Form CMS-10436 Protocol - Payers

MULTI-PAYER ADVANCED PRIMARY CARE PRACTICE DEMONSTRATION
EVALUATION
INTERVIEW PROTOCOL
Payers

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Introduction
Thank you for making time to speak with us today. As we mentioned in our email to [name of
our contact in their practice / clinic / hospital], we are researchers from RTI, the Urban Institute,
and the National Academy for State Health Policy (NASHP), evaluating the Multi-Payer
Advanced Primary Care Practice (MAPCP) Demonstration. We’d like to focus on learning
about the period after Medicare joined the state’s initiative and your thoughts on the future.
Since we’re asking about a number of different periods of time, we have created a visual timeline
and logic model to differentiate each time period [show the respondent the state’s timeline and
logic model].
We are also particularly interested in the impact of the initiative on Medicare and Medicaid
beneficiaries generally and special populations (such as those dually eligible for Medicare and
Medicaid) specifically. We understand that some changes are system wide and may not affect
these groups differently, but other changes that payers or practices make may be tailored to these
groups to some degree and have different impacts on these patient populations.
We’d like your candid views about this initiative. We want to assure you that we will not quote
you by name without getting back in touch with you to get your permission first. We would like
to record our conversation, to ensure our notes from today are complete. Is this OK with you?
Do you have any questions before we start the interview?
Background
[Try to obtain as much of this information as possible through Googling, and/or our initial
phone call to schedule the interview.]
1. [Before Visit] What is your role at [name of payer]?
2. [Before Visit] How long have you been with [name of payer]?
a. [Before Visit] Have you been involved in [name of state]’s [state-specific name of PCMH
initiative] since Medicare joined the initiative in [2011/2012]?
3. We understand that [name of payer] joined [name of state]’s [state-specific name of PCMH
initiative] in [month/year].
a. What motivated [name of payer] to join this multi-payer initiative?
4. How would you describe the goals of [name of state]’s [state-specific name of PCMH
initiative]?
a. Did those goals change after Medicare [and Medicaid (if joined at the same time)] joined
the initiative in [2011/2012]? If so, how?
b. What are [name of payer]’s goals for participating in the initiative?

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i.

How are these goals similar or different from the goals of [name of state]’s [statespecific name of PCMH initiative]?

5. What risks does participation in [name of state]’s [state-specific name of PCMH initiative]
bring to [name of payer], if any?
a. What are your plans for mitigating those risks?
6. [Before Visit] Has [name of payer] participated in similar medical home initiatives in other
states?
a. [If so:] How has [name of payer]’s participation in these other states’ initiatives shaped
what [name of payer] is doing as part of [name of state]’s [state-specific name of PCMH
initiative]?
b. [If not:] Why not?
Medical Home Program Features
7. Before [2011/2012]—when Medicare [and Medicaid (if joined at the same time)] became
involved--what major changes did [name of payer] make as a result of its involvement in
[name of state]’s [state-specific name of PCMH initiative]?
8. Did Medicare [and Medicaid (if joined at the same time)]’s entrance into [name of state]’s
[state-specific name of PCMH initiative] affect any aspect of [name of payer]’s participation?
If so, how?
9. From [name of payer]’s perspective, what are the benefits and drawbacks of Medicare [and
Medicaid (if joined at the same time)] now being involved in [name of state]’s [state-specific
name of PCMH initiative]?
10. What additional changes did [name of payer] have to make now that Medicare [and
Medicaid (if joined at the same time)] is involved, if any?
Payment
11. [Before Visit] How do you compensate practices for your insured patients participating in the
[state-specific name of PCMH initiative]? Please describe your payment model.
a. Are there other payment mechanisms [name of payer] uses to incentivize medical home
development and practice performance?
12. Were there any other major changes related to provider payment and medical homes that
[name of payer] tried to make prior to [2011/2012]–when Medicare [and Medicaid (if joined
at the same time)] became involved in this initiative--but was unable to implement?
a. [If so:] Please briefly describe.
b. [If not:] Why not?
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13. What has been your experience so far in implementing the practice payment model for the
[state-specific name of PCMH initiative]?
a. What has worked well?
b. What hasn’t worked so well?
c. How did you resolve any challenges?
14. How important is it to [payer] that all the participating payers make equal contributions to the
initiative, in terms of payments, resources, etc.?
15. [Optional] What are the strengths and weaknesses of the payment approach being used in
[name of state]’s [state-specific name of PCMH initiative] today?
a. Are practices responding to non-financial incentives, such as improving their reputation
with other provider groups or preparing to participate in an ACO?
Practice Transformation
[Note to interviewer: try to ask about (1) the time it took to implement any practices changes
discussed; and (2) the cost of implementing or sustaining any practices changes discussed]
16. We understand your state uses [name of the state’s medical home assessment or recognition
tool]. What role did [payer] have in selecting or developing that tool?
a. To what extent do you feel the tool selected accurately assesses primary care practices
medical home capabilities?
b. Do you receive this medical home assessment or recognition information?
i.

