Florida Senate - 2010 SB 2532
By Senator Peaden
2-01694-10 20102532__
1 A bill to be entitled
2 An act relating to a medical home pilot project;
3 amending s. 409.91207, F.S.; requiring the Agency for
4 Health Care Administration to establish a medical home
5 pilot project; providing definitions; providing for
6 the organization of medical home networks; requiring
7 each medical home network to provide specified
8 services; requiring the Secretary of Health Care
9 Administration to appoint a task force to develop and
10 implement the project; providing for the establishment
11 of a statewide advisory panel; providing for
12 membership and duties of the task force and the panel;
13 providing for travel expenses and per diem for members
14 of the task force, statewide advisory panel, and
15 medical advisory group; directing the agency to
16 provide staff support to the panel; directing the
17 panel to establish a medical advisory group to promote
18 and assist in the establishment of medical home
19 networks; providing for enrollment of Medipass
20 beneficiaries in the pilot project; authorizing the
21 agency to designate priority areas in the state for
22 the development of medical home networks; providing
23 for financing of medical home networks; providing
24 responsibilities of the agency; requiring the agency
25 to adopt rules; providing for distribution of savings
26 achieved by network providers under certain
27 circumstances; providing for an appropriation;
28 requiring the agency to collaborate with the Office of
29 Insurance Regulation to encourage licensed insurers to
30 incorporate the principles of the medical home network
31 in insurance plans; directing the Department of
32 Management Services to develop a medical home option
33 in the state group insurance program; requiring
34 medical home network providers to maintain certain
35 records and data; providing an effective date.
36
37 Be It Enacted by the Legislature of the State of Florida:
38
39 Section 1. Section 409.91207, Florida Statutes, is amended
40 to read:
41 (Substantial rewording of section. See
42 s. 409.91207, F.S., for present text.)
43 409.91207 Medical home pilot project.—
44 (1) PURPOSE AND PRINCIPLES.—The agency shall develop and
45 implement a medical home pilot project. The purpose of the
46 project is to establish an enhanced primary care case management
47 program to test a medical home network model for coordinated and
48 cost-effective care in a fee-for-service environment and to
49 compare the performance of the medical home network model with
50 other forms of managed care. The agency may test alternative
51 payment rates and methods for designated medical homes that meet
52 the quality and efficiency guidelines established by the agency.
53 The medical home is intended to modify the processes and
54 patterns of health care service delivery by applying the
55 following principles:
56 (a) A personal medical provider leads an interdisciplinary
57 team of professionals who share the responsibility for providing
58 ongoing care to a specific panel of patients.
59 (b) The personal medical provider identifies a patient’s
60 health care needs and responds to those needs through direct
61 care or arrangements with other qualified providers.
62 (c) Care is coordinated or integrated across all areas of
63 health service delivery.
64 (d) Information technology is integrated into delivery
65 systems to enhance clinical performance and monitor patient
66 outcomes.
67 (2) DEFINITIONS.—As used in this section, the term:
68 (a) “Case manager” means the person or persons employed by
69 a medical home network or by a member of the network to work
70 with primary care providers in the delivery of outreach, support
71 services, and care coordination for medical home patients.
72 (b) “Medical home network” means a group of primary care
73 providers and other health professionals and facilities who
74 agree to cooperate with one another in order to coordinate care
75 for Medicaid beneficiaries assigned to primary care providers in
76 the network.
77 (c) “Primary care provider” means a federally qualified
78 health center or a health professional practicing in the field
79 of family medicine, general internal medicine, geriatric
80 medicine, or pediatric medicine who is licensed as a physician
81 under chapter 458 or chapter 459, a physician’s assistant
82 performing services delegated by a supervising physician
83 pursuant to s. 458.347 or s. 459.022, or a registered nurse
84 certified as a nurse practitioner performing services pursuant
85 to a protocol established with a supervising physician in
86 accordance with s. 464.012.
87 (d) “Principal network provider” means a member of a
88 medical home network who serves as the principal liaison between
89 the agency and that network and who accepts responsibility for
90 communicating the agency’s directives concerning the project to
91 all other network members.
