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Patient-Centered Medical Home CareFirst Pilot Program Update. Primary Care Medical Home Workgroup of the Maryland Health Quality and Cost Council. April 6, 2009 Jon Shematek, MD Senior Vice President & Chief Medical Officer CareFirst BlueCross BlueShield. Contents.

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Patient centered medical home carefirst pilot program update

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, MD

Senior Vice President & Chief Medical Officer

CareFirst BlueCross BlueShield


  • BlueCross BlueShield Pilots

  • The CareFirst PCMH Pilot

    • Background

    • Foundational Requirements

    • Program Design

    • Outcomes and Evaluation

    • Issues

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

Pilots in planning phase for 2009 implementation

Pilots in progress

Pilot activity in early stages of development

Multi-Stakeholder demonstration


  • 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
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
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
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

Direct financial support
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


  • 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

  • Childhood Immunizations

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

  • Adult Immunizations

  • Influenza-A, Pneumococcal

  • Body Mass Index

  • Tobacco Use/Exposure

  • Breast Cancer Screening

  • Cervical Cancer Screening

  • Colorectal Cancer Screening

CG-CAHPS Survey Results

NCQA PPC-PCMH Certification

Patient centered medical homes open questions
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?