CareFirst BlueCross BlueShield’s Patient-Centered Medical Home Program: An Overview

CareFirst BlueCross BlueShield’s Primary Care Medical Home (PCMH) is a recently developed program designed to provide primary care providers with new incentives and tools to provide higher quality, lower cost care to CareFirst members. Understanding that ten percent of  CareFirst members account for 60 percent of the costs that CareFirst pays for health care services, and that nearly 80 percent of these patients suffer from multiple chronic conditions, the PCMH program is designed to enable physicians to closely coordinate care for the chronically ill, as well as help these patients better manage their diseases and improve their overall health. 

First-Year Results
In the first complete year of the program (ending December 31, 2011) nearly 60 percent of eligible primary care Panels (the small groupings/teams of primary care physicians and nurse practitioners that form the basis of the program) earned increased reimbursements for their performance in the PCMH program. Increased reimbursements - or Outcome Incentive Awards (OIAs) - are based on a combination of savings achieved by a particular Panel for its CareFirst members against projected annual total care costs for these members, as well as performance on quality measures related to the provision of care to Panel patients. OIAs for the program’s first year are paid to PCMH participants in the form of increased fee reimbursements for certain primary care services beginning July 1, 2012 and continuing through June 30, 2013. These incentives are earned and recalculated each year depending on Panel performance the previous year. 

Highlights of the first-year of the PCMH program include:

• Program participants (Panels) earning OIAs achieved an average 4.2 percent savings against expected 2011 care costs. 
• Panels that did not earn OIAs registered costs that averaged 4 percent higher than expected for 2011. 
• On average, Panels earning OIAs saw an increase in their reimbursement level of 20 percentage points. This increase is in addition to a 12 percentage point increase paid to all participants that continue to remain in good standing in the PCMH program. 
• The cost of care for all CareFirst members attributed to PCMH participants was 1.5 percent lower than had been projected for 2011. 
• Quality scores for panels receiving an OIA and those not receiving an OIA were comparable.