CareFirst Announces PCMH Program Results

The Washington, DC health plan provider says it has improved healthcare access for at-risk populations while lowering costs.

CareFirst BlueCross BlueShield, the dominant health plan provider for the Washington, DC area, says it has a secret sauce for reducing costs for insuring high-risk populations while improving their health.

Last week, flanked by Johnathan Blum, former principal deputy administrator and director of the Centers for Medicare & Medicaid Services, and others, Chet Burrell, CEO and President of CareFirst announced that, for a third consecutive year, the organization's Patient Centered Medical Home Program has achieved lower than expected costs.

Launched in January 2011, the PCMH program was designed to incentivize primary care providers to offer a care coordination program to CareFirst customers. It also offers access to tools and support to offer care that is theoretically higher in quality and lower cost.

The program specifically aims to work with patient populations that would benefit from personalized medical attention, such as those with multiple chronic conditions. Another goal of the program is to help these patients better manage their diseases and improve their overall health through collaboration with panels of five to 15 physicians and nurse coordinators.

Providers who participate in the program receive a 12% increase in their fee schedule. They may also receive payment for keeping care plans for select patients current or showing better treatment outcomes. The program rewards practices for ordering fewer unnecessary tests and for treating patients in an outpatient setting rather than requiring a visit to the hospital.

CareFirst also incentivizes patients for seeking quality care, reducing or eliminating copays when top performing in-network physicians are chosen.

Slowing Spending Growth
"I had hoped there would be results in three years that would be exciting to talk about," said Burrell.

Burrell said that CareFirst has seen the overall rate of increase in medical care spending for its members slow from an average of 7.5 percent per year to 3.5 percent. Additionally, he said that CareFirst has seen encouraging trends regarding patient health, including:

• 6.4% fewer hospital admissions
• 11.1% fewer days in the hospital
• 8.1% fewer hospital readmissions for all causes
• 11.3% fewer outpatient health facility visits among its members

Credit Where Credit is Due
CareFirst acknowledges that readmissions rates and emergency room visits have declined since 2010 when the PPACA was signed into law, and that access to care has generally improved over the last few years.

"It would be unfair to attribute these shifts solely to our program, but we believe the PCMH program has had a significant contributory effect," Burrell said in a press release sent about the announcement.

Other organizations have been trying similar programs. In 2013, HHS initiated improvement projects like the Partnership for Patients and the Hospital Engagement Networks (HENs), both of which are heavy on the care collaboration and use similar strategies to get patients to utilize preventative services.

As of February, about 1,500 hospitals were participating in the largest of the federally funded HENs.