Medical homes move from pilots to real-world implementation

December 1, 2011

Patient-centered medical homes (PCMHs) are gaining traction with increasing support from health plans, based on their promise to lower costs.

NATIONAL REPORTS-Patient-centered medical homes (PCMHs) are gaining traction with increasing support from health plans, based on their promise to lower costs.

"We have moved beyond pilots and have begun building a medical home infrastructure," says Allan Korn, MD, chief medical officer and senior vice president for Blue Cross and Blue Shield Assn.

He says the focus is on clinical outcomes, such as increasing generic drug use and reducing avoidable emergency room visits, inpatient stays and unnecessary imaging, to name just a few. Given the results many health plans have realized in their initial experiences with PCMHs, this isn't surprising.

COMPREHENSIVE CHANGES NEEDED

To achieve such results, PCMHs require technology and reimbursement changes. On the technology front, data sharing is critical, particularly for PCMHs that advance to Level 3 accreditation status.

For example, Empire Blue Cross Blue Shield uses WellPoint's personal health record system to support data exchange with medical homes, which has been well received among PCMHs, according to John Caby, Empire's vice president of provider engagement and network management in New York. Such technology provides PCMHs with test data, patient claims history and clinical information. Next year, Empire will be rolling out data exchange that allows PCMHs to measure their own quality relative to that of their peers, says Caby.

Quite simply, the more data and information medical homes have, the better they can coordinate and manage patient care. For example, combining clinical data and claims data provides physicians a comprehensive picture.

"With this level of data, physicians are readily aware of cost issues, and health plans are aware of how well physicians are following up and following through on care," says Paul Grundy, MD, president of the Patient-Centered Primary Care Collaborative (PCPCC).

Reimbursement is also important.

"There is a cost to physicians in becoming a patient-centered medical home," Dr. Grundy says.

First, medical homes require a care coordinator and the commitment of additional time from the physician and staff to handle the care management component. Second, PCMHs must invest in technology to support data exchange. To help offset those costs, Empire offers added reimbursement for PCMHs.

These reimbursements are also designed, in part, to attract new primary care physicians to the PCMH model.

"We hope this will create some incentives for the primary care physicians to become a PCMH," Dr. Grundy says. "Our quality has definitely improved in the PCMHs, and we have seen reductions from 8% to 10% in the total cost of care."

Once the transformation of PCMHs has occurred, Dr. Korn expects reimbursement to emphasize new areas. For example, rather than paying for what are basically start-up costs, plans could shift those funds to rewards PCMHs for results, such as care outcomes and patient satisfaction.