Healthcare Business News

Small practices key to CareFirst's medical home success

By Andis Robeznieks
Posted: July 11, 2014 - 12:45 pm ET

By combining forces, solo and small-group medical practices helped generate $237 million in savings over three years in CareFirst's Patient-Centered Medical Home Program, the insurer revealed Thursday.

CareFirst, a Blue Cross and Blue Shield affiliate covering the District of Columbia, Maryland and portions of northern Virginia, released findings demonstrating how 4,000 providers participating in its medical home initiative saved $130 million in 2013—the third year of the program—when healthcare spending came in 3.2% lower than projected for the 1.1 million Blues plan members who receive care at CareFirst primary-care practices operating as medical homes.

Chet Burrell, CareFirst's president and CEO, said savings were achieved chiefly through small practices working together in 5- to 15-provider panels that assumed no financial risk and were not subject to penalties if targets were not reached.

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The program has 422 panels composed of about 10 providers each—physicians and nurse practitioners—who receive per-member, per-month fees adjusted for risk, age and region, for a population of about 2,500 patients.

For the 69% of panels that reached their 2013 cost and quality targets, providers typically received awards of $25,000 to $30,000. The practices had to provide the care-coordination services that are the foundation of a medical-home practice model, but Burrell added that third-party certification of their medical-home capabilities—such as through the National Committee for Quality Assurance or the Joint Commission—was not required for participation.

Patients were not assigned to a particular provider, and the panels were created by the providers themselves, though Burrell acknowledged that CareFirst “ran a matchmaking service in the beginning” to help small practices find working partners. Nurse practitioners also could serve as a patient's primary-care provider.

“We did introduce people and we did hold forums,” he said, but “they chose each other.” Panels often formed based on previous professional or medical school relationships.

Engaging solo and two- to three-physician practices was important, Burrell said, because that's where roughly half of CareFirst's members receive their care.

Small practices understood the program's intent but didn't have the capabilities to make it happen, Burrell said, so the health plan provided additional support through data sharing and care-coordination nurses.

Nurses and social workers were “absolutely essential” to getting better results, he said.

Providers must be the ones to explain the medical home concept to patients. “If a patient trusts anyone, they trust their freely chosen primary-care provider,” Burrell said.

Patient trust is important because the program relies heavily on implementing care plans for seriously and chronically ill patients, and requires patient consent to carry out the plans. Crafting care plans can chew up practice resources and drive up expenses, so Burrell advised, “Be careful where you focus—don't do care plans for people who don't need them.”

CareFirst calculates that its risk-adjusted per-member, per-month cost is $254. Performance varies among the panels and is divided into quartiles of $228, $246, $265 and $295.

“Where you refer matters,” Burrell said in explaining the 30% difference between the top- and bottom-performing panels.

Follow Andis Robeznieks on Twitter: @MHARobeznieks

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