Finding a home: Blue Cross medical home pilot targets quality, costs

By Ken Ortolon
Senior Editor, Texas Medicine

Plano family physician Christopher Crow, M.D., M.B.A., says Village Health Partners, the 10-physician primary care group where he practices, was built on giving patients access to care, convenience, and quality.

So he says it was only natural for him and his colleagues to get on board when Blue Cross and Blue Shield of Texas asked them to participate in a pilot program to measure how effective a patient-centered medical home could be at improving quality and controlling health care costs. The medical home model “is basically how our model has always been at Village Health Partners,” Crow says.

The pilot couples what some are calling “aggressive care coordination” by participating physicians with extensive feedback from BCBSTX on several quality and patient satisfaction measures. Practices get a per-patient-per-month care management fee and share in whatever savings are achieved if they hit the cost and quality benchmarks. The fees and shared savings are negotiated between the individual practices and BCBSTX, Crow says.

Norman Chenven, M.D., founder and CEO of Austin Regional Clinic, whose group joined the pilot program in January, says the BCBSTX medical home model is physician-led in that the carrier chose to contract directly with the physician groups to provide coordination of care rather than bringing hospitals into the program.

Just over a year into the pilot project, Crow says the preliminary results look very favorable. His practice already has seen lower hospital readmission rates, reduced inappropriate emergency department usage, and higher quality scores on chronic disease and preventive care measures.

And he is excited about the impact of the patient-centered medical home model on health care delivery in Texas.

“In fact, I can see how we could create some win-wins across the board in terms of pushing a model that provides access and quality, and potentially could bend the curve for some cost controls,” he says.

BCBSTX officials are so impressed with the early results that the insurer added three additional practices to the pilot program. The program now includes five sites in the Dallas area, Houston, Austin, and Tyler, and covers more than 100,000 patients, including more than 40,000 beneficiaries within the Employee Retirement System of Texas, and 500 physicians.

Lee Spangler, J.D., vice president of medical economics for the Texas Medical Association, says TMA has not taken a position on the BCBSTX medical home pilot, but TMA generally supports attempts to find new ways to deliver care that truly improve outcomes, create value for patients, and don’t add hassles for the physicians.

Proof of concept

Eduardo Sanchez, M.D., M.P.H., senior vice president and chief medical officer for BCBSTX, says the insurer is looking at expanding the patient-centered medical home model throughout Texas, New Mexico, Oklahoma, and Illinois, the four states covered by Health Care Service Corp., BCBSTX’s parent company.

“We, just like everyone else, have heard a lot about the notion of a patient-centered medical home,” Sanchez says. “We reviewed all the existing evidence base and looked at what the potential was to getting that done in Texas. When all of those things got put together, we decided to start last year with two sites where we have now one year’s worth of experience with some pilots.”

Crow says participating practices have agreed to some “shared quality metrics” based on National Committee for Quality Assurance criteria for certification as a medical home. They cover disease management, preventive care services, and patient satisfaction, he says.

Sanchez says BCBSTX chose only a subset of the NCQA criteria because the company was “more interested in proof of concept as we got going and didn’t want to get caught up in a set of criteria that weren’t going to help us move the needle along as quickly as we would have liked.”

The program, referred to by BCBSTX as the Accountable Practice Model, began at Medical Clinics of North Dallas in January 2010 and then Village Health Partners in February 2010.

On Jan. 1, 2011, three additional practices—ARC, Kelsey-Seybold Clinic in Houston, and Trinity Clinic in Tyler—joined the program. Those pilots largely are centered on ERS health plan enrollees, but also include patients in BCBSTX fully insured products.

Houston internist Spencer Berthelsen, M.D., board chair of the Kelsey-Seybold Medical Group, says his group signed on because the medical home pilot was “a natural extension” of what it already was doing.

“We’ve been doing a form of coordinated care long before the phrase was coined,” Berthelsen says. “We can qualify for medical home certification under NCQA and are in the process of doing that.”

Rob Kukla, ERS director of benefit contracts, says his agency’s interest in medical homes stemmed from legislation Lt. Gov. David Dewhurst pushed in 2009.

“The Legislature and, in particular, the lieutenant governor, really wanted us to explore new methods to compensate physicians to do two things. One is to improve quality of care in our program and then try to move away from the fee-for-service model that has existed for years,” Kukla says.

While the bill didn’t pass, ERS got the message. It approached BCBSTX, which administers the ERS plan, about pilot-testing the medical home model for its enrollees.

Berthelsen says the medical home is an important concept and “a necessary first step” toward more comprehensive care coordination.

“The patient-centered medical home really focuses on primary care, which needs more focus in American medicine and public policy today,” he says. “But it’s not, by itself, sufficient. We really need to have systems of care that incorporate all aspects—outpatient, inpatient, primary care, specialty care—all together.”

Sanchez agrees. “Physicians should be responsible and incentivized to coordinate care for their patients, not only in the primary care setting but also across any specialty referrals, hospitalizations, etc.,” he says. “The literature tells us that when one organizes care around a primary care home, you get three great outcomes. One, you get better medical care outcomes; two, you get better and higher patient satisfaction; and, three, you reduce costs.”

