The Patient-Centered
Medical Home
Neighborhood
March 29, 2014
Jean Malouin, M.D., M.P.H.
Medical Director, Value Partnerships
Agenda
• Defining the PCMH-N concept
• BCBSM PGIP Overview
• The BCBSM PCMH Neighbor
• Opportunities for Collaboration
• BCBSM Specialist Fee Uplifts
2
Defining the PCMH-N Concept
3
Joint Principles of the
Patient-Centered Medical Home
(AAFP, AAP, ACP, AOA)
•
•
•
•
•
•
•
4
Personal physician
Physician directed medical team
Whole-person orientation
Integrated, coordinated care
Quality and safety as hallmarks
Enhanced access
Payment structure for added patient value
PCMH-N: American College of Physicians (2010)
The ACP developed a position paper on the PCMH-N concept:
“The Patient-Centered Medical Home Neighbor: The Interface of
the Patient-Centered Medical Home with Specialty/Subspecialty
Practices”
• Highlights the important role of specialty and subspecialty practices within
the PCMH model
• Defines the PCMH-N concept
• Provides a framework to categorize interactions between PCMH and
PCMH-N practices
• Offers principles for development of care coordination agreements
• Recognizes the importance of financial and non-financial incentives
• Introduces the concept of a PCMH-N recognition process
5
ACP PCMH-N: Processes of care
• A PCMH-N practice engages in processes that:
– Ensure effective communication, coordination and integration with
PCMH practices
– Ensure appropriate and timely consultations and referrals
– Ensure the efficient, appropriate and effective flow of information
– Effectively guides determination of responsibility in co-management
situations
– Support patient-centered care, enhanced access, and high quality care
– Support the PCMH practice as the provider of whole person primary
care and as having overall responsibility for ensuring the
coordination/integration of care
6
BCBSM PGIP Overview
7
What is the Physician Group Incentive Program?
• BCBSM partners with Physician Organizations (POs) to achieve a high
performing health care system in Michigan
• The Physician Group Incentive Program (PGIP) is moving from a fee-forservice to a fee-for-value approach
• PGIP offers rewards to:
– POs to assist with infrastructure improvement and practice
transformation
– Practitioners through fee-for-value-based fee uplifts
• Increasingly, a portion of professional reimbursement is tied to
rewarding specialists for:
– Supporting the PCMH model as PCMH-Neighbors
– Collaborating with their community of caregivers to optimize use,
efficiency and quality in their shared patient populations
8
BCBSM’s Award Winning Value Partnerships Programs
Moving from a Fee for Service to Fee For Value Environment
Physicians
Physician Group Incentive
Program
30 Initiatives
12 PCMH
7 Performance-based
8 Participation-based
3 OSC
• Approx 18,000 physicians participate
• 65% of MI PCP’s participate in PGIP
• $100M annual reward pool
• $33.7M 2014 projected specialist
fee uplift
• Affecting the lives of 1.5M Blues
members & Michiganders statewide
Hospitals
Hospital Incentive Program
Collaborative Quality Initiatives
(CQIs)
Hospital Pay-for-Performance
Program
• Rewards up to 5% based on
quality, efficiency, and
participation in selected CQIs
• 15 hospital & 5 professional CQIs
addressing surgical and medical care
•All 15 hospital CQIs analyze the care given to nearly
200,000 MI patients annually
• 75 Michigan hospitals participate in at least one CQI
Value-based Contracting (VBK)
• Ties hospital payment to
population-based performance
• Provides funding for population
management infrastructure
development
• 92% of Michigan hospitals participate in all the
Blue Distinction Centers Program
PCMH Designation Program
CQIs for which they are eligible
• 1,243 practices – up 20% over 2012
National designation for high quality
• Over 3,600 designated physicians
&
cost-efficient hospitals for Bariatric
• Four of our longest running CQIs have
• 2 out of every 3 PGIP PCPs are
Surgery, Cardiac Care, Complex and
saved over $232M in statewide savings
BCBSM PCMH-Designated
Rare Cancers, Knee/Hip Surgery, Spine
and
• $33M in 2012 PCMH related fee
Surgery, and Transplant.
over $70M for the Blues
uplifts for PCPs
Key Collaborative Relationships:
Center for Healthcare Research and Transformation (CHRT)
Michigan Health & Hospital Assn: Keystone Center for
Patient Safety & Quality
Michigan Primary Care Transformation Demonstration (MiPCT)
Michigan Quality Improvement Consortium (MQIC)
Value Partnerships programs have
been recognized by Blue Cross Blue
Shield Association (BCBSA),
Michigan Cancer Consortium (MCC),
National Business Coalition on Health
(NBCH), URAC, among others.
Physician Group Incentive Program: catalyzing health system
transformation in partnership with providers
2004

