Frank Diamond
Managing Editor
MANAGED CARE February 2011. ©MediMedia USA

BlueCross BlueShield of North Carolina’s vigorous patient-centered medical home may be an example to other plans and providers

Managing Editor

The brave new world of provider-payer cooperation requires an approach that’s somewhat at odds with traditional managed care, says Don W. Bradley, MD, senior vice president for health care and chief medical officer at BlueCross BlueShield of North Carolina.

“We understand that the old managed care days of beat-’em-with-a-stick utilization management, while moderately effective, were not very popular with anybody,” says Bradley.

The health plan has formed a partnership with UNC Health Care, a not-for-profit provider system associated with the University of North Carolina, to push the medical home concept a bit further. The practice, without an official name yet, is to be launched in the fourth quarter of this year and to serve 5,000 BCBSNC members who have chronic conditions.

“We can look in both the clinical records and the claims history of the entire population in this practice,” says Bradley.

The effort springs from a patient-centered medical home (PCMH) project that the health plan began in 2006 as part of the Bridges to Excellence project. The three-year pilot recognized — and financially rewarded — physicians who achieved performance measures set by the National Committee for Quality Assurance. The insurer has 829 physicians from 151 patient-centered medical home practices in the plan’s networks, serving approximately 325,000 patients.

“Customers who visit these physicians have 52 percent fewer visits to specialists and 70 percent fewer visits to the emergency room,” says Bradley. In addition, patients of the PCMH cost $9 less per member per month than those in non-PCMH practices. He notes, for instance, that hypertension control for diabetics was significantly better in the PCMH model, and that’s a direct result of the patient’s relationship with the PCP, Bradley believes. The practice will feature:

  • Nontraditional visit formats (e-visits, televisits, home monitoring)
  • On-site mental health
  • On-site nutritionist
  • On-site pharmacy and medication management
  • On-site laboratory
  • Case management and coordination of care for patients requiring hospitalization
  • Group and educational visits
  • Extended weekday and weekend hours
  • State-of-the-art information technology

“Telling primary care docs that we want to include things like online care and alternative providers kind of makes me quiver a little bit as a physician,” says Bradley. “But when you remember that the patient is at the center of this, it begins to make sense.”

Two porcupines

As is often the case with any payer-provider partnership, one of the challenges has been accepting the idea that the two sides can work together.

“The first piece is like two porcupines getting to know each other,” says Bradley. “This has really been a chance for us as medical directors to say, I know these guys and have worked with them both in the academic setting and the practice setting. We’re going to work together on this and part of the reason we did a joint venture, as opposed to a contract relationship, is to say, if we save money, we’ll share that. If there are losses, we’ll both share the losses.”

Of course, he’s hoping that there won’t be losses.

“We really have come to the realization that rather than try to negotiate, we need to collaborate,” says CEO Don W. Bradley, MD, of BlueCross BlueShield of North Carolina’s new partnership with a major provider.

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