Blue Cross Blue Shield of Michigan: Patient Centered Medical Home Program

Region Within State: 
Statewide
Project Category: 
Insurer-Based
PROJECT STATUS
Target Start Date: 
Tuesday, January 1, 2008
Pilot/Demo Length: 
3+ years

Blue Cross Blue Shield of Michigan’s Physician Group Incentive Program (PGIP) was established in 2004 as a collaborative partnership between BCBSM and physician organizations (POs) across the state of Michigan, with the goal of optimizing patient care and transforming the state’s health care delivery system. PGIP uses incentive dollars to achieve goals and reward physicians for their efforts. (Please note that BCBSM defines a physician organization as a physician group composed of primary care and specialist physicians, often owned by physicians).   The PGIP program currently includes approximately 100 physician groups representing 8,147 providers and 1.8 million BCBSM members.

The BCBSM Patient-Centered Medical Home (PCMH) program is open to all primary care physicians who are affiliated with a PGIP-participating PO, including specialists.  The PCMH program was developed collaboratively to strengthen the role of primary care physicians in the delivery and coordination of care, and assist them in achieving levels of patient engagement and care coordination that are consistent with the patient-centered medical home philosophy.  Secondary goals of the PCMH program include demonstration of BCBSM’s continued commitment to the improvement of core health care processes, and fulfillment of BCBSM’s responsibility to deliver the highest quality health care services, with an emphasis on prevention and early management of health problems.

To support and reward incremental progress in transitioning to a PCMH model, BCBSM designed a two-pronged PCMH approach:

  1. PCMH Related PGIP Initiatives: PGIP POs are encouraged to participate in Initiatives that support development and implementation of core capabilities in the 12 domains of the PCMH model.  For each domain, an initiative has been developed to support implementation of specific PCMH capabilities that BCBSM and our physician partners have identified as integral to achieving PCMH functionality. POs earn incentive rewards as they implement the capabilities associated with each domain. 
  2.  PCMH Designation Program:  PGIP physicians who have made substantial progress in implementing PCMH capabilities, and whose progress is reflected in strong quality-use performance, receive increased reimbursement for their efforts for one year. Unlike the PCMH Initiatives, the Designation Program is for PCPs only.

In 2009, PCMH Designation status was awarded to 304 primary care practices (comprised of over 1200 primary care physicians delivering care to nearly 400,000 BCBSM members) across Michigan.

Type of Practices: 
Other
CONVENING ENTITY/PROJECT CONTACTS
Convening Organization Name: 
Blue Cross Blue Shield of Michigan
Primary Contact: 
David Share, M.D.
E-mail: 
dshare@bcbsm.com
Phone: 
248-448-6142
Additional Contact
Name: 
Margaret Mason
Phone: 
248-448-5723
Participating Stakeholders: 

Advantage Health Physicians; Beaumont Physician Organization; Bronson Medical Group; CIPA; DMC Primary Care Physicians, C.P.; Genesys Integrated Group Physicians; Greater Macomb PHO; Henry Ford Medical Group; Holland PHO; HVPA; Integrated Health Associates; Integrated Health Partners; Jackson Physician Alliance; Livingston Physician Organization; McLaren Medical Management; Medical Network One; Mercy Community Physician PHO; Michigan Medical PC; Midwest Medical Center; MSU Health Team; Oakland Physician Network Services; Oakland Southfield Physicians; Olympia Medical Services; Physician Healthcare Network; Primary Care Partners, Inc.; Professional Medical Corp.; ProMed Healthcare; RDN West Michigan; Sparrow Medical Group; St. John Health Partners; St. John Medical Group; UOP LLC, United Physicians; U of M Health System; Upper Peninsula Health Plan; West Michigan Physicians Network.

