Patient-Centered Medical HomeCareFirst Pilot Program Update

Primary Care Medical Home Workgroup of the Maryland Health Quality and Cost Council

April 6, 2009

Jon Shematek, MDSenior Vice President & Chief Medical Officer

CareFirst BlueCross BlueShield

Contents

• BlueCross BlueShield Pilots

• The CareFirst PCMH Pilot– Background– Foundational Requirements– Program Design– Outcomes and Evaluation– Issues

Pilots in planning phase for 2009 implementation

Multi-Stakeholder demonstrationPilot activity in early stages of development

Pilots in progress

Blue Cross Blue Shield Plan Pilots (as of February 2009)

Background

• CareFirst Patient Centered Medical Home Pilot (2008-2010)– Planning process (2008)

• RAND provided environmental scan, consulting services on design

• BCBSA

• PPCPCC

• Focus groups…citizens, physicians, employers

– Recruitment completed late 2008– Implementation commenced January 2009

• Two Year demonstration/pilot Program • 11 Primary Care Practices• 84 Physicians (61 IM, 17 FP, 6 Peds)• 13 Nurse Practitioners• Over 30,000 CareFirst Members• Over 150,000 patients• Intensive facilitation• Innovative funding support

Confidential Information- Not for Distribution

Foundational Requirements

• Joint Principles – 100% attestation by all practitioners in practice

location– Personal commitment to participate by lead

physician, administrator

• NCQA PPC-PCMH Certification– Level II minimum requirement by 4Q2009

Practice Transformation• External consultant with track record in PCMH• Confidentiality• On site “Thorough Practice Assessment”

– Focus on patient-centeredness, teams• Technology Needs Assessment• NCQA PPC-PCMH Certification facilitation• Conference calls, weekly, daily as needed• Quarterly Learning Collaboratives

Data Intermediary• Participation with third party data intermediary

– EMR not required– Patient attribution (practice self-identifies)– Real-time registries– Point of service decision support– Gaps in care reminders– Continuous outcomes monitoring– Periodic reporting– No cost to practice– Applies to all patients in practice– CareFirst provides selected administrative data (dates of

diabetes retinal exams, breast, cervical and colorectal cancer screenings)

– CareFirst views aggregate data for its enrollees only

Population Care Opportunities

Patient Level Care Needs

Condition Specific Care Needs

Direct Financial Support

• Care Coordination Fee set at $4 pmpm capped at $100,000 per practice as long as practice continues to maintain all requirements

• Technology grants up to $100,000 per practice for CCHIT-certified EMR, additional technologies, electronic prescribing systems, patient portal development, participation in interoperable health information exchanges– Based on technology assessment conducted by

independent third party• Outcomes awards in Year II up to $100,000 per

practice

Outcomes

Childhood Immunizations• DTaP, IPV, MMR, HIB, VZV, Pneumococcal, Hep A, Influenza

Adult Immunizations• Influenza-A, Pneumococcal

Body Mass IndexTobacco Use/ExposureBreast Cancer ScreeningCervical Cancer ScreeningColorectal Cancer Screening

Diabetes• HbA1c testing, cotnrol• LDL testing, control• Retinal exam• Nephropathy screening

Coronary Artery Disease• Blood pressure control• LDL control• Beta blocker use• Aspirin

Hypertension• Blood pressure control

Asthma• Severity classification • Appropriate medications

CG-CAHPS Survey Results

NCQA PPC-PCMH Certification

Patient-Centered Medical Homes Open Questions

• What is the impact of the medical home on quality, cost of care, patient and physician satisfaction?

• Which aspects of this medical home pilot are sustainable? Which can reasonably be replicated?

• How to provide funding for primary care practitioners and their teams, particularly in a self-insured commercial market?

• What is the opportunity for medical homes in pediatric practices, small practices, rural practices?

• How does the medical home address the entire continuum of care, including specialty and hospital-based care?

• Most importantly, how does the person (patient) become aware of and participate in the medical home?