Facilitating the Patient-Centered Medical Home—On a Grand Scale

April 10, 2013
In Michigan, Blue Cross Blue Shield of Michigan has implemented and grown a patient-centered medical home initiative that is already the largest in the country, with over 3,000 physicians involved. What David Share, M.D. and his colleagues are learning has strong implications for PCMH development nationwide.

In August, the Detroit-based Blue Cross Blue Shield of Michigan (BCBSM), which covers 4.4 million members, designated a record number of Michigan physician practices across the state as patient-centered medical homes. Altogether, 994 medical practices comprising 3,017 physicians, were designated as patient centered medical homes (PCMHs), representing a 28-percent increase in such designations over 2011. For the fourth consecutive year, BCBSM was able to cite its program as the largest of its kind in the U.S.

Following that announcement, David Share, M.D., vice president of value partnerships, spoke with HCI Editor-in-Chief Mark Hagland regarding the program, and the implications of its success, for the healthcare industry nationwide. Below are excerpts from that interview.

Tell us about how your health plan organization achieved these numbers; they’re quite impressive.

It is the largest patient-centered medical home program in the country. In most communities, people talk about patient-centered medical home pilot programs, but our program, grounded in the medical home model, is a much bolder approach than just testing out that model—we aim to help providers create a more coordinated, effective, organized, and efficient system that engages patients and community members with providers in a partnership, and allows them to get care when they need it and where they need it, in the most efficient way possible. And the medical home by itself isn’t the end state; the goal is a highly effective program.

David Share, M.D.

What are the core concepts behind your initiative?

That you manage care, that you empower patients through self-management; that you use information systems to support e-prescribing and electronic patient registries; and that you use care management systems to proactively manage care. What’s unique about our approach is that, instead of thinking about a doctor in an individual practice, the idea is that doctors don’t practice in isolation, and that patients get care from communities of doctors. And in large part, the problem is that there’s a lack of systems to bring those doctors together, across the continuum of care.

So we’re trying to connect those doctors. And also, the individual doctor or practice doesn’t have the technical knowledge or the informational infrastructure or resources to build electronically based care management systems. But when you gather together in groups, you can aggregate resources to build new systems. And another core advantage of that is that as you build those systems together, they begin to think a lot more about what it means to actually coordinate care across systems. There are over 17,000 enrolled, and 92 physician organizations, in our program.

Practicing in groups of what size?

Somewhere around 6,000 of those 17,000 are primary care doctors, and the rest are specialists. And over half of those doctors are in practices of three or fewer practices. So we’re creating communities of physicians.

You’re actually aggregating physicians through this, then?

Well, we’re channeling their aggregational activities. We don’t tell them which hospital to affiliate with, for example. We deliver reports to the communities of doctors who come together, so they can see their results within their self-organized communities. And we also share those reports at the office level and the doctor level. And it’s not for us to try to micromanage their practices.

Here’s an example: if you have a doctor, an internist, practicing in an impoverished neighborhood, and that internist has a special interest in people with multiple chronic illnesses, such as heart disease and diabetes—we’ve found that that doctor really wants that information. And if you just measure one doctor’s practice, you might conclude that that one physician is over-utilizing medications or procedures or something, when that wouldn’t provide the full picture. If you look community-wide, it provides the fuller picture.

When did the program begin?

We organized it in 2004 with leaders in the physician community throughout Michigan. We said to them, let’s sit down and talk about what a high-performance health system would look like, and how we might incentivize that. Sin January 2005, we organized the Physician Group Incentive Program, and we had 10 physician organizations and 3,000 doctors at the beginning. And at the time, the patient-centered medical home model wasn’t yet begin talked about; instead, its precursor, the chronic care model was being focused on. It was similar, except that it only focused on members with chronic conditions. Over time, we were able to expand the concept to include well people who needed preventive care to keep them healthy.

So within a couple of years after that, we began talking about the advanced medical home model, and shortly after that, the patient-centered medical home model. And we had begun to describe a set of 12 domains within the medical home model—elements like care management, patient registry, preventive services, linkage to community services—different domains of activity. And we’ve described 130 capabilities for a very detailed, specific system. So that was in 2007 that we first described all that, and created these very specific capabilities and incentives—the more capabilities they create, the more incentives they gain. And by 2009, there were enough practices within these physician organizations that had built many of these capabilities, that we were able to identify 300 practices in the state in the incentive program that achieved both a critical mass of medical home capabilities, and also good performance on quality and cost within the medical home model.

And so in 2009, we started the designation of the patient-centered medical home model, with 300 designated practices. Then we began to tell our insured members about these 300 patient-centered medical home-designated provider practices, and began encouraging patients to go to them. We also began paying those doctors an additional 10 percent for providing this more comprehensive, team-based care.

What kinds of outcomes have you been able to document?

One of the elements we put into place was a generic medication use rate, to encourage the use of low-cost generics. And the practices in the incentive program began using generics at a much higher rate than the practices not in the program. Also, the practices in the incentive program began to reduce the use of diagnostic imaging, and so high-tech imaging use rates began to flatten. And very specifically, if you look at the medical home practices, they have a use rate for high-tech services that is eight percent lower than those not in the program, during calendar year 2011. For acute respiratory infection or diarrheal illness, you look at whether they’re admitted to the hospital or not, as the admission rate for conditions that could be managed well in the outpatient setting if people had good access—and the medical home model includes the concept of improving access to care in the outpatient setting. So you should see a lower rate of admissions in that area. In fact, we’ve seen a 23.8-percent reduction in t
The rate of admissions among the medical home practices, compared to the non-designated practices, during calendar year 2011.

Do you have any kind of health information exchange going on?

There are three communities that are developing a health information exchange, and are using one on a limited basis, in terms of the information involved or providers involved. They’re not widely used in Michigan yet.

It seems to me that HIE would be a natural area for collaboration in this arena.

Well, we have incentives in place, domains of function in the medical home. And one of the areas concentrates on patient registry, electronic records, and mobilizing electronic information to provide caregivers with comprehensive communications to support care. So that is included within the 130 capabilities. But we don’t declare that the practices will only get the incentive money if they’re in an HIE. We tell them, we would like you to get these capabilities in place, and how you get them is up to you. Some are vertically integrated systems, and some are federations of independent practices. But the resources involved are substantial. And we’re trying to help support them with finances to overcome the barriers, but we’re not prescribing that they follow specific paths.

What would you like the physician practices to be doing, IT-wise, to support this kind of care?

There are two key capabilities related to IT. The most important one is that when you have a group of primary care practices and specialists and they’re involved with hospitals in organized systems of care (and we have incentives in that area also), the most important element is to have a comprehensive electronic patient registry, one that is uniform and accessible to all its caregivers. Without that, you don’t know who your population is, and are unable to provide effective, care, so that comprehensive development of uniform registries is number one. And the other is, for the purposes of care management and care coordination—the coordination and management of care, so, links to the registry that allow caregivers to communicate seamlessly about patients’ records, medications, imaging. So the purposes of a systematic management of care, capability number two, that’s my other wish.

What will happen in the next few years in this program?

These federations have now created 40 systems of care, and they are now building linkages between their office-based and facility-based physicians, to create a highly-functioning system. So as we move towards value-based purchasing, these systems will become more mature, and will be able to guarantee a higher level of efficiency. So this has come into focus. And I expect that this will develop rapidly over the next few years.

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