The New Mexico Primary Care Payment Reform Initiative, a mandatory program led by the New Mexico Health Care Authority, marks a significant shift in the state’s Medicaid approach, as it transitions from a volume-based to a value-based payment model.
This change is geared towards enhancing the efficiency and quality of health care delivery and introduces new payment structures that will reward patient outcomes and cost-effectiveness.
A crucial element of this reform program is the quality measurement framework, designed to ensure high standards of care are maintained by Medicaid providers in the state. This framework includes specific metrics for assessing patient care, focusing on effectiveness, satisfaction, and outcomes.
Beginning July 1, 2024, all primary care providers participating in New Mexico’s Medicaid program will be enrolled in the soft launch of the program, which will offer enhanced fee-for-service payments and incentive payments.
The full three-tiered program will launch on January 1, 2026, offering the ability to participate in a full capitation arrangement with potential downside risk. Each subsequent tier will be tied to increased quality reporting requirements and higher performance standards.
Tier One: Enhanced Reimbursement and Quality Rewards
Tier one begins on July 1, 2024.
This program introduces two new funding sources, including enhanced fee-for-service tied to provision of services and incentive payments for quality metrics, data submission, and continuation of current services.
Tier Two: Collaborative Partnerships
Tier two begins on January 1, 2026.
This will serve as an entry point into capitation, with the provider and managed care organizations (MCOs) establishing a capitation arrangement that’s ideal for the provider, for example, care management per member per month (PMPM) payments or direct service payments on a PMPM basis.
Tier Three: Capitation with Shared Savings
Tier three begins on January 1, 2026.
Tier three includes a full capitation arrangement with the integration of more services, such as bundled payments or shared savings, where the provider may have more upside and downside risk.
With the initial launch of the program in 2024, primary care providers will continue to deliver care as they currently are, with the quality framework focusing on reporting, access to care, and patient-centered metrics. Most proposed metrics will align with Turquoise Care, the state’s managed Medicaid program.
Over the first 18 months of the program, providers will be considered successful if they can maintain their historical level of performance for the following measures.
The reporting standards are deemed as follows:
- Encounter acceptance rate: The percentage of claims and encounters accepted by the MCO’s claims adjudication system
- Encounter completion rate: The percentage of practice-reported volume captured by accepted encounter and claim submissions
The following quality metrics will be introduced in 2024.
Access to Care: Third Next Available Appointment
This measures the average length of time in days between the day a patient requests an appointment and the third available appointment for a new patient physical, routine exam, or return visit exam. This metric will be self-reported quarterly.
Initiation and Engagement of Alcohol and Other Substance Use Treatment (IET)
- Initiation phase: This measure will evaluate the percent of members 13 years of age or older who initiate treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or medication for addiction treatment (MAT) within 14 days of diagnosis
- Engagement phase: The percent of members 13 years of age or older who initiated treatment and had two or more additional services within 34 days of the initiation visit
Consumer Assessment of Health Care Providers and Systems (CAHPS) Survey
Select items from this tool will be utilized to measure patients’ experiences with their providers, focusing on access to care and satisfaction with their provider, for both adults and children.
Beginning January 1, 2026, the following additional quality metrics will be introduced:
- Breast cancer screening
- Cervical cancer screening
- Prenatal and postpartum care
- Lead screening in children
- Follow-up after emergency room (ER) visit for substance abuse
- Follow-up after ER visit for mental illness
Additional measures starting in 2027 will include statin therapy for cardiovascular disease and child and adolescent well-care visits.
Measures beginning in 2028 include:
- Controlling high blood pressure
- Comprehensive diabetes care
- Immunizations for adolescents
Reimbursement will continue to be tied to the first set of metrics introduced in July 2024 until the introduction of new quality metrics in 2027. At this time, reimbursement will expand to include all metrics.
Providers will work directly with MCOs and data intermediaries to establish arrangements for data collection and reporting. All metrics will be standardized across MCOs, which will allow for identical reporting structures to alleviate provider burden.
Providers can find more information about upcoming webinars and in-person training events on the Primary Care Council website.
We’re Here to Help
Many primary care providers in New Mexico will be impacted by this reform initiative, given the significant volume of Medicaid patients served in their practices.
To learn more about the program as requirements are released, contact your Moss Adams professional. Our team can provide guidance on operational planning, quality data reporting, and performance improvement, to help providers thrive under the new payment model.