Lessons from Industry Leaders

Issam Zeinoun, October 2018 [Download PDF]

U-Turn

Don’t be jaded by the ever increasing complexities and costs of modern healthcare because the solution we have all been looking for is here: Patient Centered Medical Home (PCMH). Real data from the past 3-5 years show how effective a proper PCMH can be. This is not your usual managed care story, like the inadequate HMO or PCP models of the seventies. PCMH takes the Primary Care model to the another level, creating a continuum of care and resources for the patient, managed by the PCP, in a cost effective and quality focused manner, not previously achieved. Looking at the largest PCMH programs and their success stories, we present their lessons and related outcomes. Though many other successes exist, the selected ones sufficiently present the effectiveness in driving employee success, patient satisfaction and quality outcomes, all while controlling utilization of services and reducing overall costs.

Background

The cost we pay as consumers, and as a society, for fragmented care is astronomical and well documented by many reliable sources. Individual physician-based care, and its associated silos, create complexities in the care process, difficulty in patient experience, and limited visibility into health outcomes. Studies show that coordinated patient-centered care has a direct impact on health status, and reduces utilization like preventable hospitalizations and ER visits. Coordinated care also optimize the use of medications and treatments to reduce redundant testing, fill gaps in care, and reduce misdiagnosis. The Patient Centered Medical Homes (PCMH) concept has proven to be a successful model for delivering such care, by bringing together a diverse team of caregivers (physicians, counselors, nurses, community services, family members, etc.) and empowering the PCP to easily and effectively coordinate their services around the patient’s needs.

Success

Though many example exist, I focus on a few of the most impactful ones: CareFirst, BCBSM, and Horizon BCBS, and the Patient Centered Primary Care Collaborative (PCPCC). Each report specifies methods for success, but I’ve combined a summary of the top ten lessons, below. Keep in mind that financial viability and culture change are cornerstones for success. The authors of the Robert Graham Center summarize this best as follows: “This important evolution of care will require active demonstrations, change facilitation, and a business plan that can either survive in the current payment environment or that is specifically financed.” [1].

Payers

Health plans play a large role in the PCMH world because they have pervue across providers, and can leverage their claims and connectivity to HIEs to surface actionable information centered around each member. Care Analytics play a big role here, in finding the needles in the haystack (those high risk members that require immediate or near-term attention). Here are a few of the success strategies adopted by these plans:

1. Setting clear and simple incentives, measurable today.
2. Integrate systems: Payer, Provider, Pharmacy, Vision, Lab, Community services.
3. Measure, report and share on all incentives and related outcomes (accountability).
4. Support providers/panels for making the change (with training, tools, hotline, etc.).
5. Use best-of-breed technology for communication, information sharing, data aggregation and actionable analytics. Maximize the value of your data.
6. Connect across provider disciplines and specialities (BCBSNJ examples) - relationships with neighborhood providers, community resources, clinics, behavioral health, etc.
7. Localize incentives based on regional constraints, such as economic condition, network, proximity of externally used services, demographics and other factors.
8. Encourage PCMH panels and ACOs to learn from each other (discussions, boards, events, etc.)
9. Personalize attribution of PCP to patient preferences and needs - critical to patient engagement.
10. Create benefit packages that align with the goals of the PCMH program, to contain out-of-pocket cost for members, and create predictability in claims costs.

Providers

Providers succeed because they have the patient’s trust, unlike plans who are still working on gaining it. Providers, however, have incomplete views of the patients, and so need to integrate and communicate with each other more effectively. Here are a few of the success strategies that providers have adopted:

1. Encourage teamwork through regular meetings around the highest risk patients, reviewing charts, care plans, results etc. Ensure everyone has a voice.
2. Target a specific goal, identify the specific segment, and generate the specific list of patients to address (e.g., mammograms for women of a specific profile).
3. Leverage every interaction with the patient to drive behavior (e.g. addressing gaps in care).
4. Use office time to detect and tackle risk (unnoticed by the patient) before they end up in the ER.
5. Create a 24/7 support system / access for patients to access when in a tough situation, and to avoid them rushing to the ER.
6. Change the scheduling processes to better accommodate continuity and regularity in visits.
7. Provide options for same day appointments.
8. Address medical and behavioral needs in a connected and unified manner.
9. Regularly review and adjust patient medications.
10. Follow up and connect with family members who support the patient.

Results

Early on, the results were mixed and unclear. However, in the recent 3 to 5 years, as PCMH programs matured, expanded, and fine-tuned, positive results surfaced and have shown to be consistent and repeatable. Here are some specific outcomes from the cases studied:

Horizon BCBS: Within six months, the practice was able to increase its mammography rates by approximately 25 percent for all eligible patients. Using similar techniques and proactive outreach strategies, this practice was able to reach the 90th national percentile for seven quality process and outcome measures, including controlling high blood pressure and increasing colorectal cancer screenings, within nine months.

BCBS of Michigan: Physician practices that have transformed to the Blue Cross PCMH model are reducing their patients’ use of emergency services by 3.7 percent and hospital visits by 3.8 percent. What’s more, for patients with six specific chronic conditions who were being closely monitored, this reduction was three times greater – 11.2 percent for emergency department and 13.9 percent for hospital use. The Michigan experience is one of the largest (4,534 primary care physicians) and has resulted in a 15% decrease in adult ED visits and a 21% decrease in adult ambulatory care sensitive inpatient stays.

BCBS of Massachusetts: Participating groups exhibited exceptionally high performance for all clinical outcome measures (2009-2013), with many approaching performance levels believed to be the best achievable for chronic conditions, such as diabetes, heart disease, and hypertension. The result was a 6.8% savings over four years when calculated as a proportion of the average post-AQC spending level in the 2009 AQC cohort. Another measure showed $107 savings per patients in 2nd year of program.

CareFirst BCBS: Approximately 67 percent of participating Panels in 2017 achieved savings for their members against the expected cost of care. For a PCMH PCP earning an average award in 2017, this translates into approximately $32,000 in increased income. The estimate for incentives to be paid out for the 2017 performance year is $78 million. Net savings in cost of care across all panels was 4%. Independent Evaluators found that the CareFirst PCMH program reduced total spending 2.8% per year by year 2 and 3 of the program (2012-13).

Patient-Centered Primary Care Collaborative: A total of 45 reports from the peer-reviewed literature were assessed, in addition to outcomes from CMS initiative reports and independent state evaluations. The report show favorable results related to cost, ED utilization and PCP Utilization. The data around quality were half favorable and half mixed, depending on the program design.

Next

As PCMH and other value-based care models continue to evolve and show success, the marketplace needs to continue to improve in handling complexities and costs across the ecosystem. The top three emerging trends that are critical to this expansion are:

1. Deeper and more targeted care analytics at the population level and the individual level.
2. Wider integration across health systems, providers and payers.
3. Optimizing and stabilizing government regulations and incentives at the Federal and State levels.

Most important to the expansion of the PCMH care model is the realization of its benefits and the buy-in of the stakeholders, especially at leadership levels where the most impactful decisions are being made.

Sources

[1] The Patient Centered Medical Home, ROBERT GRAHAM CENTER, Report.

[2] The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization, Report.

[3] CareFirst BCBS PCMH Performance 2017, Report.

[4] Horizon BCBS PCMH Performance 2017, Report.

[5] BCBS Michigan PCMH Performance 2017, Article.

[6] BCBS Massachusetts AQC Performance 2014, Article.