As the nation looks to transform healthcare from delivering too much care to consistently delivering higher quality, high-value care, Blue Cross and Blue Shield of South Carolina isn't waiting for a healthcare reform law.
While reform percolates
S.C. Blues, docs team up for medical home pilot
We are working with the provider community to look at things differently. A great example is a patient-centered medical home pilot with Palmetto Primary Care Physicians in three counties in the Charleston, S.C., area.
A yearlong collaboration that started in April, the pilot focuses on our diabetic members who are patients of PPCP. More than 1,500 people are enrolled.
Payment is transformed to align with delivering quality care. In addition to traditional fee-for-service payments, a per-participant, per-month fee is added to allow the practice to hire case managers to coordinate patients' care plans, cover physician time to participate in case management meetings and hire staff to conduct on-site education.
The PPCP case managers integrate with Blue Cross disease managers to coordinate use of insurance benefits and disease-management programs. An electronic link from the disease-manager coaches to the practice's electronic health record speeds communication with providers and aligns communication with the physician's treatment plan.
Blue Cross started the project by mailing introductory information to eligible members. PPCP hired case managers who contacted eligible patients by phone to further explain the program, gather baseline health data and encourage them to use an online portal. The portal contains tools to manage their disease and an option for “e-visits” with a physician, so continuity of care can be maintained when patients are traveling.
There is no copayment or extra charge to the patients, and very few opted out.
The case managers are now following each patient through their care continuum as they aim to reduce gaps in care and address lifestyle issues. They perform outreach, such as registering patients for diabetic education, scheduling appointments with specialists, providing discount vouchers for medications, offering discounted memberships to local gyms and monitoring quality processes and outcomes measures.
At the end of the pilot's year, if improvement in quality measures has been achieved, we will reward PPCP with a bonus.
There have been challenges. The case managers reported that most people never read the first Blue Cross mailing, and many had a hard time understanding the concept but were still willing to participate because there was no charge. It also took longer than expected to reach each patient by phone, even with night and weekend calls. Setting up the online portal and establishing links with Blue Cross and local emergency rooms was technologically challenging.
But early successes were noted. A case manager called a patient and found he had just lost his job. He had little feeling in his feet and had an infected toe but did not plan to address the problem because of his high-deductible insurance plan. The case manager and Blue Cross' diabetic educator coordinated to provide a bridge supply of medication and test strips, education materials, drug copay assistance and an office visit. The patient later reported that his finances had improved, and he “never felt better.”
Another patient was confused about glucose levels and shocked to find her levels were high at a recent appointment. After conversations with the case manager and a Blue Cross certified diabetes educator, the patient attended a diabetic education class and described it as “fantastic and enlightening” and said she is “looking at everything differently.”
The goal of this pilot is for health plans and physicians to work together to reduce the disconnects in healthcare, improve quality of life for patients, create tighter relationships and better communication and add a focus on measurement of quality and continuous improvement of clinical outcomes.
We believe this could become a model for South Carolina.
Laura Long, a physician, is vice president of clinical quality and health management at Blue Cross and Blue Shield of South Carolina, Columbia.
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