redesigns of primary care that invested in multi-interdisciplinary teams, a lot of home visiting and community visiting for assessments and response to problems, developing resources allocations and personalized care plan -- as opposed to the more typical insurance or HMO utilization or management structures -- could really make the difference for these populations. Most significantly, the hospitalizations, which over 90 percent of the time were due to predictable complications of pre-existing chronic illness, could be substantially reduced.
HPN: Patients with Commonwealth Care Alliance can choose their own doctors and specialists. What kind of providers are in your networks?
Master: We are working in our network with community-based primary care sites. Many are in the safety net system, the community health centers. We found that people with developmental disabilities or very-involved physical disabilities, we really needed to create our own practices. They really didn't exist. People with, say, high-level spinal cord injury, you don't see them in typical primary care practices and, by and large, they get their care through multiple disconnected specialists, often a network that they've put together.
What we have done there is create and model what a specialized primary care practice would look like. In all cases in these populations, the investment in the clinical primary care teams and care coordination is quite a bit more robust. It had to be quite a bit more robust than envisioned in the patient-centered medical home models, which really are bringing up a practice in terms of infrastructure for a more general population, of which small subsets would be these people with more complex problems.
For example, we will invest on average, depending on the population, somewhere between $300 per person per month and up to $800 or even higher, in terms of robust interdisciplinary teams. What we see in terms of the added investment in the standard patient-centered medical home is something in the order or $6 or $8 or $10 per person per month. That's for a more general population, but the principles are the same: How do you improve the infrastructure, the coordination, the ability to manage across other settings?