92 (e) “Tier One medical home” means a primary care provider
93 designated by the agency as meeting the service capabilities
94 established in paragraph (4)(a).
95 (f) “Tier Two medical home” means a primary care provider
96 designated by the agency as meeting the service capabilities
97 established in paragraph (4)(b).
98 (g) “Tier Three medical home” means a primary care provider
99 designated by the agency as meeting the service capabilities
100 established in paragraph (4)(c).
101 (3) ORGANIZATION.—
102 (a) Each participating primary care provider shall be a
103 member of a medical home network and shall be designated by the
104 agency as a Tier One, Tier Two, or Tier Three medical home upon
105 certification by the provider of compliance with the service
106 capabilities for that tier.
107 (b) The members of each medical home network shall
108 designate a principal network provider who shall be responsible
109 for maintaining an accurate list of participating providers,
110 forwarding this list to the agency and updating the list as
111 requested by the agency, and facilitating communication between
112 the agency and the participating providers.
113 (4) SERVICE CAPABILITIES.—A medical home network shall
114 provide primary care, coordinate services to control chronic
115 illnesses, provide or arrange for pharmacy services, provide or
116 arrange for outpatient diagnostic and specialty physician
117 services, and provide for or coordinate with inpatient
118 facilities and rehabilitative service providers.
119 (a) Tier One medical homes shall have the capability to:
120 1. Maintain a written copy of the mutual agreement between
121 the medical home and the patient in the patient’s medical
122 record.
123 2. Supply all medically necessary primary and preventive
124 services and provide all scheduled immunizations.
125 3. Organize clinical data in paper or electronic form using
126 a patient-centered charting system.
127 4. Maintain and update patients’ medication lists and
128 review all medications during each office visit.
129 5. Maintain a system to track diagnostic tests and provide
130 followup services regarding test results.
131 6. Maintain a system to track referrals, including self
132 referrals by members.
133 7. Supply care coordination and continuity of care through
134 proactive contact with members and encourage family
135 participation in care.
136 8. Supply education and support using various materials and
137 processes appropriate for individual patient needs.
138 (b) Tier Two medical homes shall have all of the
139 capabilities of a Tier One medical home and shall have the
140 additional capability to:
141 1. Communicate electronically.
142 2. Supply voice-to-voice telephone coverage to panel
143 members 24 hours per day, 7 days per week, to enable patients to
144 speak to a licensed health care professional who triages and
145 forwards calls, as appropriate.
146 3. Maintain an office schedule of at least 30 scheduled
147 hours per week.
148 4. Use scheduling processes to promote continuity with
149 clinicians, including providing care for walk-in, routine, and
150 urgent care visits.
151 5. Implement and document behavioral health and substance
152 abuse screening procedures and make referrals as needed.
153 6. Use data to identify and track patients’ health and
154 service use patterns.
155 7. Coordinate care and followup for patients receiving
156 services in inpatient and outpatient facilities.
157 8. Implement processes to promote access to care and member
158 communication.
159 (c) Tier Three medical homes shall have all of the
160 capabilities of Tier One and Tier Two medical homes and shall
161 have the additional capability to:
162 1. Maintain electronic medical records.
163 2. Develop a health care team that provides ongoing
164 support, oversight, and guidance for all medical care received
165 by the patient and documents contact with specialists and other
166 health care providers caring for the patient.
167 3. Supply postvisit followup care for patients.
168 4. Implement specific evidence-based clinical practice
169 guidelines for preventive and chronic care.
170 5. Implement a medication reconciliation procedure to avoid
171 interactions or duplications.
172 6. Use personalized screening, brief intervention, and
173 referral to treatment procedures for appropriate patients
174 requiring specialty treatment.
175 7. Offer at least 4 hours per week of after-hours care to
176 patients.
177 8. Use health assessment tools to identify patient needs
178 and risks.
179 (5) TASK FORCE; ADVISORY PANEL.—
180 (a) The Secretary of Health Care Administration shall
181 appoint a task force by August 1, 2009, to assist the agency in
182 the development and implementation of the medical home pilot
183 project. The task force must include, but is not limited to,
184 representatives of providers who could potentially participate
185 in a medical home network, Medicaid recipients, and existing
186 MediPass and managed care providers. Members of the task force
187 shall serve without compensation but are entitled to
188 reimbursement for per diem and travel expenses as provided in s.
