Primary Care Alternative Payment Models
The act requires the division of insurance (division) to collaborate with the department of health care policy and financing, the department of personnel, the department of public health and environment, and the primary care payment reform collaborative (collaborative) to develop and promulgate rules for alternative payment model parameters for primary care services offered through health benefit plans.
The alternative payment model parameters must:
- Include transparent risk adjustment parameters that ensure that primary care providers are not penalized for or disincentivized from accepting vulnerable, high-risk patients and are rewarded for caring for patients with more severe or complex health conditions and patients who have inadequate access to affordable housing, healthy food, or other social determinants of health;
- Utilize patient attribution methodologies that are transparent and reattribute patients on a regular basis, which must ensure that population-based payments are made to a patient's primary care provider rather than other providers who may only offer sporadic primary care services to the patient and include a process for correcting misattribution that minimizes the administrative burden on providers and patients;
- Include a set of core competencies around whole-person care delivery that primary care providers should incorporate in practice transformation efforts to take full advantage of various types of alternative payment models; and
- Require an aligned quality measure set that considers the quality measures and the types of quality reporting that carriers and providers are engaging in under current state and federal law and includes quality measures that are patient-centered and patient-informed and address: Pediatric, perinatal, and other critical populations; the prevention, treatment, and management of chronic diseases; and the screening for and treatment of behavioral health conditions.
For health-care plans that are issued or renewed on or after January 1, 2025, each carrier must ensure that the carrier's alternative payment models for primary care incorporate the aligned alternative payment model parameters created by the division.
By December 1, 2023, the commissioner of insurance must promulgate rules detailing the requirements for alternative payment model parameters alignment. The division shall allow carriers the flexibility to determine which network providers and products are best suited to achieve the goals and incentives set by the division.
Once the division has 5 years of data, the division is required to analyze the data, produce a report on the data, and present the findings to the general assembly during the department of regulatory agencies' presentation to legislative committees at hearings held pursuant to the "SMART Act".
To assist carriers with implementing primary care alternative payment models, the division is required to retain a third-party contractor to design an evaluation plan for such implementation and retain a third-party contractor to provide technical assistance to carriers.
With regard to the collaborative, the act:
- Requires the collaborative to annually review the alternative payment models developed by the division and provide the division with recommendations on the models; and
- Adjusts the date on which the collaborative must deliver its annual reports.
With regard to the all-payer health claims database, the act:
- Requires the administrator to include in the annual primary care spending report data related to the aligned quality measure set determined by the division; and
- Adjusts the date on which the annual reports are due.
For the 2022-23 state fiscal year, $56,328 is appropriated to the department of personnel from the general fund for use by the division of human resources to implement the act.
(Note: This summary applies to this bill as enacted.)