UPMC Patient-Centered Medical Home Model

Program Location: 
Pittsburgh, PA
Payer Type: 

Reported Outcomes


The UPMC Health Plan is part of a large, integrated delivery and financing system headquartered in Pittsburgh, Pennsylvania. From 2008 through 2010, sites participating in the plan’s PCMH pilot achieved lower medical and pharmacy costs; and lower utilization of services such as ED visits, hospital admissions and readmissions. The plan also experienced a 160 percent return on the plan’s investment when compared with nonparticipating sites. As part of the initiative, UPMC provided each participating site with a practice-based nurse care manager, who was trained and employed by the health plan. Six care managers were assigned to the ten sites and were made available by telephone and electronically to their assigned practices, regardless of which office they were in at any particular time. Practice-based care managers provided care management support at the participating sites for certain high-need members with one or more chronic conditions, including diabetes, heart disease, depression, and asthma. Members were identified as high need based on a risk-stratification methodology that combined data from a variety of sources. 

The State Health Care Innovation Plan cites that the UPMC Health Plan has been contracting for PCMH services for several years, initially on behalf of Medicare Advantage members and currently for all lines of business, including commercial, Medicaid and CHIP. UPMC Health Plan currently has 178 PCMH sites, employing 45 practice-based care managers and serving 155,178 members. The sites have already madesignificant strides in improvements to quality of care and UPMC is hopeful to also impact and reduce the total cost of care. Recently, UPMC has added shared savings (upside risk only) to its PCMH site contracts and has shared savings agreements with eight practices, serving 121,451 enrollees. UPMC provides financial and programmatic support for the PCMH models in primary care, specialty medical care and those with a behavioral health base. 
Payment Model: 

A practice-based care manager is assigned to each practice site, and a care support team located at UPMC Health Plan works with the care manager to support care coordination for the Health Plan members who use that practice. The support team also links the member to community resources when appropriate.

Fewer ED / Hospital Visits: 

Changes in Hospital Service Use (per 1,000 members)

  • 0.5% increase in inpatient admissions v. 3.1% for non-PCMHs (2008-2009); 2.8% fewer inpatient admissions v. 1.6% increase in non-PCMHs (2009-2010)
  • 12.5% fewer readmissions v. 0.4% increase in non-PCMHs (2008-2009); 18.3% fewer readmissions vs. 1.4% fewer in non-PCMHs. (2009-2010)
  • 6.1% increase in ED visits v. 8.1% increase in non-PCMHs (2008-2009); 5.1% reduction in ED visits v. 1.5% reduction in non-PCMH's (2009-2010)
Cost Savings: 
  • 2.6% reduction in total costs
  • 160% health plan ROI
  • $15.84 lower PMPM for total costs, p<.001 (2009-2010)
  • $4.74 lower PMPM for medical costs (2009-2010)
  • $11.11 lower PMPM for pharmacy costs, p<.001 (2009-2010)
  • $0.03 lower PMPM for behavioral health outpatient costs (2009-2010)

The total cost reduction for sites participating in the PCMH program initially lagged behind improvements in service use and clinical quality.  However, within the first year, overall medical costs were contained, while decreases in pharmacy costs were accelerated. This led to a significant reduction in total costs by the end of the second year.

Increased Preventive Services: 

From 2008-2010:

  • 6.6 percentage point increase in HbA1c testing v. 3.4 percentage point increase in non-PCMH
  • 23.2 percentage point increase in eye exams v. 7.1 percentage point increase in non-PCMH
  • 9.7 percentage point increase in LDL screening v. 2.9 percentage point increase in non-PCMH
  • 6.8 percentage point increase in nephropathy monitoring v. 4.8 percentage point increase in non-PCMH
  • 2.0 percentage point increase in breast cancer screening v. 0.1 percentage point decrease in non-PCMH
  • 0.2 percentage point increase in management of acute depression v. 0.1 percentage point decrease in non-PCMH
Last updated September 2014
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