CareFirst Patient-Centered Medical Home - DC

Program Location: 
Washington, DC
Payer Type: 
Carefirst Blue Cross Blue Shield

Reported Outcomes


CareFirst’s PCMH program is designed to provide primary care providers with a more complete view of their patients' needs and of the services they receive from other providers so that they can better manage their individual risks, keep them in better health and produce better outcomes. The program requires greater provider-patient engagement and it meaningfully compensates providers for that engagement. To support its PCMH program, 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. Approximately 66 percent of participating primary care panels – groups of physicians that join together to participate in the PCMH program – earned increased reimbursements for their 2012 performance in the program. 

Payment Model: 
  • 12 percentage point increase added to current fee schedule
  • New fees for developing care plans for select patients with certain chronic or multiple conditions that put them at risk and for monitoring progress against those plans
  • Additional fee schedule increases (up to an 80 point increase) based on providers’ engagement with their patients, the quality of care delivered to their entire cohort of patients, and actual aggregate costs of care compared to expected costs.

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

Fewer ED / Hospital Visits: 

CareFirst Industry Report (July 2015)  evaluation of the 4th year of the program. Service area includes Northern Virginia and DC

  • Since the beginning of the program in 2011, PCMH members have had*:
    • 19% fewer hospital admissions
    • 15% fewer days in the hospital
    • 20% fewer hospital readmissions for all causes
    • 5% fewer outpatient health facility visits
  • In 2014 alone, PCMH members experienced*:
    • 5.1% fewer hospital admissions
    • 10.7% fewer days in the hospital
    • 8.5% fewer hospital readmissions for all causes
    • 12.5% fewer outpatient health facility visits

CareFirst Industry Report (July 2014)

  • 6.4% fewer hospital admissions
  • 8.1% fewer hospital readmissions for all causes
  • 11.1% fewer days in the hospital

* results per 1000 CareFirst members

Improved Health: 

CareFirst Press Release (June 2013)

  • 3.7% higher quality scores for panels that received incentives
  • Quality scores for PCMH panels rose by 9.3% from 2011 to 2012
Cost Savings: 

CareFirst Industry Report (July 2015)  evaluation of the 4th year of the program. Service area includes Northern Virginia and DC

  • Health care costs for CareFirst members in a PCMH were $345 million less than projected in 2014
    • this is an improvement over 2013 data when costs were $130 million less than expected
  • Since 2011, medical costs for PCMH members have been $609 million less than expected
  • Approximately 84% of provider panels earned Outcome Incentive Awards (OIA) based on quality and degree of savings they achieved
    • An average award, in addition to a particiaption fee, amounted to $41,000 -$49,000 in increased revenue

CareFirst Industry Report (July 2014)

  • In all, the PCMH Program has saved $267 million in avoided costs when measured against the projected cost of care from 2011 to 2013

CareFirst Press Release (June 2013)

  • average of 4.7% savings for primary care panels that received an Outcome Incentive Award
  • $98 million in total costs savings 
Other Outcomes: 

CareFirst Industry Report (July 2014)

  • 11.3% fewer outpatient health facility visits
Last updated July 2015
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