Leadership in Patient-Centered Medical Homes

Local Blue innovation to inform the transformation of care delivery nationwide
The Blues are working in collaboration with national and local industry stakeholders to enhance the practice and delivery of primary care. The Patient-Centered Medical Home (PCMH) places the patient and primary care practice at the center of care, creating a partnership between the patient and their personal physician. The goal of the PCMH is to provide comprehensive and coordinated care delivery by a primary care team focused on continuous care across all aspects of the healthcare system. Among the first organizations to further the PCMH model with the Patient-Centered Primary Care Collaborative (PCPCC), the Blues® have also been working closely with major primary care societies, patient advocacy groups and employers. To date, Blue Cross and Blue Shield (BCBS) companies have PCMH initiatives underway in 39 states, the District of Columbia, and Puerto Rico, with the goals of transforming primary care and improved patient outcomes. Already, more than 4 million Blue members have access to a PCMH.


The Blue System’s scale, local presence and longstanding relationships with physicians throughout the United States provide an ideal structure for identifying and implementing new innovations in the delivery of patient care. The practice of medicine happens at the local level, and the Blues are well-suited to lead, covering nearly 100 million people in the U.S. and having 90 percent of the nation’s hospitals and 80 percent of physicians within Blue networks. The Blues are actively pursuing a variety of approaches to help improve the quality and value of care, since an issue of this magnitude cannot be addressed with any single solution. While differences within local markets and the pursuit of innovative solutions creates a degree of variability across Blue PCMH models, this document focuses on trends that have been identified across models and early, yet promising, results with potential for adoption across other markets.

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PCMH Providers and Disease Focus
Currently, the majority of Blue PCMH models are single-payer, with a focus on primary care practices and patients with multiple chronic conditions. In addition, more than half of Blue models require that participating provider groups achieve nationally-recognized PCMH recognition or accreditation. More than half of the Blue models are disease-specific, focusing on select chronic conditions. Critical areas of focus for most Blue models are Diabetes, Asthma and Heart Disease (including Coronary Artery Disease, Hypertension and Congestive Heart Failure). Diabetes is the only disease addressed in some way within all Blue PCHM models.

Payment Methodology and Incentives
The Blue reimbursement and incentive structures for the medical home concept are aligned to support practice transformation, clinical process/outcomes, resource utilization/cost of care and satisfaction. The majority of Blue PCMH models utilizes a hybrid approach to establishing payment models, with most models using a fee-for-service base payment. Prospective payments are provided to support practice transformation initiatives such as process redesign, care coordination and adoption of health information technology. A bonus payment for performance is also provided to practices achieving improved clinical processes, outcomes, satisfaction and cost metrics. In conjunction with monetary incentives, Blue Plans are also supporting practice transformation in the following ways: • Critical infrastructure and technology such as electronic health records (EHR), clinical support decision tools and patient registries. • Best practice sharing to communicate and conduct evidence-based practice in the clinical setting. • In-depth education and motivational interviewing. • Actionable reports to providers. • Practice transformation coaching.

Performance Measurement
To date, the majority of Blue PCMH models track disease-specific, preventive or utilization measurements, with more than half utilizing a pay-for-outcomes component if specific quality and cost targets are achieved. Providers receive incentives for achieving performance targets for process, outcome and utilization measures. • Disease-specific quality metrics include both process measures (e.g., HgbA1c test conducted) and outcome measures (e.g., HgbA1c control), and may vary depending on the disease focus of the PCMH model. • Preventive measures such as immunization rates and BMI measurement are included to help ensure patients receive appropriate preventive care in an effort to achieve improvements in long-term overall health. • Models may also include metrics to gauge impact on utilization across the care continuum and the impact on total cost. Measures may include prescription fill rates, inpatient days, emergency room visits and lab services costs.

Quantifiable Results
Early indications demonstrate that Blue PCMH models have the ability to contribute to improvements in both quality of care and cost reduction. Multiple Blue Plans have identified quantifiable results related to quality improvement and outcomes, as demonstrated by the following.

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Examples of Blue PCMH models with demonstrated results include:
Blue Cross and Blue Shield of Michigan (BCBSM) Patient-Centered Medical Home – Physician Group Incentive Program (PGIP)
This initiative involves criteria that measure and incent a robust set of activites that collectively encourage patient engagement and a strong patient-physician relationship and supports coordination and efficiency across physicians. One principle of BCBSM’s PCMH is to ensure that patients have enhanced access to care with their primary care physician, which helps encourage care delivery in the appropriate setting. BCBSM has 12 essential components that practices need to meet in order to be recognized as a PCMH: Patient-Provider Partnership, Patient Registry, Performance Reporting, Individual Care Management, Extended Access, Test Results Tracking, Preventive Services, Linkage to Community Services, Self-Management Support, Patient Web Portal, Coordination of Care and a Specialist Referral Process. Once the PCMH designation is achieved, enhanced reimbursement for office visits and care coordination is provided to reward practices for their improved performance.

