DSS advisory group debates fee-for-service, PMPM and shared‑risk options for Medicaid primary care

The Department of Social Services convened an advisory group on April 4 to review Phase 2 work and to solicit feedback on a proposed Medicaid primary‑care payment model that blends fee‑for‑service (FFS), per‑member‑per‑month (PMPM) payments and quality‑based incentives.

Presenter (S2) told the group the meeting’s purpose was to “play back what we've heard with a, you know, a semi concrete, structure” for how an alternative payment model might work and to gather feedback. The proposal presented a high‑level framework with multiple tracks for providers and a set of cross‑cutting design elements, including member attribution, social and clinical risk adjustment, and a quality‑performance slate.

Debate centered on how much of the base payment should remain FFS versus be shifted to PMPM or partial capitation. A range of views emerged: some participants urged keeping FFS as the foundation and adding PMPM as targeted care‑coordination funding; others supported partial capitation for predictability and to enable investments in care transformation. As one participant summarized, the group heard “a diverse group of opinion about, like, the benefits and downside” of moving away from FFS.

Participants repeatedly raised concerns about placing global financial risk on primary‑care practices. A hospital‑affiliated speaker said the committee should avoid treating primary care as fully accountable for total cost of care because hospitals, specialists and community partners also drive many high‑cost events. In response, presenters emphasized that the slide deck represented a straw proposal and that the final design could include tiers, glide paths and regional accountability approaches to limit risk for smaller practices.

Speakers urged stronger investment in community health workers (CHWs) and flexible funds to address health‑related social needs (HRSN). Alice (S13) said the discussion lacked “flex funds,” a flexible cash assistance model used by DCF, and cautioned that the meeting’s use of “flexible funds” as a provider PMPM differed from the cash‑assistance definition she advocated. Presenter (S1) acknowledged that a flexible‑funds component appears in the materials and said details will be shared soon.

On data and measurement, Presenter (S2) said DSS recently “applied for and got a $2,100,000 grant from Arnold Ventures to ramp up our analytics team,” a one‑time award to fund Yale‑led analytics capacity for testing interventions and measuring what works. Several panelists recommended focusing early on a small set of measurable outcomes that align across payers.

The group also discussed practical implementation details: how to define a base payment, what services would be carved into PMPM versus retained as FFS, benchmarking for any shared‑savings calculations, and how to adjust benchmarks if Medicaid rates change during the program. Multiple participants urged keeping the base FFS simple and explicit so providers understand what is being paid for and are held accountable for any additional responsibilities attached to payments.

Presenters proposed forming a technical‑design subcommittee to meet monthly to resolve detailed issues (financial modeling, quality measures, benchmarking) and to report quarterly to the full advisory group. The subcommittee will develop options for tracks and tiers, clarify the flexible‑funds definition, model potential PMPM amounts, and assess implementation timelines and federal (CMS) approval pathways.

The advisory group did not take formal votes. Organizers said the next steps include refining the straw design with stakeholder input, clarifying budget implications for summer/fall budget cycles, and standing up the technical subcommittee to produce more detailed proposals.