2005
2006
2007
2008
2009
Physician Group Incentive
Program
Patient Centered Medical
Homes
Chronic Care Model
Primary Care
Transformation
Physician Organizations have the
structure and technical expertise to
create highly functioning systems of
care

Design and execute programs in a
customized and collaborative
manner

Measure performance at the
population level and reward
improvement as well as absolute
performance: initial focus on
generic drug rate and building
patient registries


2010
Launch PCMH and quality
and use Initiatives
 Support building of PCMH
infrastructure
 In addition to generic drug
rate, measure preventive
and evidence-based care,
preventable emergency
department use, high and
low-tech imaging, inpatient
use
Include specialists involved
in chronic care
2011
2012
2013
OSCs
Organized
Systems of
Care

Build PCMH-Neighbor
model: expand PGIP to
include specialists

Catalyze building of
Organized Systems of
Care that assume
responsibility and
accountability for
managing the PCPattributed population of
patients across all
locations of care
1
3
PCMH designated physicians steadily increase each year
PCMH Designations
4,000
3,623
3,500
3,029
3,000
2,552
2,500
2,000
1,852
1,500
1,259
1,243
1,000
995
776
500
513
302
0
2009
2010
2011
2012
2013
Red denotes PCMH Designated Primary Care Physicians (PCPs)
Green denotes PCMH Designated Practice Units (PUs)
4
Health Services Research, July 5, 2013, Paustian, et al
5
BCBSM Department of Clinical Epidemiology and Biostatistics, June 2013
6
Physician participation in PGIP doubled in the past three years, driven
largely by the expansion to specialists
PGIP physicians
18,000
16,960
16,420
16,000

Today, over 70 percent of
BCBSM’s members are
attributed to a PGIP primary
care physician (PCP),
accounting for approximately
85 percent of costs

Specialists in PGIP cover 55
percent of BCBSM’s book of
business, with all physician
specialties participating
 In 2014, specialties
eligible for value-based
fee uplifts will increase
from seven to 24

