CareFirst BlueCross: 2,500 docs in patient-centered medical homes in 2011


Next year, CareFirst BlueCross BlueShield in Baltimore hopes that half of the 5,000 primary-care physicians in its network will be participating in the first-year launch of its full-scale patient-centered medical home program (called the Primary Care Medical Home, or PCMH, to emphasize the central role of primary-care physicians), spokesman Kevin Kane tells FierceHealthPayer.

CareFirst anticipates launching the PCMH program on Jan. 1, 2011, if the Maryland Health Care Commission grants regulatory approval by September as expected. (The state of Maryland plans to begin its own three-year patient-centered medical home pilot program in 2011 as well, and physicians will be able to participate in both programs, reports the Baltimore Business Journal.)

The health insurer, which serves close to 3.4 million members in the mid-Atlantic region, is still finalizing how the program will work, says Kane. However, participating physicians will get an increase in base reimbursement rates, as well as the chance to earn a bonus amounting to 50 to 80 percent of those base rates, relates the Business Journal.

CareFirst wants to start with practices of five to 20 physicians who have a wide range of patient types. The insurer will use previous claims as the basis for forecasting the annual total health costs for each patient population. Practices whose claims are higher than budgeted won't receive either a bonus or a penalty, while physicians whose claims total below budget and who meet certain nationally recognized National Committee for Quality Assurance (NCQA) standards will earn annual bonus payments.

The full PCMH program builds on a two-year pilot program that is 18 months complete, says Kane. "The program includes nine primary care practices, with 86 physicians. About 45,000 CareFirst members will directly benefit from the program and more than 150,000 patients overall (non-CareFirst). Cost of the program is expected to reach $5 million over the two years."

While CareFirst isn't ready to release the results of its pilot, Blue Cross Blue Shield of Michigan (BCBSM) in Detroit offers a glimpse of the possibilities. BCBSM's PCMH program, which began in July 2009, includes 1,200 designated doctors in 45 communities statewide. According to the insurer's preliminary analysis of 2009 claims data, its PCMH practices show the following improvements over non-PCMH practices:

  • A 2 percent lower rate of adult radiology usage and a 1.2 percent lower per-member, per-month (PMPM) cost.
  • A 1.4 percent lower rate of adult ER visits and a 0.6 percent lower PMPM cost.
  • A 2.6 percent lower rate of adult inpatient admissions and a 2.6 percent lower PMPM cost.
  • A 2.2 percent lower rate of pediatric ER visits and a 4.2 percent lower PMPM cost.

To learn more:
- read these Baltimore Business Journal articles: article 1 and article 2
- read the Blue Cross Blue Shield of Michigan press release

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