Approximately one out of every ten patient-centered medical homes recognized by the National Committee for Quality Assurance is located in Pennsylvania. Philadelphia-based Independence Blue Cross has been a big part of the state's medical home explosion ever since it launched a pilot program four years ago.
Donald Liss, MD, a senior medical director for Independence Blue Cross, discusses the health plan's PCMH program and how physicians and hospitals fit into it.
Question: Walk us through the Independence Blue Cross patient-centered medical home model. How did it form? What are some of its key features?
Dr. Donald Liss: There are two parts to the story. As part of a state-led effort beginning in 2007, IBC was the lead health plan in southeastern Pennsylvania to collaborate with 32 primary care practices in the state, taking as part of the then-governor's plan to promote better care for chronic illness. We worked with these practices and six other health insurers in the Philadelphia metropolitan area to put together a payment model that would allow primary care physicians to transform themselves into medical homes.
The state effort launched in May 2008. Health plans put up the initial funding for infrastructure: the cost of setting up a registry; the cost of applying for an application with the National Committee for Quality Assurance to become a recognized home; and funding to allow practices to send a physician and administrator to a week-long learning collaborative for instruction on how to transform their practices into medical homes. .
The initial program ran for three years; once a practice achieved recognition from NCQA, they became eligible for a bonus of anywhere between $35,000 to $90,000 per physician per year, based on the level the medical home achieved. The payment was split between insurers depending on how many members they had in each medical home office.
We learned a lot about what it took for practices to transform — the work they needed to do and the support it required. It was an incredibly positive experience.
Beginning in January 2011, IBC started offering financial incentives to every primary care practice in our network — approximately 1,100 — to become recognized NCQA medical homes. To date, 263 practices in our network have received recognition and are receiving incentive payments.
The original 32-practice program continues to this day. It's become part of a federal government’s Medicare advanced primary care demonstration that began in January of this year. We're now into the second year of our network-wide incentive for practices that are recognized.
Q: What feedback have you received from partnering physicians?
DL: We were a bit hat surprised by the incredibly positive feedback from practices that were part of academic medical center residency programs.
By happenstance, among the original PCMHs were four practices that were part of the teaching clinics of residency programs in pediatrics and family medicine. They very much appreciated the new model of care coordination. The directors of the family practice programs even presented on the topic at their professional organizations. It was somewhat unexpected that those types of practices would be some of the early adopters of the medical home model..
Working with PCP's we learned how to change the way we offer services as a health plan. For example, at one large practice we've figured out how to deploy a clinical pharmacist to help physicians. The goal is to find more opportunities to simplify medical regimens and lower out-of-pocket costs for patients.
Something else we learned is that practices weren't looking for health plans to help them with clinical management. They were looking for people who understood the benefit structure to help the staff identify how a patient's benefits works so they can organize services, such as durable medical equipment, homecare services, and pharmacy prescriptions in a way that optimizes the patient's health plan benefits.
Primary care doctors sincerely appreciate the intent of our effort. Some may be a little hesitant about having to get yet another credential, but I think they appreciate we are doing this for the right reason.
Q: Has Independence Blue Cross saved money through PCMH participation despite paying out millions of dollars in physician bonuses?
DL: It’s a bit early to say we've definitely saved money. We're analyzing that and we have a very keen interest in making sure what we do is financially prudent. The initial participation in the program was to support primary care. We realized we're going to have to put more resources into primary care, but considered this a way to do it in a way that would guarantee improvement.
The concept of patient-centered care is self-evident: if we can avoid redundant studies; if primary care practices are more accessible and patients can avoid emergency department use when unnecessary; if patients are more adherent to follow medical regimens, it doesn't take a whole lot to offset our investments.
At the same, we realize that medical homes may result in some spending increases in certain areas. In the early part of the program we wouldn't be surprised if we saw some increases in preventive care. Our hope is that over time we will see a financial advantage.
Q: How have hospitals in the area reacted to the medical homes?
DL: Hospitals were very directly involved; they were part of the steering committee with the original state program. Every community is unique, but in the Philadelphia area, pretty much every hospital is either a health system or part of a larger one. Beyond being brick and mortar establishments, many area hospitals own practices. And, if they haven't already established a mechanism to become an ACO, they are certainly thinking about that and studying it. Hospitals seem very interested in testing the waters and learning about PCMHs, seeing how to organize primary care practices. It seems pretty clear that, at least the dominant mechanism now for assigning patients to an ACO or similar entity, is by virtue of who they select as a PCP .
I think health systems are keenly aware that primary care practices will be the mechanism by which they manage a population. I think they are very much interested in seeing better organization, coordination, and infrastructure development.
Perhaps the question could be asked: Will primary care development take business away from hospitals? Certainly, our hope is that it is only taking waste out of the system. I think hospitals appreciate that. When we have frank discussions with hospitals, they understand that, to the extent medical care in the community is better organized they may see less discretionary ER utilization and fewer redundant tests. But it's hard to argue that isn't a good thing.
Q: Where might Independence Blue Cross' PCMH model be headed in the future?
DL: Being a leader in this space has taught us a lot about what we need to do different as an organization to support this effort. Our hope is the vast majority of our network will transform themselves into PCMHs. We think they will be the foundation for bigger ACO-like entities that are emerging and organizing themselves to do business not just with us but with CMS and other payors.