• Currently, 60 percent of patients in participating practices have 24/7 access to care, compared to 25 percent of non-participating patients. (Similar differences apply to patient registries, patient-provider partnership processes, performance reporting, care management services, e-prescribing, test result notification process, etc.) • The initiative experienced a $7 million decrease in radiology cost on a risk-adjusted standard cost basis. • BCBSM PCMH-designees have more favorable risk-adjusted utilization and standard cost profiles. For example, PCMH-designated practice units have: • 17 percent fewer inpatient admissions for ambulatory care sensitive conditions. • 6 percent lower 30-day readmission rate. • 4.5 percent lower ER visit rate. • 7 percent lower use of high tech and low tech imaging. • 51 percent lower self-referral rate for low tech imaging.

Independence Blue Cross – Pennsylvania Chronic Care Initiative, Governor’s Office for Healthcare Reform (GOHCR)
The initiative focuses on chronic care management across the Commonwealth, specifically for Diabetes and Asthma. For example, physicians in this PCMH model not only track whether patients are receiving regular Hemoglobin A1c tests (a common indicator of how well a patient is managing their Diabetes), but they are also measured and incented on whether this number is actually improving (i.e., the patient is controlling their Diabetes or getting healthier). Additional support includes: best practice sharing, providing actionable reports for providers, practice transformation coaching and registry development. In-depth education and motivational interviewing, risk-tiering enrollees for follow-up interventions, open access scheduling and use of registry with encrypted e-mail, and health educators and care managers are also provided.

After only one year, patients with Diabetes experienced significant improvements: • Patients with HgbA1c < 9.0 experienced a 23 percent improvement in their Hemoglobin (HdbA1c) levels. • Patients with HgbA1c < 7 experienced a 33 percent improvement in their Hemoglobin (HdbA1c) levels. .0 • Practices also experienced a 104 percent improvement in the documentation of Asthma action plans and a 195 percent improvement in the number of patients with documented self management goals.
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Regence Blue Shield and Boeing Pilot – Intensive Outpatient Care Program (IOCP)
Boeing designed the pilot so that its “highest risk” employees — those representing 65 percent of the company’s total healthcare costs — would receive enhanced care through the IOCP The goal of the program was to deliver . highly personalized, coordinated care that would improve health, increase patient and provider satisfaction, improve worker productivity and reduce overall costs. Boeing employees with chronic conditions who received services from participating providers also received access to a personal RN Care Manager and 24/7 access to a care team via phone, email and in-person visits. The RN Care Manager was a critical member of a multidisciplinary team that worked with patients to develop a shared care plan, review medications and integrate behavioral health, diet and physical therapy into their treatment (as needed). In addition, Regence provided timely information back to providers regarding patient claims history so that the care team could identify gaps in care and target interventions accordingly.

• During the pilot, IOCP reported high patient and provider satisfaction scores. Testimonials showed exceptional reception on the part of patients, and surveys confirm improvements in virtually all measures of care and patient experience including access, communication, provider relationship, and care coordination. • Surveys documented self-reported improvements in functional scores and productivity. • Physicians and nurses provided testimonials in support of the better care they were able to provide. • Lab data demonstrated objective improvements for key clinical measures. • Healthcare costs of pilot participants were 20 percent less than the control group primarily due to reduced emergency room utilization, hospital admissions and inpatient days. • Participants also reported a 14.8 percent increase in physical function and a 16.1 percent increase in mental function. Additionally, the average number of patient-reported workdays missed in the last six months of the pilot decreased by 56.5 percent.

While the above examples are promising, it is understood that investments being made in the PCMH may not always result in significant, short-term returns. However, the Blues believe that the long-term payoff will be significant, as patients receive integrated and coordinated care from a healthcare system in which delivering quality, not quantity, of care is rewarded. The Blues are committed to finding solutions that work. Improving the way that primary care is delivered and financed is a priority for the system. The medical home is one of the concepts to support these objectives, and the PCMH is laying the foundation for Accountable Care Organizations (ACOs). For more information regarding the Blue System’s work in the area of Patient-Centered Medical Homes, please visit www.bcbs.com/medicalhome or email medicalhome@bcbs.com.

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