The Patient Centered Medical Home Positive Impact On Health Care Cost And Quality: CareFirst

Rationale / Objectives

The high cost of health care for patients with chronic conditions and high risk as a result of aging population and unhealthy lifestyles Unsatisfactory healthcare outcomes due to insufficient or inadequate treatment. Lack of communication between primary healthcare providers and independent specialists with regard to chronic care for patients

Project/Program Description & Major Achievements

CareFirst BlueCross BlueShield in Northern Virginia implemented the Patient Centered Medical Home to resolve the high cost in health care and unnecessary referrals, and enhance the clients’ satisfaction. Since the implementation in 2011, the program has save nearly 100 million dollars for its members in the region.

Lessons Learned

Primary care physicians play a key role in making care decisions and recommendations for their patients. Decisions on when and where to refer a patient for tests or to a specialist directly affect the subsequent quality and cost of care.

Further Description

The Patient Centered Medical Home (PCMH) Collaborative is implemented by CareFirst Blue Cross Blue Shield to provide primary care providers with a more complete view of their patients' needs and of the services they receive from other providers. This would help them better manage their individual risks, keep them in better health and produce better outcomes. The program facilitates implementation of care plans directed by primary care physicians with the support of local care coordination teams led by RN care coordinators. The care coordinators arrange for and track the care of those members who are at highest risk or who would benefit most from a comprehensive care plan. Moreover, web and broad band connection are provided between physicians and subscribers to enhance communication. Plus, the clinical decision – making of primary care physicians are supplemented with resources and information from program. Physicians are given rewards and increase their reimbursement while healthcare cost for client can be decreased.

Major Achievements

Metric Result Detail
Implementation of the PCMH Program     $98 million less for 1 million member covered by the program at CareFirst, servicing services in Maryland, Washington and Northern Virginia   2014 PCMH Program Performance Report 1
Group of primary care physicians join the PCMH program 66% of participating primary care panels   12%point increase added to current fee schedule  
Hospitals Admissions for members since 2011 19% fewer hospital admissions
Days in the hospital since 2011 15% fewer days in hospital
Hospital readmissions for all causes since 2011 20% fewer hospital readmissions
Outpatient health facility visits 2011 5% fewer outpatient facility visits