We see PCMHs as the best foundation for an effective health delivery system.
Study: PCMH Processes Do Not Change Patient Experience
CMS Might Expand Medical Home Demonstration to Other States
Donald Liss, MD, a senior medical director for Independence Blue Cross, discusses the health plan's PCMH program and how physicians and hospitals fit into it.
Question: Walk us through the Independence Blue Cross patient-centered medical home model. How did it form? What are some of its key features?
Dr. Donald Liss: There are two parts to the story. As part of a state-led effort beginning in 2007, IBC was the lead health plan in southeastern Pennsylvania to collaborate with 32 primary care practices in the state, taking as part of the then-governor's plan to promote better care for chronic illness. We worked with these practices and six other health insurers in the Philadelphia metropolitan area to put together a payment model that would allow primary care physicians to transform themselves into medical homes.
The state effort launched in May 2008. Health plans put up the initial funding for infrastructure: the cost of setting up a registry; the cost of applying for an application with the National Committee for Quality Assurance to become a recognized home; and funding to allow practices to send a physician and administrator to a week-long learning collaborative for instruction on how to transform their practices into medical homes. .
The initial program ran for three years; once a practice achieved recognition from NCQA, they became eligible for a bonus of anywhere between $35,000 to $90,000 per physician per year, based on the level the medical home achieved. The payment was split between insurers depending on how many members they had in each medical home office.
We learned a lot about what it took for practices to transform — the work they needed to do and the support it required. It was an incredibly positive experience.
Beginning in January 2011, IBC started offering financial incentives to every primary care practice in our network — approximately 1,100 — to become recognized NCQA medical homes. To date, 263 practices in our network have received recognition and are receiving incentive payments.
The original 32-practice program continues to this day. It's become part of a federal government’s Medicare advanced primary care demonstration that began in January of this year. We're now into the second year of our network-wide incentive for practices that are recognized.
Q: What feedback have you received from partnering physicians?
DL: We were a bit hat surprised by the incredibly positive feedback from practices that were part of academic medical center residency programs.
By happenstance, among the original PCMHs were four practices that were part of the teaching clinics of residency programs in pediatrics and family medicine. They very much appreciated the new model of care coordination. The directors of the family practice programs even presented on the topic at their professional organizations. It was somewhat unexpected that those types of practices would be some of the early adopters of the medical home model..
Working with PCP's we learned how to change the way we offer services as a health plan. For example, at one large practice we've figured out how to deploy a clinical pharmacist to help physicians. The goal is to find more opportunities to simplify medical regimens and lower out-of-pocket costs for patients.
Something else we learned is that practices weren't looking for health plans to help them with clinical management. They were looking for people who understood the benefit structure to help the staff identify how a patient's benefits works so they can organize services, such as durable medical equipment, homecare services, and pharmacy prescriptions in a way that optimizes the patient's health plan benefits.
Primary care doctors sincerely appreciate the intent of our effort. Some may be a little hesitant about having to get yet another credential, but I think they appreciate we are doing this for the right reason.
Q: Has Independence Blue Cross saved money through PCMH participation despite paying out millions of dollars in physician bonuses?
DL: It’s a bit early to say we've definitely saved money. We're analyzing that and we have a very keen interest in making sure what we do is financially prudent. The initial participation in the program was to support primary care. We realized we're going to have to put more resources into primary care, but considered this a way to do it in a way that would guarantee improvement.
The concept of patient-centered care is self-evident: if we can avoid redundant studies; if primary care practices are more accessible and patients can avoid emergency department use when unnecessary; if patients are more adherent to follow medical regimens, it doesn't take a whole lot to offset our investments.
At the same, we realize that medical homes may result in some spending increases in certain areas. In the early part of the program we wouldn't be surprised if we saw some increases in preventive care. Our hope is that over time we will see a financial advantage.
Q: How have hospitals in the area reacted to the medical homes?
DL: Hospitals were very directly involved; they were part of the steering committee with the original state program. Every community is unique, but in the Philadelphia area, pretty much every hospital is either a health system or part of a larger one. Beyond being brick and mortar establishments, many area hospitals own practices. And, if they haven't already established a mechanism to become an ACO, they are certainly thinking about that and studying it. Hospitals seem very interested in testing the waters and learning about PCMHs, seeing how to organize primary care practices. It seems pretty clear that, at least the dominant mechanism now for assigning patients to an ACO or similar entity, is by virtue of who they select as a PCP .
I think health systems are keenly aware that primary care practices will be the mechanism by which they manage a population. I think they are very much interested in seeing better organization, coordination, and infrastructure development.
Perhaps the question could be asked: Will primary care development take business away from hospitals? Certainly, our hope is that it is only taking waste out of the system. I think hospitals appreciate that. When we have frank discussions with hospitals, they understand that, to the extent medical care in the community is better organized they may see less discretionary ER utilization and fewer redundant tests. But it's hard to argue that isn't a good thing.
Q: Where might Independence Blue Cross' PCMH model be headed in the future?
DL: Being a leader in this space has taught us a lot about what we need to do different as an organization to support this effort. Our hope is the vast majority of our network will transform themselves into PCMHs. We think they will be the foundation for bigger ACO-like entities that are emerging and organizing themselves to do business not just with us but with CMS and other payors.
We see PCMHs as the best foundation for an effective health delivery system.
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