Proactive coordination

Austin family physician Gregory Sheff, M.D., the medical director for the ARC pilot, says the program includes 21 measures that look at both processes and outcomes. For example, the measures gauge whether a hemoglobin Alc test was done for patients with diabetes and whether the Alc results were below an established level.

BCBSTX spokesperson Margaret Jarvis says the full list of measures is proprietary but is centered on chronic diseases such as diabetes, coronary artery disease, and asthma, as well as preventive screenings and patient satisfaction.

Sheff says ARC has 44,000 BCBSTX patients in its practice, including more than 25,000 ERS enrollees. He says ARC approaches the pilot in a manner that allows it to provide “more proactive and coordinated care for all of our patients.” That includes creating a clinical data repository that allows them to make sure they are addressing gaps in care that are identified.

Chenven says it uses the care management stipends it gets from BCBSTX to develop that clinical data repository. ARC includes not only patient data from its own electronic medical record system, but also claims data received from BCBSTX, as well as prescription data from the ERS plan’s pharmacy benefits manager.

Chenven says the repository allows ARC physicians to print reports that can be used during office visits so they can address preventive care gaps for otherwise healthy patients, such as whether a female patient has had a mammogram in an appropriate period of time. Physicians also can use the reports to ensure that patients with chronic illnesses are current on all needed tests or treatment, he says.

“That allows the physician at that visit … either to catch up on the issues or schedule a follow-up appointment to catch up on them,” Chenven says.

Crow says getting additional data on their patients from BCBSTX is essential to understanding where Village Health Partners stands in meeting both quality and cost measures.

“Physicians can never truly understand costs unless they’re getting them fed back to them in some type of relevant way,” he says. “And once you understand where you fall above or below the average and what the average is—whether that be ER visits or hospitalizations or hospital readmissions or specialist referral rates—then you can know what to focus on and whether what you’re focusing on is appropriate.”

For example, data he receives from BCBSTX show his practice has a higher than usual referral rate for physical medicine and rehabilitation specialists. “But that’s because we make sure that all of our back pain patients go to a PMR physician, which is nonsurgical, and make sure they get all the things possible done for their back pain, and surgery is the last resort,” Crow says. “We’re okay with being an outlier there because it improves the total cost of care if you’re keeping people out of unnecessary back surgeries.”

On the flip side, the data showed that Village Health Partners patients use hospital emergency departments for care even when their offices are open. Crow says his practice would not even know those patients were going to the emergency department without the feedback reports it is getting from BCBSTX. That led the practice to beef up efforts—including partnering with employers—to encourage patients to call their office before going to the emergency room.

“What we found was well over half of those emergency room visits could have been handled in our office at a more appropriate place, at a more appropriate cost level,” Crow says.

Meeting the goal

Participating physicians are optimistic they will be able to meet the quality and cost measures set out in the pilot, even though there likely will be added cost early in the program as they catch up on preventive and chronic disease care their patients need.

“It’s a three-year pilot, and we’re definitely optimistic that we’ll improve quality and cost over the course of the three years,” Sheff says. “We certainly expect to see an improvement over our baseline in the first year and definitely want to be hitting all the quality goals by the second, and we think that’s realistic.”

Sanchez also is optimistic and says BCBSTX hopes to add additional self-funded employer groups as the program evolves.

And, Kukla says ERS believes so strongly in the program that it would entertain discussions with other physician groups interested in joining the program.

“Our feeling is that by coordinating care and helping ensure that members are compliant with a doctor’s regimen, we will in fact be able to control health care spending because the members will have better total outcomes and will be healthier as a result of this outreach.”

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Basic elements of a medical home

The National Committee for Quality Assurance has identified nine standards required for achieving status as a medical home. Within those standards are some 30 additional elements and 183 so-called data points.

Among the NCQA’s required standards are:

• Patient access and communication, including elements such as coordinating visits with multiple clinicians or diagnostic tests in one trip; providing telephone advice on clinical issues during office hours by a physician, nurse, or other clinician within a specified time; and providing secure e-mail consultations with a physician or other clinician on clinical issues, answering within a specified time.
• Use of patient tracking and registry functions, including status of age-appropriate preventive services, presence of an advance directive, age-appropriate risk factor assessment, and more.
• Care management, including conducting pre-visit planning with physician reminders of preventive or other services that need to be addressed, use of individualized care plans, and use of individualized treatment goals.
• Use of patient self-management support, including documenting communication needs; assessing patient/family preferences, readiness to change, and self-management abilities; and providing a written care plan to the patient or family.
• Use of electronic prescribing.
• Use of test tracking, including use of electronic systems for managing tests, follow-up on abnormal test results, and notifying patients of normal test results.
• Use of referral tracking systems that include information on origination of the referral, clinical information, referral status, and other details.
• Use of performance reporting to facilitate quality improvement efforts.
• Use of advanced electronic communications, including an interactive website that allows patients to request appointments, referrals, test results, and prescription refills.

For more information on the NCQA standards, go to the NCQA website, www.ncqa.org.

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First published by Texas Medical Association (May 2011). Reprinted with permission.