$155 million in savings
were associated with PCMH
over a three year period,
through outcomes such as a
20 percent reduction in
ambulatory care sensitive
inpatient admissions
14,778
14,000
12,000
11,329
10,813
11,274
10,000
9,112
Specialists
8,148
8,000
Total
6,657
6,000
5,980
4,798
4,000
2,903
2,000
2,671
4,904
5,823
5,526
5,748
5,666 5,6075,631
4,270
2,325
1,076
0
5,330
PCPs
232
1,327
528
*
*Source data used to identify a PCP versus a specialist was changed, resulting in a more accurate depiction of PGIP composition.
2
PCMH partnerships are foundational for building Organized Systems of
Care to improve quality and reduce cost
Examples of Quality Improvement and Cost
Reduction Opportunities
Patient-Centered
Medical Home
PCMH
Care Partners
Neighbors
Health Care Providers
Community Services
Other Facility Providers
Hospitals
Other Specialists
Major Specialists
(Cardiology, Orthopedics,
etc.)
Complex Moderate
Care
Care
Manager Manager
• Coordinated health and
social services support
Shared Patient
Population:
Shared
Information
Systems and
Care Processes
PCP Attributed Patients
Primary Care
Physician(s)
*Derived from Harold Miller’s depiction of ACO models
• Improved management of
complex patients
• Improved outcomes and
efficiency for major
specialties
• Reduction in preventable
emergency room visits and
admissions
• Appropriate use of testing
and referrals
• Prevention and early
diagnosis
• Self-management support
7
What is an Organized System of Care?
PCMH
PCMH-N
Patient
Population
(PCP-attributed)
Other caregivers and
community services
17
Hospitals and other
facilities
OSC – Michigan Landscape
• As of January 2014, there are 39 OSCs in Michigan, spanning 16 counties.
Together, these OSCs account for 4,300 primary care physicians, 9,500
specialists and 1.3 million patients.
• The payment model currently provides incentives to support capability
development, with an underlying fee-for-value infrastructure. This model
will continue to evolve over time to support comprehensive population
management.
18
Ongoing OSC Development
• Organizations are continuing to implement OSC capabilities in
the following areas:
– Integrated patient registry — Creating a system-wide electronic
database of clinical data on patients
– Integrated performance reporting — Providing current, clinically
relevant health care information on the entire population of
OSC patients
– Integration of care processes — Developing processes to
communicate, coordinate and collaborate to achieve clinical
integration at the OSC level
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The BCBSM PCMH Neighborhood
20
PCMH-Neighbor +
Organized Systems of Care (2012 - present)
“BUILDING CONNECTIVITY TO IMPROVE POPULATION HEALTH”
PGIP participating
PCPs
Hospitals
PGIP participating
Specialists
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BCBSM PCMH-N Overview
• BCBSM recognizes the extremely valuable role that specialist physicians
and their care teams play in creating the ideal patient experience.
• To support specialists in building PCMH capabilities, BCBSM has expanded
its Patient-Centered Medical Home interpretive guidelines to incorporate
the Patient Centered Medical Home – Neighborhood (PCMH-N).
• The BCBSM PCMH-N program supports implementation of capabilities
that will further the development of a highly functioning OSC by enabling
specialists and sub-specialists, including behavioral health providers, to
partner with primary care physicians to help ensure good communication
and care coordination.
22
Patient Centered Medical Home – Neighbor
(PCMH-N)
•
•
23
Recognizes the important role of specialty practices within the PCMH
model
PCMH-N principles include:
– Providing appropriate and timely consultations and referrals that
complement and advance the aims of the PCMH practice(s)
– Establishing shared responsibility for relevant types of clinical
interactions
– Supporting patient-centered high-quality safe care and enhanced
access
– Recognizing the PCMH practice as the source of the patient's
primary care
– Understanding that the PCMH practice has overall responsibility for
coordination and integration of care provided to the patient
The Neighborhood and the Specialists
• Examples within the care delivery system where PCMH – N
capabilities might be applicable:
– Preconsultation exchange—intended to expedite/prioritize care, or
clarify need for a referral
– Formal consultation—to deal with a discrete question/procedure
– Co-management:
• Co-management with Shared Management for the disease
• Co-management with Principal care for the disease
• Co-management with Principal care of the patient for a consuming
illness for a limited period
• Transfer of patient to specialty PCMH for the entirety of care.
24
What does your medical neighborhood look like?
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Opportunities for Collaboration
• COMMUNICATION!
• Development of common IT platforms
– Health Information Exchange
– Electronic Health Record
•
•
•
•
•
Transmission of Admission, Transfer, Discharge information
Standardization of referral process - clear expectations for all parties
Test tracking
Access Optimization across primary and specialty care
Optimization of clinical care
–
–
–
–
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Standardization of clinical guidelines
Standardization of PCP follow up (oncology surveillance, etc.)
Appropriateness of tests and procedures
Collaboration on process for closing gaps in care
27
Choosing Wisely®
• Choosing Wisely® is an ABIM Foundation initiative
focused on specialty-specific evidence-based
recommendations around topics to help patients and
physicians make wise decisions about the most
appropriate care.
• http://www.choosingwisely.org/doctor-patient-lists/
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PGIP Specialist Fee Uplifts
30
Specialist Fee Uplifts: Key Points
• Fee uplifts are the primary method for rewarding specialists
• The fee uplift program rewards specialists who actively collaborate
with PCPs and their PO leadership to:
– Create improved systems and care processes