189 112.061. When the statewide advisory panel created pursuant to
190 paragraph (b) has been appointed, the task force shall dissolve.
191 (b) A statewide advisory panel shall be established to
192 advise the agency on the development and implementation of the
193 medical home pilot project and to promote communication among
194 medical home networks. The panel shall consist of seven members,
195 who shall be appointed as follows:
196 1. Two members appointed by the Speaker of the House of
197 Representatives, one of whom shall be a primary care physician
198 licensed under chapter 458 or chapter 459 and one of whom shall
199 be a representative of a hospital licensed under chapter 395.
200 2. Two members appointed by the President of the Senate,
201 one of whom shall be a physician licensed under chapter 458 or
202 chapter 459 who is a board-certified specialist and one of whom
203 shall be a representative of a Florida medical school.
204 3. Two members appointed by the Governor, one of whom shall
205 be a representative of a Florida-licensed insurer or a health
206 maintenance organization and one of whom shall be a
207 representative of Medicaid consumers.
208 4. The Secretary of Health Care Administration or his or
209 her designee.
210 (c) Members of the statewide advisory panel shall serve
211 without compensation but may be reimbursed for per diem and
212 travel expenses as provided in s. 112.061.
213 (d) The agency shall provide staff support to assist the
214 panel in the performance of its duties.
215 (e) The statewide advisory panel shall establish a medical
216 advisory group consisting of physicians licensed under chapter
217 458 or chapter 459 who shall act as ambassadors to their
218 communities for the promotion of and assistance in the
219 establishment of medical home networks. Members of the medical
220 advisory group shall serve without compensation, but are
221 entitled to reimbursement for per diem and travel expenses as
222 provided in s. 112.061.
223 (6) ENROLLMENT.—Each Medipass beneficiary served by a
224 designated Tier One, Tier Two, or Tier Three medical home shall
225 be given a choice to enroll in a medical home network.
226 Enrollment shall be effective upon the agency’s receipt of a
227 participation agreement signed by the beneficiary.
228 (7) PRIORITY AREAS.—The agency may designate primary care
229 providers in any area of the state in which Medipass operates
230 and shall identify priority areas for the development of medical
231 home networks based on an analysis of emergency department use
232 and rates of hospitalization for ambulatory care-sensitive
233 conditions. In these priority areas, the agency shall conduct
234 outreach to Medicaid primary care providers to explain the
235 medical home network model and encourage participation in the
236 pilot project. At least one medical home shall be designated in
237 each priority area by October 1, 2010.
238 (8) FINANCING.—
239 (a) Subject to a specific appropriation provided for in the
240 General Appropriations Act, medical home network members shall
241 be eligible to receive an enhanced case management fee. The Tier
242 One medical homes shall receive a base fee equal to 110 percent
243 of the standard Medipass case management fee. Tier Two medical
244 homes shall receive a base fee equal to 130 percent of the
245 enhanced fee for Tier One medical homes. Tier Three medical
246 homes shall receive a base fee equal to 200 percent of the
247 enhanced fee for Tier One medical homes. The base fee for each
248 tier shall be adjusted based on the age, gender, and eligibility
249 of the enrollees.
250 (b) Services provided by a medical home network shall be
251 reimbursed based on claims filed for Medicaid fee-for-service
252 payments.
253 (c) Any hospital, as defined in s. 395.002(12),
254 participating in a medical home network and employing case
255 managers for the network shall be eligible to receive a credit
256 against the assessment imposed under s. 395.701. The credit is
257 compensation for participating in the medical home network by
258 providing case management and other medical home network
259 services.
260 1. The credit shall be prorated based on the number of
261 full-time equivalent case managers hired but shall not be less
262 than $75,000 for each full-time equivalent case manager. The
263 total credit may not exceed $450,000 for any hospital for any
264 state fiscal year.
265 2. To qualify for the credit, the hospital must employ each
266 full-time equivalent case manager for the entire hospital fiscal
267 year for which the credit is claimed.
