The Maryland health plan, 3,600 primary care providers-strong, says it has saved $136 million in projected healthcare costs over two years through its large-scale network of patient-centered medical homes.
CareFirst BlueCross Blue Shield, the giant Maryland insurer, says it has saved $136 million in projected healthcare costs over two years through its large-scale network of patient-centered medical homes.
More than one million members are served by the 3,600 primary care physicians and nurse practioners who have joined team-based panels to reduce healthcare costs and improve the quality of patient care. There are 297 PCP panels across Maryland, Virginia, and Washington, DC.
PCPs drive the program because they are in the position to best understand patient needs, explains Mike Sullivan, director of external/internal communications at CareFirst. He notes that the PCP is responsible for two of the most "value-laden decisions in healthcare:"
1. When to refer a patient for additional care, and
2. Where to refer a patient for additional care
Most of the CareFirst members in the program are chronically ill with diseases such as diabetes. PCPs develop care plans for these patients with the goal of keeping them from getting sicker and incurring additional healthcare costs.
For their efforts, physicians are guaranteed a 12% boost on top of CareFirst's existing fee schedule. If the insurer normally pays $100, PCMH doctors receive $112. And that is for just participating in the program.
About 66% of the PCP panels also earned outcome incentive awards, which are based on a combination of savings against projected member costs and performance on quality measures.
"The incentives are significant enough to get doctors to take notice," says Sullivan. On average, qualifying panels will see an increase in their reimbursement level of 29 percentage points in 2013.
Sullivan says CareFirst developed its PCMH program with the thought that it would take 3—5 years for the program to sustain success. In only the second year of the program, however, 75% of the panels receiving incentive awards were repeat performers from the first year, meaning their patients registered lower-than-expected total healthcare costs for two consecutive years.
That's a sure sign that the care management concept is taking root and can build on success.
Perhaps a more telling indication of the program's success is the comparison between one million patients in the PCMH and one million members who are not attributed to the program because they don't see a PCP, or their physician doesn't participate in the program, Sullivan says "we are beginning to see hospital admissions, hospital readmissions, and the average length of stay looking better for the members in PCMH compared to those who are not in the program."
In the future, Sullivan says CareFirst wants more of its physicians using the data support it provides, which includes a portal specifically for PCMH providers. The portal provides access to a member health record for each CareFirst member within the PCMH. "The portal allows physicians to see every bit of information that we have for that member," explains Sullivan.
"Even the best EHR operated by a stand-alone PCP only has a record of what that physician does. Our member health record includes every bit of claims-based medical information that we have. So if a patient get a prescription from another doctor, has an ER visit, or visits another provider, the PCHM doctor knows it. That's very useful information."
Through the portal physicians may also access the complete care plan tool to develop a longitudinal, ongoing record of everything that has been done to a patient as part of a care plan, including notes from other providers.
There is also the searchlight function, which provides a view of a panel's entire patient base to identify gaps in care or the areas where they are doing well.
"It's a rich benefit that doctors can mine to improve their performance," says Sullivan.
CareFirst recently announced the selection of several organizations to conduct comprehensive evaluations of its PCMH. A joint team from Harvard University, Brandeis University and the Massachusetts Institute of Technology was selected, along with a team from George Mason University.
The groups will conduct qualitative and quantitative analysis of the PCMH program. "We want that independent evaluation to capture what's working and how we can improve, states Sullivan.
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