– Implement evidence-based care
– Promote efficient and effective care
• The measures BCBSM uses to select which specialists receive fee
uplifts are population-based and reward specialists who serve
patient populations with higher overall performance
• Eligibility for fee uplifts is determined on an annual basis with an
effective date of February
31
Specialist Fee Uplifts: Key Points (continued)
• Practitioners must be on the PGIP list by July 1 of the prior year to be
eligible for fee uplifts
• Fee uplifts are applied to most professional codes, excluding ambulance,
durable medical equipment, prosthetics and orthotics, anesthesia,
immunizations, hearing, lab, vision, dental and most injections
• Fee uplifts are applied only to PPO/Traditional Commercial claims
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Specialist Fee Uplifts Goals and Principles
Accelerate specialist
engagement in PGIP
Encourage
conversations and
collaboration between
specialists and primary
care practitioners
(PCPs)
Assess and improve
population-based
metrics of
performance
Focus on
communities of
caregivers with
shared responsibility
for managing a
patient population
33
Take steps towards
transforming
reimbursement from
traditional fee-forservice to fee-for-value
Support and promote
organized systems of
care
Accelerate the
adoption of PCMHNeighbor principles and
agreements
Determining Which Practices Receive a Performance-Based
Fee Uplift
• Eligible practices must be nominated by their member PO and, if
applicable, another PO
– Physician organizations nominate practices based on written and publicly
available criteria and founded upon Patient-Centered Medical HomeNeighbor principles
– Nomination is a necessary, but not sufficient, factor in receiving the uplift
• The practitioner must be signed up with PGIP by July 1 (prior to the fee
uplift year)
• BCBSM selects nominated practices based on one or more populationbased metrics of cost, quality, utilization and/or efficiency
• In 2014, BCBSM selected the top two-thirds of nominated, nonpediatric specialty practices plus all nominated pediatric specialty
practices to receive a fee uplift
34
Eligibility for Specialist Fee Uplifts – 2014
• A specialist must:
– Be a member of a PGIP PO
– Be listed with PGIP as a specialty type eligible for an uplift (based
on their primary credentialed specialty or “functioning as”
specialty) as of August 1, 2013 (i.e., the snapshot from the
Practitioner Alignment Tool)
– Be nominated by the member PO
– Be nominated by the principal partner PO (if applicable)
– Have a signed Primary Care-Specialist agreement with the PO
– Have a signed Primary Care-Specialist agreement with the
principal partner PO (if applicable) within the past 2 years
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Specialties Eligible for Fee Uplifts
2011
2012
2013
2014
2015
Oncology
Oncology
Cardiology
Oncology
Cardiology
Emergency Medicine
Gastroenterology
Nephrology
Obstetrics/Gynecology
Orthopedics
Oncology
Cardiology
Emergency Medicine
Gastroenterology
Nephrology
Obstetrics/Gynecology
Orthopedics
Allergy
Chiropractic
Critical Care
Endocrinology
Infectious Disease
Neonatal Care
Neurology
Otolaryngology
Pain Management
Podiatry
Psychiatry
Psychology
Pulmonology
Physical Medicine
Sports Medicine
Rheumatology
Urology
Oncology
Cardiology
Emergency Medicine
Gastroenterology
Nephrology
Obstetrics/Gynecology
Orthopedics
Allergy
Chiropractic
Critical Care
Endocrinology
Infectious Disease
Neonatal Care
Neurology
Otolaryngology
Pain Management
Podiatry
Psychiatry
Psychology
Pulmonology
Physical Medicine
Sports Medicine
Rheumatology
Urology
PLUS:
Most remaining specialties
36
Specialist Fee Uplift Metrics – 2014
• Metrics Used for Selection
– BCBSM scored and ranked practices based on one or more metrics of
quality, utilization, efficiency and/or cost performance
– BCBSM has specialty-specific metrics for Cardiology, Emergency
Medicine, Endocrinology , Gastroenterology, Nephrology, Ob/GYN,
Oncology, Ortho, Otolaryngology , Pulmonology
• Most metrics measure population-level performance, not practice unitspecific performance
• BCBSM develops comprehensive, specialty-specific metrics based on a
thorough review of the literature and evidence and in consultation with
subject matter experts
– For the 14 specialty types that have yet to be put through a metric
vetting process, population-level cost of care per member per month
is the only performance metric
37
2014 Specialist Fee Uplift Results
 69 percent of specialists in PGIP (8,348) were eligible for a
specialist fee uplift+*
 63 percent of the eligible specialists (5,300) were selected for a fee
uplift ranging from 2 to 15 percent on most of their professional
procedure codes
• 5056 practitioners selected for performance-based fee uplifts
• 215 physicians selected for a fee uplift based on participation in
oncology programs
– 175 physicians participated in PDCM-Oncology (a 5 percent fee
uplift added to any other fee uplifts received)
– 40 physicians received a 5 percent fee uplift for participation in
an oncology quality improvement program
• 226 physicians selected for a 2 percent CQI recognition fee uplift
+ Based on 8/1/2013 PGIP list containing 12,042 specialist practitioners
* Count includes 34 physicians awarded CQI recognition and 7 oncologists that were not in PGIP as of 8/1/2013
38
2014 Specialist Fee Uplifts – Tools and Resources
Available on the PGIP Collaboration Site/Uplifts Tab
• Specialty-specific fact sheets
• Specialty-specific slide decks (new!)
• FAQs
• Letter from David Share to individual practitioners receiving uplifts
Available on the PGIP Collaboration Site/Analytics Tab
• Training module – Specialist Fee Uplift Webinar (Feb. 2014)
Coming Soon!
• Specialty-specific, recorded webinars on specialist fee uplifts
• Slide deck on identifying and addressing PMPM cost opportunities
This document,
unique for
each specialty
type, describes
the specialtyspecific metrics
and the overall
selection
methodology
Thank You!
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