Delivery System Reform

The Maine Department of Health and Human Services (DHHS) and the Office of MaineCare Services (OMS) are committed to improving health care access and health outcomes for MaineCare members, demonstrating cost-effective use of resources, and creating an environment where providers can innovate and collaborate in delivering high-quality care. To ensure we continue moving toward this goal, DHHS and OMS set a goal to have at least 40 percent of MaineCare payments paid through Alternative Payment Models (APMs) by the end of 2022 [Specifically, APMs that meet the criteria for Category 2C “Pay for Performance” or higher of the HCPLAN framework].

An APM is a health care payment method that uses financial incentives to raise the quality of care, improve health outcomes, and lower costs for patients, purchasers, payers, and providers.  In concert with other strategies, APMs are key tools to advance policies that improve the quality and value of health care.

Maine is utilizing the Health Care Payment Learning & Action Network (HCPLAN) framework for assessing progress toward this goal. HCPLAN is a national organization comprised of public and private health care leaders which maintains the most commonly used framework for aligning APM design and classification. To learn more about APMs, please visit the Health Care Payment Learning & Action Network at https://hcp-lan.org/.

Example Initiatives

MaineCare’s delivery system reform initiatives include, but are not limited to:

  • Accountable Communities
  • Behavioral Health Homes
  • Certified Community Behavioral Health Clinics
  • Community Care Teams
  • MaineMOM
  • Opioid Health Homes
  • Primary Care Plus

For questions, please contact HH-BHH-Services.DHHS@maine.gov 

Performance Measures

Accountable Communities 

Quality Measures

Behavioral Health Homes 

Pay-for-Performance

In April 2018, a Pay-for-Performance (P4P) provision for Behavioral Health Home (BHH) providers was implemented, placing one percent of total BHH payments at risk pending performance on a quality measure.

The current quality measure is as follows: Of the MaineCare members assigned to the BHHO who had two or more fills of antipsychotic medication, the percentage of members who had at least one HbA1c or fasting blood glucose test. This measure was designed based upon the American Diabetes Association’s (ADA) recommendation: "Annually screen people who are prescribed atypical antipsychotic medications for prediabetes or diabetes." (Diabetes Care 2004 Feb; 27(2): 596-601. http://dx.doi.org/10.2337/diacare.27.2.596 / as amended 2010). The performance threshold for the quality measure has been set at 70%.

More information on the performance measure and P4P provisions can be found in the MaineCare Benefits Manual.

MaineMOM

MaineMOM Benchmarks 2024

Nursing Facilities
Opioid Health Homes 

Opioid Health Homes Initial Pay-for Performance Benchmark announcement:

In August 2022, MaineCare introduced a Pay-for-Performance (P4P) provision within the Opioid Health Home (OHH) model. The resulting performance measures represent core expectations of team-based, whole-person care for individuals Opioid Use Disorder (OUD).

Continuity of Pharmacotherapy for OUD – Assesses gaps in pharmacotherapy treatment of OUD. Community Engagement – Assesses member engagement in employment, volunteering, education, parenting, etc. as a recovery support. Access to Preventive and Ambulatory Care – Assesses members utilization of primary care services.

 

Available data for benchmarks demonstrates considerable variability in performance by OHH provider organizations. The Department will provide regular data reports, collaborate with OHH providers, and utilize other data sources or evidence-based materials to support quality improvement and identify and address identified health disparities.

The “minimum performance threshold” is a composite score of 27%.

When an OHH provider meets this minimum, they will receive the balance of their full OHH reimbursement (the remaining 4% of the rate). The “excellence performance threshold” is a composite score of 34%. When an OHH provider meets this threshold, they are eligible to receive a bonus payment, when funding is available. Eligible funding is dependent on how many OHHs, if any, are below the minimum performance threshold thereby releasing funds for higher performers. See MBM, Chapter III, Section 93, Opioid Health Home Services for a full description of the pay-for-performance measures and methodology, including how benchmarks are established.

This provision will be adapted over time as the Maine Department of Health and Human Services, stakeholders, and OHH providers collaboratively assess performance and identify areas of focus to improve the value of OHH services.

The initial roll-out of P4P utilizes two benchmarks (see below) which represent the composite score of the above performance measures. These baseline benchmarks are based on data from OHH providers before the new P4P provision was effective.1 OHH providers should expect to see benchmark expectations increase over time.

 

Primary Care Plus 
 

 

Value-Based Purchasing Supplemental Pool – Hospitals 

Proposed Performance Measures for Value-Based Purchasing Supplemental Pool (PDF)

Hospital Service Area Mapping (PDF)