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Patient-Centered Medical Home Benefits Payers, Providers, Patients

The patient-centered medical home (PCMH) model brings clinical benefits to patients as well as financial rewards for payers and providers.

PCMH is good for patients, payers and providers

Source: Thinkstock

By Jesse Migneault

- Blue Cross-Blue Shield of Michigan has one of the nation’s most successful patient-centered medical home (PCMH) networks.  The model has improved patient outcomes, lowered payer costs and increased provider satisfaction and revenue.  As healthcare across the nation moves to a more population-health management model, investment in the PCMH system has proven to bring quality and results.

In a PCMH, primary care physicians lead care teams that focus on each patient’s needs. These provider teams coordinate patients' health care, conditions and test results to ensure the most effective treatment is provided.

The result is an integrated practice with certification standards that require providers meet IT data benchmarks, staff physicians who are focused on individual and chronic care management, and employ a stringent system of referral tracking and overall coordination of service. 

Dr. David Share, BCBS Michigan
Dr. David Share, BCBS Michigan Source: BCBS Michigan

In an interview with HealthPayerIntelligence, David Share, MD, MPH, senior vice president, Value Partnerships, Blue Cross Blue Shield of Michigan addressed the three specific qualities he believes has made the BCBS of Michigan PCMH system a success.

 “First, the model was developed in partnership with physicians. They have a sense of ownership over it, and they believe in it. Doctors are motivated to transform their practices to earn designation,” said Share.

READ MORE: How to Favorably Manage Risk in Value-Based Care Reimbursement

“Second, the model has some flexibility. Physicians who have made the most progress on a set of more than 140 capabilities earn the designation. Designation requires a minimum of 50 discrete PCMH capabilities in place, and good performance on cost and quality metrics.”

According to Share, the average PCMH-designated practice has about 90 capabilities in place. He noted also that not all PCMH-designated practices have the same capabilities. 

“They implement the capabilities that will have the most impact on their ability to identify problems and proactively treat and manage ongoing problems in partnership with their patients,” he explained.

The third factor for the success of the BCBS Michigan PCMH model is the network it has built across the state. The system currently includes more than 40 physician organizations statewide and is the largest designation program of its kind nationally.

“We currently have 1,638 PCMH-designated practices with 4,534 primary care physicians in those practices throughout the state,”he said. 

READ MORE: How Care Management Strategies Could Reduce Medical Costs

There are Blue Cross-designated patient-centered medical home physicians in 97.5 percent of the state.      

A study on the program published in the journal Health Services Research  revealed that providers who adopted the PCMH model have reduced emergency department visits by 3.7 percent and inpatient hospitalizations by 3.8 percent.  

For patients who suffer from six specific chronic conditions (asthma, angina, diabetes, chronic obstructive pulmonary disease, high blood pressure and congestive heart failure), the reduction was even greater with an 11.2 percent drop for emergency department visits and 13.9 percent for general hospital use.

The study found that practices with higher levels of PCMH competency saw the greatest reductions in unnecessary service utilization and the associated costs.

“It results in improved outcomes for our members – members get better access to their physicians, appropriate care in the doctor’s office so conditions are better managed and they stay out of the ER and the hospital,” said Share. 

READ MORE: Risk-Stratified Care Management Enables Customized Treatment

This improvement in members health is also a benefit to payers.

Results from the study showed PCMH network cost-reductions of 17.2 percent for hospital visits, with emergency department costs down 9.4 percent for patients with the six most common chronic conditions. 

“Our PCMH program has consistently achieved dramatic reductions in ED and inpatient use, and significant improvements in performance on HEDIS, QRS and STARS quality metrics,”said Share.

For payers to improve their PCMH models, Dr. Share says it’s all about communication with providers. 

“Develop relationships with the physician organizations and Physician-Hospital Organizations (PHOs) in their service areas. Get their input and work together with them,” advised Share.  By gaining provider input, it creates a sense of ownership by the clinic in the PCMH program.

Proactive guidance from payers can also foster success, he added.

“Work together to provide guidance and support to practices engaged in transforming into team-based, PCMH practices. They need expert guidance and resources to succeed in this transformation.”

Providers can also reap the financial rewards of cutting costs across the care continuum, Share pointed out.

“Providers can earn anywhere from 10 to 40 percent in additional value-based reimbursement, depending on their performance on quality and care management measures,” he said.“This can result in many thousands of dollars per year per physician.”

Although the Michigan PCMH system is already producing positive results, the effort to refine and streamline the PCMH system is a continual challenge. Through an active collaboration of over 300 provider groups, Dr. Share works “to explore how to refine and strengthen the program and its component quality and cost improvement initiatives.”

“We have iteratively broadened and refined the approaches we use to share performance data at the practice and population level to help identify opportunities for improvement.” 

The future improvement of PCMHs come as the healthcare industry overall adopts more interoperability technology and population health management approaches.

“We also use this data to support our value-based reimbursement approach, which rewards and holds practices accountable for transitioning to PCMH-based practice and for optimizing cost and quality performance.”

 “Most importantly, physicians are more satisfied practicing in a PCMH-based practice as they have more confident that their patients’ needs will be met.”

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