Maryland’s Total Cost of Care Model

New Amendment to Total Cost of Care Agreement and Memorandum of Understanding Signed 

Amendment increases flexibility for providers, availability of Medicare data at point of care
The Health Services Cost Review Commission (HSCRC) and the Maryland Department of Health (MDH) have worked diligently with the Centers for Medicare and Medicaid Services (CMS) and the Centers for Medicare and Medicaid Innovation (CMMI) to develop additional deliverables for the Total Cost of Care Model and recently signed an amendment formalizing their addition to the agreement. Maryland’s original Total Cost of Care Agreement was signed by Governor Hogan, the MDH Secretary (Robert Neall), and the HSCRC Chairman (Nelson Sabatini) on July 9, 2018. Since then, HSCRC, MDH, and CMMI have worked collaboratively to identify additional deliverables that will increase the likelihood of Maryland’s success in the Total Cost of Care Model. These new deliverables are intended to increase flexibility for Maryland providers and increase the availability of Medicare data at the point of care. The amendment can be found here.​​
Amendment Deliverable #1 – CMS will allow Maryland Nurse Practitioners to Issue Home Health Orders Medicare requires that a physician certify if a beneficiary needs home health services and establishes a plan of care as a condition of payment for home health care. Patients who lack access to a primary care physician must be under the care of a facility-based physician in order to receive home health services. This may result in higher costs and unnecessary facility utilization before patients receive home health services. Nurse practitioners can independently practice medicine in Maryland and can oversee care for patients who do not have a primary care physician. CMMI has approved Maryland’s Medicare waiver request to allow Nurse Practitioners located in Maryland to issue orders to Home Health Agencies operating in Maryland.   A second amendment on this provision can be found here.

Amendment Deliverable #2 – CMS will allow additional Medicare data to be displayed in CRISP CMS has approved the State's request to allow Medicare fee-for-service data to be shared at the point of care through the CRISP system (the State’s designated health information exchange). This information will be important to enable hospitals and non-hospital providers to coordinate care and reduce the likelihood of redundant healthcare services across disparate providers. The HSCRC, MDH, CMMI, and CMS will continue to work with stakeholders to identify additional opportunities to support Maryland providers and promote the success of the Model. 

Memorandum of Understanding Signed to Support a Statewide Strategy to Address Population Health

The HSCRC, MDH, CMS, and CMMI recently signed a Memorandum of Understanding to support the implementation of a statewide strategy to address key health priorities, also referred to as the Statewide Integrated Health Improvement Strategy.  HSCRC and MDH have worked collaboratively to identify opportunities provided by the Total Cost of Care Model to not only lower costs but also to improve population health across the State.  The Model encourages the development of programs and provides financial credit for improvement on key health priorities.  HSCRC and MDH have begun to identify key health priorities including diabetes and opioid use that are well suited for a statewide approach that mobilizes and integrates public and private resources to reduce the impact these conditions have on Marylanders. The Memorandum of Understanding can be found here.  ​

​TCOC Model Overview​

Improving Marylanders’ Health and Quality of Life

The State of Maryland is committed to ensuring that all Marylanders have access to the nation’s best health care and that our critical health needs are met.  Our priorities:

       Ensure that all Marylanders have access to quality health care by the nation’s best health care providers in every corner of the state – whether rural or urban.

       Address the needs of our senior population, which is expected to increase by 40% over the next ten years.

       Fight the opioid epidemic and other population health improvements such as diabetes prevention and other chronic conditions.

Addressing Health System Limitations

Maryland’s current approach to hospital payment is known as the “Maryland All-Payer Medicare Model Contract,” and runs from January 1, 2014 through December 31, 2018.  The All-Payer Model’s success metrics are based on enhancing quality, improving health outcomes, and constraining the growth of Medicare costs for hospital inpatient and outpatient services. 

Since 2014, Maryland’s hospitals have successfully reduced unnecessary readmissions and hospital-acquired conditions, while decreasing the growth in hospital cost per capita.  However, the current approach focused on hospitals does not sufficiently provide for comprehensive coordination across the entire health care system.  Because of this limitation, the federal government required Maryland to develop a new model that encompasses all of the health care that patients receive, both inside the hospital and the community.  The Progression Plan served as the blueprint for this Model development, known as the “Total Cost of Care Model”.  On July 9, 2018, Maryland and the federal government signed the Total Cost of Care Model State Agreement, which will be effective January 1, 2019.

​​Key Elements of the Total Cost of Care Model
To achieve a patient-centered system, the Total Cost of Care Model includes the following key elements:

    Care will be coordinated across both hospital and non-hospital settings, including mental health and long term care.


    The Model will invest resources in patient-centered care teams and primary care enhancements. 


    Maryland will set a range of quality and care improvement goals.  Providers will be paid more when patient outcomes are better.


    Maryland will set a range of population health goals addressing opioid use and deaths, diabetes, and other chronic conditions.


    State flexibility will facilitate programs centered on the unique needs of Marylanders, the provider community, geographic settings, and other key demographics.  


As part of the federal agreement to put the new Total Cost of Care Model in place, all-payer hospital cost growth will continue to be limited to 3.58% per capita, a limit that was set in 2014 based on long term growth in Maryland’s economy.  As part of this Model, Maryland commits to saving $300 million in annual, total Medicare spending by the end of 2023. The Medicare savings required in the TCOC All-Payer Model will build off of the ongoing work of Maryland stakeholders, which began in 2014. 

Next Steps and Opportunities for Engagement

The State of ​Maryland remains committed to a robust process for input and feedback during the implementation of the TCOC Model.  Maryland stakeholders will continue to provide feedback through participation in workgroups, councils, and provider-led innovation groups. 


  Additional information is available in the following resources and the list of documents below:


    A brief background and summary​ of the Total Cost of Care Model with key requirements;

    Announced Terms of the TCOC Model; ​ 

    Stakeholder engagement through HSCRC and MDH workgroups​; ​ 

    All-Payer Model Performance, through 2018 Year-to-Date Results​​​​; and 

    Maryland Primary Care Program​

For additional information or to seek clarification on the Total Cost of Care Model, please send an email to the HSCRC staff at hscrc.all-payermodel@maryland.gov​.​​​​​​​​​​

 Key Documents