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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?