1. Patient-Centered Medical Home: From Concept to Reality
Consumer Purchaser Disclosure Project
October 17, 2007
Lisa Latts MD, MSPH
VP, Programs in Clinical Excellence

2. More than 34 million Members Across the Country
WellPoint, Inc
More than 34 million Members Across the Country NH CT ME MA VA KY OH IN IL WI MO TX CO CA NV GA NY
BC or BCBS licensed plans
UniCare >100K members
9/18/2018

3. Patient-Centered Medical Home
Definition of an “Patient-Centered Medical Home” (PCMH): a primary care practice that provides patients with accessible, continuous and coordinated care through a patient-centered, physician-guided, cost-efficient and longitudinal approach to care
What is a Medical Home:*
Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care
Physician-directed medical practice in which a team of individuals collectively take responsibility for ongoing care of patients
Whole-person orientation of care for all stages of life
Care is coordinated and/or integrated across all elements of the health care system
Quality and safety are hallmarks of the medical home
Patients have enhanced access to care through systems such as open scheduling, expanded hours and new options for communication
Payment appropriately recognizes the added value to patients who have a medical home
Medical Home is NOT:
Reemergence of capitation
Just another way to increase primary care reimbursement
Panacea for rising heath care costs
Net increase of dollars into the health care system
9/18/2018
* Adopted by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP),
American College of Physicians (ACP) and the American Osteopathic Association (AOA)

4. Why the Medical Home
Primary care is important to the delivery system – current crisis in primary care recruitment and retention
Medical home may be the (a) answer to increased quality, reimbursement and provider/patient satisfaction
Aging population & increased prevalence of chronic diseases
Current system emphasizes episodic treatment for acute care and more care, not better care; Capitation led to less care
Rising healthcare costs and gaps/variations in quality and safety
Need for better coordination of care among providers; care coordinated by a personal physician associated with better outcomes, especially in many chronic diseases
Disease management as currently exists yielding mixed results; DM activities most successful when integrated into a physician practice
Collaboration with national and local primary care providers to explore innovations and piloting PCMH models
Goals to improve safety, quality, affordability, and experience of care
9/18/2018

5. Collaborating for Quality and Affordability
Primary Care
ACP
AAFP
AOA
AAP
Purchasers
Patient-Centered
Medical Home
Patient Advocacy Groups
Health Insurers
9/18/2018
© 2007 Blue Cross Blue Shield Association. All Rights Reserved.

6. Health Information Technology Clinical Process and Outcome Measures
Pilot Program Model
Implementation
Coordination
Implement in states across the country
Recruit variety of practice shapes and sizes
Large IPAs/ multi-specialty groups
Smaller PCP group practices
Solo and Duo Practice groups
NQCQ Practice Designation - PPC
Timing: Q1/Q2 2008
Coordinate pilot sites with other payers, especially CMS
Critical mass of patients necessary for PCMH success
Coordinate with other programs
Pay for Performance
Disease Management
Transparency Programs
Decision-support
Evaluation
Care Coordination
Health Information Technology
Clinical Process and Outcome Measures
Resource Use
Cost of Care
Satisfaction
Comprehensive evaluation
Discussions with Commonwealth Fund, RAND
9/18/2018

7. Patient-Centered Medical Home Demonstrations - BCBSA
Pilot Planning WA ME MT MT ND VT MN NH OR MA WI NY ID SD ID MI RI WY PA NJ CT IA NE OH NV MD DE NV IN IL UT WV DC CA CO VA KS MO KY NC TN NM OK AR SC AZ MS AL GA LA AK TX FL HI PR PR
9/18/2018
= States where PCMH demonstrations are in planning for 2008
Participation as of 10/15/07

8. Personal Medical Home
Reimbursement and incentive structure aligned to support
practice transformation, clinical process/outcomes, cost of care and satisfaction
Payment Methodology
Prospective Payment
FFS
Pay For Quality
For services currently recognized through Medicare RBRVS system; potential for additional services
NCQA’s
PPC Recognition:
Care Coordination
Process Redesign
HIT
Evaluate Levels of Achievement
Clinical
Process and Outcomes
Resource Use/
Cost of Care
Satisfaction
Pre-Assessment of Practice Readiness
Support from ACP, AAFP and AAP
9/18/2018

9. PCMH Project Questions
Practice Recruitment
Current WellPoint interest in ME, NH, WI, VA, CO, CA
Coordinate with local ACP, AAFP chapters to recruit
Urban/suburban/rural
Large/medium/small/single
What is critical payer mass for practice
PCMH Designation
NCQA PPC Program – time to get practices designated
Who pays?
Differences by level of designation attained
Technical Support
“Reward” for increasing levels
Purchaser participation
Employee incentives to use Medical Home practices?
Care Coordination Payment
All patients or just chronic disease? Which disease(s)?
How much? How often?
Opt in or opt out model for patients
Timing of Program: Start, interim evaluation, final evaluation
At least 18 month for adequate trial of effects
What to do in the interim
Evaluation
Where, What, Who and How
Definition of Success?
Key components of success vs. elements that provide no incremental value
Transparency
What if…..
9/18/2018