QUEST Primary Care Patient-Centered Medical Home & Pay for Quality Program

Program Location: 
Honolulu, HI
Payer Type: 
Blue Cross Blue Shield of Hawaii

In 2010, the Hawaii Medical Service Association (HMSA) adopted the patient-centered medical home (PCMH) model for primary care providers as its value-based health care initiative. Hawaii QUEST is a Medicaid managed care program run by the Blue Cross Blue Shield health plan HMSA. The HMSA QUEST value-driven health care initiative consists of a PCMH program, a pay-for-quality program, and a Hospital Value-Driven Health Care Program. These programs represent the goals of value-driven health care by aligning payment with quality and efficiency and one of the major goasl of this state program is to integrate behavioral health and social services with primary care.

The QUEST pay-for-quality program is designed around adult and pediatric primary care and will include all of the commercial pay-for-quality measures . The first year of the QUEST PCMH and pay-for-quality program will run from July 2012 through June 2013 . For the first year, providers with 100 or more QUEST members will be eligible to participate in the QUEST pay-for-quality and/or PCMH programs.

Payment Model: 

A hybrid reimbursement model is used that incorporates FFS with a population health management fee.  The population health management fee is paid on a PMPM basis in recognition of the physician’s responsibilities in managing the overall health and health care needs of the member. HMSA is funding the PCMH population health management fees as follows:  Level 1 - $1.00 PMPM, Level 2 - $1.50 PMPM, Level 3 - $2.00 PMPM.

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Last updated May 2014
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