PCMH Program Delivers Healthier Patients and Happier Providers

By James Napoli, MD, MMM, CPE, Senior Medical Director, Provider Partnership and Clinical Transformation, Blue Cross Blue Shield of Arizona

Providing high-quality care is multifaceted and requires everyone in the healthcare field to think differently. At Blue Cross Blue Shield of Arizona, we are committed to finding approaches that will enhance the patient experience while reducing the cost of healthcare.

We believe it’s important to harness new models of primary care, such as Patient-Centered Medical Homes (PCMH), to make healthcare better for all Arizonans. In fact, we’ve been helping physicians evolve their practices to a value-based setting for several years and we are seeing a difference in the outcomes. Patients are healthier and more engaged, and practices are becoming more productive and efficient.

The PCMH Model

The BCBSAZ PCMH program embraces a pay-for-performance model, emphasizing evidence-based quality care and documented outcomes. When we launched our PCMH program in 2011, we focused on four chronic conditions. We have since expanded it to include the big six—asthma, diabetes, congestive heart failure, chronic obstructive pulmonary disorder, hypertension and coronary artery disease.

As a provider, it’s important to manage the total patient by addressing condition management, social and behavioral health, and maintaining a healthy and productive lifestyle. BCBSAZ collaborates with our PCPs through our care management program that helps patients with complex conditions navigate through the medical system and achieve their personal health goals. Those are the types of outcomes we all want.

But this level of care requires a commitment from you. Patients with chronic conditions often require more time than normally allotted for a routine office visit. By providing financial incentives that reward best clinical practice, BCBSAZ enables patients to have better access to providers and gives providers the flexibility to spend extra time with patients, when appropriate and needed to manage the patient’s overall condition.

At BCBSAZ, we agree you should have those resources. We provide access to a BCBSAZ care manager to help in managing patients with very complex conditions. We also share best practices throughout Arizona to make offices highly organized while using evidence-based care standards, ensuring adequate access to care and delivering coordinated services. We use analytic tools to track these conditions and share the data with providers to help align their practice with our population health management goals. (See sidebar for more registry details.)

Numbers Don’t Lie

Nearly 1,400 primary care physicians and almost 500 mid-level providers throughout the state have signed on to BCBSAZ’s PCMH program. That covers more than 215,000 of our members, including more than 46,000 with a chronic illness.

We started with a focus on patients needing help in managing a chronic condition, but we’re working with providers to enhance care coordination for all patients. That’s because patients can benefit from the program even if they don’t have a chronic condition.

In fact, according to the latest data comparing PCMH to non-PCMH practices, utilizing the difference-in-differences statistical methodology, over a two-year period, PCMH patients experience:

• 31.3 percent fewer ambulatory-sensitive hospital admissions
• 25 percent fewer ER visits
• 12 percent fewer hospitalizations
• 8.3 percent greater generic dispensing rate

It’s not just patients who are happy, either. Providers in the program have expressed their pleasure with the quality interactions they have with their patients. They are focused on providing exceptional care and seeing the results in many of their patients’ health.

“Since joining the BCBSAZ PCMH program, we seem to be more thorough as a team in checking necessary criteria, covering specific patient education items and meeting minimum standards on a very reliable basis,” says PCMH participant Marv L. Erickson, M.D. “Our office practice has also become more predictable at following up on items and following through with specific required tasks.”

Helping Providers Succeed

The benefits of the PCMH model are clear. Still, some hesitation to participate is understandable. After all, we’re talking about a shift in the medical practice operations. That’s why at BCBSAZ, we emphasize collaboration and have a team dedicated to helping our providers succeed.

That begins by meeting each individual practice where it is. Then we use baseline data to set incremental goals. At the conclusion of the reporting period, PCPs may be eligible for incentive payments based upon achievement of the goals that are outlined in the care plans. We seek ongoing feedback and engage with our providers regularly, and if practices need more help, we ascertain why and assist them. Best of all, we’ve found that as we continue to raise the bar, our PCMH physicians successfully meet the targets and earn their incentives.

We consider the PCP key to care delivery, but we’re not stopping with primary care. We also understand that complex patients require specialized care, so we’ve developed a specialist PCMH program for OB/GYNs. To date, we have more than 300 providers in this program.

Healthcare is in the midst of a transformation. There’s no denying that. And it’s a shift that requires innovation and teamwork to allow providers to better serve their patients and insurers to better serve their members. Indeed, moving our industry forward and advancing the mission of quality care compels us to work together. Let’s start now.

Join the PCMH Program

At BCBSAZ, we are committed to working with providers who are share our vision for patient-focused care. To learn more about our commitment to move health forward and our PCMH program, call 602-864-4360.

About the author
As the Senior Medical Director, Provider Partnership & Care Transformation for Blue Cross Blue Shield of Arizona (BCBSAZ), Dr. James Napoli leads a team focused on provider collaboration to create innovative models designed to advance healthcare quality, improve the health status of members, and improve care efficiency. He is Board Certified in Internal Medicine with over a decade of clinical experience in hospital medicine and physician leadership roles. Dr. Napoli holds a Masters of Medical Management degree from University of Southern California, a Doctor of Allopathic Medicine degree from Medical College of Ohio and a bachelor’s degree from The Ohio State University.