New rules designed to better manage Maryland’s Medicare costs

The Maryland Primary Care Program is part of the Maryland Total Cost of Care Model that has been agreed to by the state of Maryland and the Centers for Medicare and Medicaid Services. The MDPCP is aimed at reducing overall spending for traditional Medicare beneficiaries in Maryland by offering care coordination to keep patients healthier and out of the hospital.

Basically, primary care providers and their affiliated Care Transformation Organizations (CTOs) are paid additional amounts by Medicare to manage the care of Medicare patients, and they can earn even additional payments from Medicare if that management is successful.  These payments are called Care Management Fees (CMFs) and  Performance Based Incentive Payments (PBIPs).

In 2022, it is estimated that the MDPCP reached over four million Maryland patients via 545 sites and over 2,000 providers.

As the MDPCP pilot continues, the Maryland Department of Health announced changes to the program that went into effect in 2023.

When the MDPCP began in 2019, participating practices chose either Track 1 (Standard Track) or Track 2 (Advanced Track). Both tracks require practices to provide comprehensive primary care functions to patients, but at different levels. As a result, the practices offering more complex care management services received generally higher payouts from the MDPCP.

The underlying payment model also changes between the two tracks. In Track 1, primary care programs continue to be paid under the traditional Medicare Fee for Service (FFS) model. However, Track 2 uses a hybrid model that shifts payments away from FFS and into Comprehensive Primary Care Payments (CPCPs), paid in advance on a quarterly basis. The amount of the practices’ payments made via CPCPs increases over time.

In January of 2023, CMS opened Track 3, allowing providers time to transition to Track 2 or 3 before CMS closes Track 1 at the end of 2023.

Track 3 increases the total cost of care accountability of participating primary care practices by introducing upside and downside risk based on practice performance on cost and quality metrics.

Unlike the earlier tracks, Track 3 does not include a CMF, a PBIP, or a CPCP. Instead, Track Three participants will receive a Total Primary Care Payment (TPCP).

The TPCP consists of two parts: (1) a Population-Based Payment that pays a portion of fee-for-service prospectively; and (2) a Flat Visit Fee at the time of service for certain primary care services.

Track 3 also introduces risk through a positive or negative Performance Based Adjustment based on measures of quality, utilization and total cost of care.

Track 3 participants can also receive a Health Equity Advancement and Resource Transformation payment for practices to identify health-related social needs for high-cost and socioeconomically disadvantaged Medicare beneficiaries, and to address complex needs while improving health outcomes.

Barry F. Rosen is the chairman & CEO of the law firm of Gordon Feinblatt LLC, heads the firm’s health care practice group, and can be reached at 410-576-4224 or [email protected] Alexandria K. Montanio is counsel in Gordon Feinblatt’s health care practice group and Gordon Feinblatt’s director of corporate social responsibility and can be reached at 410-576-4278 or [email protected]