[If yes] How do you use it? For example, do you use it to determine practice
payment levels or to guide learning collaborative activities?

17. In your opinion, were the [state-specific name of PCMH initiative] payments paid to
practices for the past [number of years the multi-payer medical home initiative has been
operating prior to Medicare’s (and Medicaid’s, if applicable) entrance] years before
[2011/2012]—when Medicare [and Medicaid (if joined at the same time)] joined the
initiative—enough for practices to fully implement the medical home infrastructure? Why or
why not?
a. Now that Medicare [and Medicaid (if joined at the same time)] has joined the [statespecific name of PCMH initiative], does this additional reimbursement now provide
enough resources to practices for them to further develop and maintain their medical
home infrastructure?

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18. [Before Visit] Do these new [state-specific name of PCMH initiative] payments to
practices—implemented in [2011/2012]—increase or decrease the number of participating
practices, and in turn, patients served? Why or why not?
19. How do practices participating in [state-specific name of PCMH initiative] use the medical
home payments they receive from [payer] and other participating payers? For example, do
they use it to hire new staff, expand office hours, or purchase or upgrade health IT?
a. Are any of these medical home services they provide targeted to Medicare and/or
Medicaid beneficiaries or special populations of patients? Special populations can
include: Medicare and Medicaid dual eligibles; children; racial and ethnic subgroups;
people living in rural or inner-city areas; and persons with chronic illnesses, mental
illnesses, and disabilities.
20. In your opinion, do the [state-specific name of PCMH initiative] payments that have been in
place (since CMS joined the initiative in [2011/2012]) incentivize improvements in clinical
processes and patient outcomes (i.e., promote efficient service utilization, care quality
improvements, patient experience and satisfaction, care transitions and coordination)?
a. [Optional] Why or why not?
b. [Optional] Are there any differences for Medicare beneficiaries, Medicaid beneficiaries,
and special populations?
21. What activities has your [plan / organization] undertaken to support participating practices or
the [state-specific name of PCMH initiative] in general? For example, have you solicited
member input on the medical home model or provided information to members on their
medical home?, Have you provided more timely or user-friendly data? Care coordination or
disease management support? Support for learning collaboratives? Practice coaches or
consultants?
a. Which of these activities have been most helpful to participating practices?
b. Have you reached out to or undertaken any activities with consumers and [beneficiaries /
plan members] served by participating practices? If so, please describe. If not, why not?
22. What activities has your [plan/organization] undertaken to support community health
networks/teams or other community resources or linkages between primary care practices
and these networks/teams or other community resources? For example, do you work directly
with state and local social service agencies such as housing departments, office of aging, or
transportation services for the disabled?
a. How do encourage and help support primary care practices’ efforts to create linkages to
and work with these community health networks/teams or other community resources?

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23. Since the state initiative began, how successful has the [state-specific name of PCMH
initiative] been in getting practices to change the way they deliver care, particularly
improving access, care coordination and transitions, and making linkages with community
health resources?
a. What impact is Medicare’s participation having, or what additional impact do you
anticipate?
Health Information Technology
24. What state and/or federal health IT-focused projects or programs does [payer] participate in?
(e.g., Health Information Exchange grants to the state, Beacon communities)
25. What has [payer] done to support [medical home / health care home] practices in health IT
implementation or upgrade? For example, does the [payer] have any financial incentive for
practices to implement or upgrade their electronic health record (EHR) and/or electronically
exchange data with the plan and other providers?
26. To what extent are EHR requirements and quality measures used by [state-specific name of
PCMH initiative] aligned with the Medicare and Medicaid Meaningful Use (MU) measures?
For example, have stage 1 MU requirements to collect demographic information, provide online access to patients, or report particular clinical quality measures been incorporated into
the medical home assessment or recognition criteria?
Outcomes
[Note to interviewer: (1) Try to ask respondents to identify medical home features that
contributed to the observed impacts, or features that could be added to the initiative to improve
outcomes. (2) More specific examples of impacts to care might be discussed during the
interview. For example, referrals to community resources and specialists are examples of care
coordination. Other more specific examples that may be discussed in this section are: timeliness
and continuity of care, coordination with specialists (physician and mental health), medication
reconciliation, discussion of current and potential changes to a patient’s drug regimen, shared
decision-making, patient self-management, provision of information such as test results to
patients in a way that is easy to understand, health literacy, discussion of patient medical history,
proactive care (e.g. generating lists of patients who need to come in for an office visit), and
active reminders about tests, treatment, and/or appointments.]
27. Since the initiative began in [year that the state initiative began], what impacts has the [statespecific name of PCMH initiative] had on [payer]’s [beneficiaries / plan members]?
a. Is there evidence of improvements in:
i.

