For years, before working with primary care practices as a team, "we tended to move the needle very slowly—1%, 2%, or 3% a year," Snyder says, referring to improved outcomes. "We had to change the paradigm to better coordinate the care by reducing the number of redundant tests and avoidable admissions, and that coordination started with primary care."
In a review of patients who received care from 20 physician practices, at least 33% of them had patients with poorly controlled diabetes four years ago, says Snyder. By 2013, that figure for those with an A1c of greater than 9% was reduced nearly in half to 18%, he says.
"What we are seeing is that medical homes are moving ahead very substantially, getting to a nearly 20% to 30% improvement year over year," he says. "The kind of coordination and order that is in patient-centered medical homes has resulted in
Success key No. 1: Amassing physician groups
When Independence Blue Cross began a medical home model in the City of Brotherly Love three years ago, it started coordinating care with 32 physician practices. Within a year, it expanded to more than 170 practice groups, which included more than 1,000 physicians, says Snyder. Those numbers also translated into significantly improved patient outcomes, he adds.
Independence Blue Cross is part of the Blue Cross and Blue Shield Association. IBC established its medical home physician incentive program, the Quality Incentive Payment System, in early 2010 to "attract and retain high-performing" primary care physicians in southeastern Pennsylvania. There were 32 multiphysician practices designated to serve 220,000 patients under the governor's Chronic Care Initiative.
Other insurers, including Aetna, UnitedHealthcare, Keystone Mercy Health Plan, AmeriChoice, and CIGNA, participated. Independence Blue Cross had more members in the practices than the other plans.
The IBC-led program focuses on a medical home model to improve care coordination by relying on an electronic tracking system to evaluate outcomes. Care coordinators use the system to keep tabs on patients with diabetes, heart failure, or blood pressure issues, for instance.
The coordination resulted in notable improvements in compliance with reporting health metrics among physician practices participating in the collaborative. "That's the kind of data that turns the heads of chief medical officers at health plans," Snyder says. In a report from 2008 to 2011, Snyder and colleagues found that "adoption of the PCMH model reduced overall cost for diabetic members by 21% within the first year, driven largely by eliminating inpatient costs, which fell by 44%.
A significant element of the program was the insurer's reimbursement changes for treatment by primary care physicians. Doctors were rewarded for improving quality of care and providing that care in a more efficient manner. The program allowed participating primary care doctors who met their goal numbers to double their reimbursement, and Independent Blue Cross paid out nearly $37 million in 2011, though there was not a specific breakdown in doubled reimbursements.
In addition to earning extra pay for running their practices as medical homes, doctors can earn incentives based on measures such as coordinating cost-effective care, delivering effective care, and prescribing generic drugs. Individual bonuses reached over $35,000 annually based on the level of the medical home achievement.
"We learned that practices weren't looking for health plans to help them with clinical management," Snyder says. "They were looking for people who understand the benefit structure to help their staff identify how a patient's benefits work, so they can organize services—such as durable medical equipment, home-care services, and pharmacy prescriptions—in a way that optimizes the patient's health plan benefit."