5 Big Ideas from WellPoint's PCMH Pilot

In 2009 WellPoint, the giant health insurer, began a patient-centered medical home pilot. It has developed 10 PCMHs across the country involving more than 100,000 WellPoint plan members and about 1,200 providers.

A recent report in Health Affairs highlights the promising results of the pilots in Colorado, New Hampshire, and New York. According to the report there was a significant drop in hospital admissions and emergency department visits. Specialty visits remained flat and measures of diabetic care improved.

And WellPoint scored a significant return on its investment. Every dollar pumped into the program returned between $2.50 and $4.50.

I spoke to Jill R. Hummel, WellPoint's vice president of patient innovation, about the program and what WellPoint learned along the way that will help the company as it launches its nationwide PCMH program across all line of business—commercial, Medicare, and Medicaid.

The key, she says, is leveraging resources and remaining actively engaged with the physicians. "It's not just congratulations, here's the money, and good luck. It's here's a new financial model, and here's information and resources to help you be successful."

She adds that a successful PCMH is all about keeping patients healthy and figuring out what happens when hospital stays or ED visits increase. The process requires the right payment structure to keep people healthy and a focus on care coordination.

Here's a look at five of the major takeaways WellPoint has developed over the course of the PCMH pilot:

1. Money matters
There is no delivery system reform without payment system reform. Hummel cautions that payment reform is not just about aligning incentives for clinical interventions, it's also about providing physicians and other providers with the funds to invest in resources such as electronic medical records (EMR) or a disease registry.

Hummel notes that the fee-for-service system provides no compensation for physicians to conduct the clinical interventions that take place outside of a traditional patient encounter, such as helping a patient get an appointment with a specialist and then following up with that specialist.

WellPoint has designed a program that includes clinical coordination fees as well as shared savings. The fees are paid on a per-member-per-month basis and are not tied to patient visits or services. Payments for shared savings are based on projected medical expenses for a defined population supported by historical experience and trends. If physicians have performance that's less than the projected expenses and they meet quality projections then they participate in a portion of the savings.

Hummel explains that physicians compensated with clinical coordination fees are incentivized to dig deeper to optimize the health of their patients. "It's not just about the disease. It's also about socioeconomics, patient preferences, and the cultural issues that a patient brings to the table that can impact compliance."

2. Coordinated care and care management
Physicians should focus on patient numbers such as blood pressure and blood sugar and not just on numbers of patients.

The WellPoint pilot emphasized identifying patients with chronic conditions such as diabetes and congestive heart failure. Many hospital stays "are a reflection of the failure of our healthcare system. (The patients) are people who have conditions that aren't being managed," states Hummel.

An aligned approach that moved from care silos to care collaboration produced "phenomenal results in improving the health of our members and their quality of life, as well as reducing costs," she adds.

3. Meaningful and actionable information is important
Physicians aren't always able to identify the patients they need to focus on. Even physicians that have EMR systems may not know about a patient's emergency department visit or a hospital stay. Hummel says behavioral health conditions can also have a significant impact on patient compliance in terms of following treatment plans, but a primary care physician can't depend on patients to always share that type of information.

Physicians need a longitudinal patient record that includes behavioral health information, ED visits, and inpatient stays. By pulling together claims data, Hummel says insurers can help physicians focus on the patients that need the most attention. "It's incredibly important in supporting the change in delivery system from episodic intervention to true proactive population health management."

There is a time lag on some claims data, but Hummel says, "this is an example of when we can't let great get in the way of good. Even with the lag our information is better than what the physician has now."

WellPoint's pharmacy claims data is refreshed each night. Physician data is available within about two weeks. Hospital billing cycles contribute to a 30 to 60 day lag in making that information available to physicians.

4. Physician practices need help
Even with the money, coordination, and information, physicians practices need additional help making the shift to the new delivery model.

Transformation to the coordinated care model requires physicians to redesign how they deliver care in their offices. WellPoint is hiring patient-centered care consultants to help physicians learn the basic elements of patient centered care. "They need to understand how to interpret data, how to develop care plans, and how to develop strategies for frequent ER fliers," explains Hummel.

5. Access is important
If you don't address the access issues then the other stuff just doesn't matter. Hummel explains that many inpatient admissions and avoidable ER visits come about because patients don't have access to their physicians.

WellPoint requires that PCMH physicians be available 24/7 either themselves or through call arrangements.

But Hummel says the insurer also provides physicians with tools to help facilitate the afterhours access requirement, including:

• Implementing web-based visits on Skype or Facetime for after-hours patients visits.
• Providing a web-enabled tool that allows physician to access patient information from home. "If it's after hours and you don't have access to a patient's information,  it's a little hard to give advice," states Hummel.
• Using retail clinics as an extension of the physician's office. WellPoint is developing relationships with retail clinics located in stores such as Walmart, Walgreens and Rite Aid to provide physicians with treatment information when their patients visit a clinic. WellPoint is also developing information about clinic locations, hours, and services for physicians to provide patients who need after office hours care but not necessarily the full services of an ED.

WellPoint is a big enough player that it can drive market changes on its own, but Hummel says the process will be easier for physicians if other insurers in a market also shift from volume to value payments.

In sharing information about the success of the PCMH pilot WellPoint hopes it will help other insurers develop their PCMH programs. "We know we can make a difference," Hummel says.