Participating Organization Types: 
Physician Organization
EXPECTED OR ACTUAL DEMOGRAPHICS OF PARTICIPATING PRACTICES
Number of Practices: 
2477
Number of Participating Physicians: 
8147
Physicians per practice: 
1-90
Types of Practices: 
Internal Medicine, Family Medicine, Pediatrics, Other: Geriatrics, specialists (oncologists, cardiologists, ob-gyns, etc.), mixed PCP/specialist practices
Overall Number of Covered Lives: 
1800000
Technology Characteristics at Start of Pilot: 

Estimated % of Practices with practice management systems: unknown

Estimated % of practices with EMR: Unknown

Estimated % of practices with registry software: As of May 2010, 48% of practice units have a diabetes registry fully in place and in use. This is approximately 1.5 years after the PCMH program started, and represents an increase of 860% over baseline.

Please note that while we collect data regarding which software systems and other technology are in use at practice sites, we do not collect data about the number of practices that are using the particular technology systems, with the exception of the patient registry.

Consumer Involvement: 
  1. Indirect consumer input via physician organizations that partner with BCBSM on the PCMH program
  2. Patient Satisfaction Survey (last conducted in 4Q 2008)
PRACTICE TRANSFORMATION SUPPORT (INCLUDING TECHNOLOGY)
Focal areas of transformation: 

The primary areas of practice transformation targeted by the BCBSM PCMH program include:

Care Coordination
Extended Access
Health Information Technology

Services participating practices have added as a result of their participation: 

Practices have added self-managment support and care management services, extended access, linkages to community services, group visits and planned visits, and specialist referral tracking and processes, as part of their involvement in the PCMH program.

Technology that participating practices have added as a result of their participation: 

Patient registry systems, e-prescribing technology, patient Web portals and electronic health records. We have also seen practices dedicating or adding staff positions for the purposes of care coordination and care planning, including disease-specific health care travel teams and/or health care navigators.

Payment Model: 

PGIP-enrolled primary care physicians who are members of a designated PCMH practice receive a higher level of reimbursement for office-based E&M codes from July 1, 2009 through June 30 of 2010. For 2009, the uplift for E&M codes was 10%. However, the amount of uplift will be reviewed annually and is subject to change.

All practices and providers in PGIP are also eligible to receive payments for care coordination via T-codes. T-codes can be billed for telephone or in-person care coordination/care management services delivered by non-physician clinical team members following a physician visit where patient-specific chronic illness management goals have been established.

In addition to the uplift and T-codes, all physician organizations in PGIP receive incentive pool payments based on the practice transformation activities and performance outcomes of their associated practices. The incentive payments are distributed to practices by POs, at their discretion, and are meant to facilitate further practice transformation and improved clinical quality outcomes.

PROJECT EVALUATION
Types of data to be collected : 

Clinical quality/cost/efficiency; patient experience/satisfaction; provider experience/satisfaction. Data are measured by increased access to care, reduced cost and use, improved health care processes and outcomes, and increased satisfaction rates.

Which of the data types are being shared?: 

Progress toward implementing PCMH capabilities, quality and use data, qualitative data regarding practice transformation activities, barriers to success, catalysts of success, and methods used to collaborate with other providers.

Are the practices involved in the demonstration participating in any data sharing arrangements? If so please describe.: 

Yes; there is a data-sharing workgroup, and POs are expected to collaborate on a variety of programmatic elements, including data use.

Results to Share: 

A rigorous evaluation of the PCMH Designation program will be completed in fall of 2010, after year one of the program has been completed. Preliminary results from 2008 indicate the following:

  • PCMH-designated practice units had radiology utilization rates that were 13.7% lower than non-designated practice units.
  • PCMH-designated practice units had ER visit rates that were 12.3% lower than non-designated practice units.
  • PCMH-designated practice units had inpatient discharge rates that were 11.3% lower than non-designated practice units
  • PCMH-designated practice units had low-tech imaging rates that were 11.3% lower than non-designated practice units
  • PCMH-designated practice units had high-tech imaging rates that were 16.4% lower than non-designated practice units
Relevant links: 

http://www.valuepartnerships.com