Proposition for a new Medicaid Primary Care–Focused Healthcare Delivery System

In a recent perspective in the New England Journal of Medicine (DOI: 10.1056/nejmp1104873), Richard E. Rieselbach, M.D and Arthur L. Kellerman, MD, MPH have written a proposal for how to save the community health centers (CHCs) that treat the majority of Medicaid patients from cost-cutting actions by states that need to cut their budgets. Dr. Rieselbach is a professor emeritus of internal medicine at the University of Wisconsin School of Medicine and Public Health. Dr. Kellerman was the founding chairman of the department of Emergency Medicine at Emory University and is currently the director of RAND Health.

The authors' proposition is the creation of a new accountable care organization (ACO) called CHAMPS, for Community Health Center and Academic Medical Partnerships. CHAMPS would bring together local academic medical centers with CHCs. This would merge the primary care experience of CHCs with the medical technology, inpatient care and sub-specialist expertise of the academic centers, according to Dr. Kellermann and Dr. Rieselbach. The authors believe that health care professionals in training treat low-income Americans will provide high-quality and cost-effective care to the Medicaid population. Furthermore, they believe that is a way to train primary care providers, of which there are a shortage in the United States, and especially in areas of large Medicaid populations.

Currently 76 million Americans are treated under the Medicaid program and an additional 16 million are schedule to enter this system. To treat these patients well, the authors envision CHAMPS to utilize a specific teaching subset of CHCs called teaching health centers that are already supported by electronic medical records and other medical technology, providing primary care through a "network of patient-centered medical homes." The academic medical centers would provide the supporting specialist care, imaging, and laboratory testing. To highlight the primary care aspect of CHAMPS, residents in training will gain experience in an environment with innovative healthcare tools such as electronic records and team-based patient care.

Drs. Rieselbach and  Kellerman propose that the new Center for Medicare and Medicaid innovation provide the financial support needed to start up the new CHAMP model. This innovation is exactly intended to explore positive changes to the Medicare and Medicaid healthcare system, with the innovation center providing financial indemnification for THCs and academic medical centers to work together, perhaps even inspiring them to join a CHC/THC upon completion of their training.

The potential ways that CHAMP ACOs would facilitate cost savings, as listed by the authors, include: utilization of senior residents as primary care providers funded by Medicare, elimination of billing, administration costs for managed care via global capitation, decreased emergency room visits for conditions that can be treated in an a clinic setting, decreased hospital, readmission, laboratory and imaging costs, decreased fragmentation of care and less fragmented patient care.

The authors see regulation and not finance as the largest hurdle for their new ACO entity. As they explain, a rule of the Centers for Medicare and Medicaid Services (CMS) has recently been proposed that will prevent Medicare patients who go to a CHC for primary care from being part of an ACO, The rationale for this is that patients are treated by a team at a CHC, rather than by a specific clinician. Their proposition for circumventing this rule would be to assign each THC patient to a specific primary care resident, if the CMS rule is not changed.

The authors believe that "CHAMP ACOs would combine the best qualities of AMCs and CHCs to serve economically disadvantaged patients who have a high incidence of chronic conditions." If the Medicare Payment Advisory Commission allocates a portion of their spending to focus on physician training that would bolster the US healthcare delivery system, CHAMP creation would also greatly facilitate THC-based training. "If savings and improved quality are realized, CHAMPs could strengthen our country’s Medicaid safety net, pioneer new approaches to health care delivery, and build a well-trained and highly motivated primary care workforce for the future".