Access to care?

ii.

Coordination of care? (e.g., care transitions)

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iii.

Patient and family participation or behavior? (e.g., patients engaging more in
decisions and managing their care)

iv.

Increased delivery of preventive services? (e.g., cancer screenings, smoking
cessation, weight management, influenza vaccination)

v.

Reduced use of acute care? (e.g., emergency department visits, hospitalizations,
readmissions)

vi.

Improved health care quality or patient safety?

vii.

Patient experience and/or satisfaction?

b. To what extent do you see similarities or differences in impact on Medicare, Medicaid,
and special populations, versus the privately or commercially insured?
i.

Other?

Performance Reports and Feedback
28. Do you collect any quality or safety data from the practices participating in [name of state]’s
[state-specific name of PCMH initiative]?
[If not:]
a. Why not?
[If yes:]
b. What data do you collect?
i.

Do you collect any preventive service use data? If so, which ones? For
example, cancer screening, smoking cessation, weight management, influenza
vaccination, or pneumonia vaccination?

ii.

Do you collect any safety data or in other ways support patient safety activities
and measurement? For example, do you measure and monitor follow-up after
hospital discharge or medication reconciliation?

iii.

How aligned is your plan and states’ clinical quality measure and other reporting
requirements aligned with those required for other CMS programs?

c. What do you do with the data you collect?
d. What structures have been put in place to ensure the accuracy of practices' data?

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29. Does [name of organization] provide data to participating practices on their performance
(e.g., quality of care your patients are receiving, costs your patients are generating, or their
utilization of health care services)? (For example, statistics on their patients’ hospital or
nursing home admissions or readmissions)?
[If not:]
a. Why not?
[If yes:]
a. What performance data do you provide?
i.

Which of these data did you report prior to [2011/2012]—before Medicare joined
the [state-specific name of PCMH initiative]?

ii.

Which of these data (if any) did you begin reporting after [2011/2012]--when
Medicare [and Medicaid (if joined at the same time)] joined the [state-specific
name of PCMH initiative]?

b. How often do you provide these data to participating practices?
c. How are the data reported (e.g., via website, reports)?
d. How do you expect the practices to use these data? In reality, do they use the data and, if
so, how do they use it (e.g., for quality improvement purposes)?
e. Are there any special issues or challenges to the plan or practices reaching Medicare or
Medicaid beneficiaries or special populations? Please describe briefly.
Beneficiary Experience with Care
30. [Before Visit] [Optional] Have you conducted, or do you plan on conducting, a patient
experience survey among your [members / beneficiaries]? We are particularly interested in
any survey that may more specifically assess aspects of the medical home, such C-G CAHPS
or the newly developed PCMH CAHPS.
Wrap-up
31. [Before Visit] Is [payer] conducting data analyses or evaluations, independent of any
analyses or evaluations being conducted by the state or CMS? Why or why not?
a. What outcomes does [name of payer] need to see for it to be willing to extend or expand
its participation in the [state-specific name of PCMH initiative]?
i.

How long will it wait for these outcomes to be observed before it will make a
decision about whether to continue or terminate its participation in the [statespecific name of PCMH initiative]?

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b. Do you believe the [state initiative] is generating savings for [name of payer]?
i.

[If so:] For what types of services are you seeing cost savings?

ii.

[If not:] Why not?

32. What opportunities do you foresee in the near future through [name of payer]’s participation
in the [state-specific name of PCMH initiative]?
a. [Optional] What challenges do you anticipate?
33. What lessons has [name of payer] learned so far from the experience of this initiative—either
since it began, or since Medicare joined?
a. What would [name of payer] have done differently, knowing what it knows now?
b. [Optional] [If needed:] Are there any aspects of the [state-specific name of PCMH
initiative] that your organization or the state is considering changing?
34. What would be your advice to CMS and the state if [name of state]’s [state-specific name of
PCMH initiative] was extended or expanded to another state?
35. In the next year, what are the key implementation issues you’ll face related to the [statespecific name of PCMH initiative]?
36. [Optional] In the next year, what are the key developments (outside of the [state-specific
name of PCMH initiative]’s control) that might affect the implementation of this initiative?
(For example, implementation of health reform generally, tight state budgets, other health
care market developments?
37. Is there anything else about [name of state]’s [state-specific name of PCMH initiative] and its
impact on [name of payer], your primary care provider network, or [beneficiaries / plan
members] that we haven’t covered that would be important for our team to know?

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