268 3. The hospital must certify the number of full-time
269 equivalent case managers for whom it is entitled to a credit
270 using the certification process required under s. 395.701(2)(a).
271 4. The agency shall calculate the amount of the credit and
272 reduce the certified assessment for the hospital by the amount
273 of the credit.
274 (d) The enhanced payments to primary care providers shall
275 not affect the calculation of capitated rates under this
276 chapter.
277 (9) AGENCY DUTIES; RULEMAKING AUTHORITY.–
278 (a) The agency shall:
279 1. Designate primary care providers as Tier One, Tier Two,
280 or Tier Three medical homes consistent with the principles and
281 applicable service capabilities of each primary care provider as
282 provided in subsections (1) and (4).
283 2. Develop a standard form to assess the implementation of
284 the principles and service capabilities of each medical home
285 tier as provided in subsections (1) and (4) to be executed by
286 primary care providers in certifying to the agency that they
287 meet the necessary principles and service capabilities for the
288 tier in which they seek to be designated.
289 3. Base any alternative payment rates and methods that may
290 be established for medical homes on quality indicators that
291 demonstrate improved patient outcomes compared to the Medicaid
292 fee-for-service system, such as reductions in hospitalizations
293 due to preventable causes, readmission rates, or emergency
294 department use rates and efficiencies in the form of savings
295 associated with these and other quality indicators.
296 4. Develop a process for designating as Tier One, Tier Two,
297 or Tier Three medical home managed care organizations that
298 establish policies and procedures consistent with the principles
299 and corresponding service capabilities provided for in
300 subsections (1) and (4) and provide documentation that such
301 policies and procedures have been implemented.
302 5. Establish a participation agreement to be executed by
303 Medipass recipients who choose to participate in the medical
304 home pilot project.
305 6. Analyze spending for enrolled medical home network
306 patients compared to capitation rates that would have been paid
307 for these medical home patients if they had been assigned to a
308 prepaid health plan. The agency shall report the aggregated
309 results of this comparison to the Social Services Estimating
310 Conference.
311 7. Report and publish medical home network financial
312 performance on a quarterly basis. Annual assessments of spending
313 pursuant to subparagraph 6. shall be submitted to the President
314 of the Senate and the Speaker of the House of Representatives by
315 March 1, 2011, February 1, 2012, and February 1, 2013.
316 8. Report community network utilization performance. The
317 agency shall contract with the University of South Florida to
318 evaluate the use and determine any change in the use of
319 emergency departments, in-hospital care, and pharmaceuticals by
320 patients in the medical home pilot project. An initial
321 assessment of the utilization performance shall be submitted to
322 the President of the Senate and the Speaker of the House of
323 Representatives by March 1, 2011.
324 (b) The agency shall adopt any rules necessary for the
325 implementation and administration of this section.
326 (10) ACHIEVED SAVINGS.—Each medical home network that
327 achieves savings equal to or greater than the spending that
328 would have occurred if its enrollees participated in prepaid
329 health plans is eligible to receive funding based on the
330 identified savings pursuant to a specific appropriation provided
331 for in the General Appropriations Act. The savings shall be
332 distributed as a multiplier to Medicaid fees paid to primary
333 care and principal network providers during the period of the
334 earned savings. Subject to a specific appropriation, it is the
335 intent of the Legislature that the savings that result from the
336 implementation of the medical home network model be used to
337 enable Medicaid fees to physicians participating in medical home
338 networks to be equivalent to 100 percent of Medicare rates as
339 soon as possible.
340 (11) COLLABORATION WITH PRIVATE INSURERS.—To enable the
341 state to participate in federal gainsharing initiatives, the
342 agency shall collaborate with the Office of Insurance Regulation
343 to encourage Florida-licensed insurers to incorporate medical
344 home network principles in the design of their individual and
345 employment-based plans. The Department of Management Services is
346 directed to develop a medical home option in the state group
347 insurance program.
348 (12) QUALITY ASSURANCE AND ACCOUNTABILITY.—Each primary
349 care and principal network provider participating in a medical
350 home network shall maintain medical records and clinical data
351 necessary to assess the use, cost, and outcome of services
352 provided to enrollees.
353 Section 2. This act shall take effect July 1, 2010.