Highmark’s Accountable Care Future Starts With Expansion of PCMH Model

A patient-centered medical home pilot project yields results that lead the health plan to launch a major effort

Frank Diamond
Managing Editor

As Highmark greatly expands its patient-centered medical home, the Pittsburgh-area insurer does so with the idea that the PCMH will lay the foundation of even more encompassing systems: accountable care organizations.

Highmark’s PCMH relies on primary care physicians, as do all PCMHs, and that’s where health care reform starts but not necessarily where it ends, says Paul Kaplan, MD, senior vice president for provider strategy and integration.

“We acknowledge that this is a journey, and accountable care organizations cannot be successful unless you have the right infrastructure,” says Kaplan. “You need to give the doctors time to get organized, to experiment until they find what works. But we do intend to move into the ACO world and we’re having discussions with health system entities.”

Paul Kaplan, MD

“The goal is to ensure that the practice of medicine is fun for doctors,” says Paul Kaplan, MD, Highmark’s senior vice president for provider strategy and integration. The team model fostered by the PCMH allows physicians to focus on the things that they do best.

Start with primary care

Michael Fiaschetti, Highmark’s president for health markets, says, “The medical home is the foundation of the broader accountable care organization. When you think of the large systems that own hospitals and groups, you start with the primary care doctors and all the members who those doctors serve.”

Energized by the results of a PCMH pilot program, Highmark, a Blue Cross & Blue Shield affiliate, is expanding the initiative this year to include nearly 1,050 primary care physicians in more than 100 practices. They serve about 170,000 patients. The pilot, begun in 2011, included 160 PCPs in 12 practices that cover about 45,000 members.

In the pilot:

  • Inpatient acute admissions dropped 9 percent.
  • Thirty-day readmissions dropped 13 percent.
  • Seven-day readmissions dropped 14 percent.
  • Per-member, per-month costs for patients with coronary artery disease dropped 5 percent.
  • Per-member, per month costs for diabetics dropped 3.5 percent.

The basis of the pilot and what now drives the expansion is that physicians are paid more for delivering better care. “We’re not going to compromise quality for cost,” says Fiaschetti. “This isn’t the old days; that may have happened 20 years ago at some of the old HMOs. There will be huge returns because we’ll eliminate many emergency visits, unnecessary admissions, and unnecessary readmissions.”

Kaplan says that specialists will probably play an outsider role in how the PCMH functions. “Our view is that we start by reorganizing and re-­empowering primary care doctors. Just as when you build a home it needs a strong foundation, we see PCMH as one brick in the foundation of the house.

“Specialists will be involved as we need to create the infrastructure for the primary care physicians and the specialists to improve communications with each other. Eventually the PCMH really is a collaboration between the primary care physician and the specialist based on real-time useful information exchange and real-time ability to communicate.”

Mature doctors

All doctors are not equal when it comes to who’s ready to become part of a PCMH or can use “real-time data” effectively and efficiently. “We’re already having discussions with the more mature doctors in the system about accountable care and how to make it work,” says Kaplan. “The less mature doctors — we need to help them get to the point where they have the capability, because our goal is that 75 percent of all our primary care doctors will be part of a PCMH and will be working very effectively and efficiently with their specialist physicians.”

Innovation encouraged

Meanwhile, the PCMH encourages innovation. For instance, the members of one practice huddled over the appointment book at the end of the shift to see which patients were scheduled for the next day.

“One doctor would say, Mrs. Smith is coming in tomorrow,” says Kaplan. “But I also look after Mrs. Smith’s four kids. Let’s pull the charts of the children and see if they’re up to date on their immunizations.”

Two of the children in this particular instance were not. “So the doctor said to the team, Give Mrs. Smith a ride and have her children come with her. Ask Mrs. Smith if she’s willing to let the two not-up-to-date children get up to date while they’re here. That saves her from having to come in a second time with her kids.”

In this way, PCMHs encourage effective visits, says Kaplan. “People are busy. They don’t want to have to go back to the doctor frequently when a lot of things could be addressed at once.”

He also tells the story of a practice that wanted to reduce ER admissions. “They got together with some patients and the hospital staff and they realized they could do one very simple thing: Leave Monday mornings completely open with no appointments and guarantee patients who called that they would be seen on Monday. Their ER utilization dropped. People who were sick over the weekend, but not bad enough that it was life-threatening, waited to see the doctor because they were guaranteed that they could get in.”

Michael Fiaschetti

“Physicians can earn more for better care,” says Highmark’s Michael Fiaschetti, president for health markets, about the PCMH model. “There will be huge returns because we’ll eliminate many emergency visits” for one thing.

As Fiaschetti puts it: “Lower costs for the patient, lower costs for the system. It is going to take a different approach, a much tighter alignment between Highmark and physicians than we’ve had in the past.”

The insurer will be sharing much more information. “Data about services that have been provided to these members, data about clinical information about these members,” says Fiaschetti. “For example, the actual sugar levels of the diabetic patient and what can be better done to control those levels so that those patients have a better quality of life, stay out of the emergency room and, God forbid, stay away from being admitted to the hospital.”

Kaplan adds, “The goal is to ensure that the practice of medicine is fun for doctors. Doctors are working harder and harder and aren’t always convinced they’re catching the patient at the best time. By creating a team environment in which the doctor can hand patients off to other members of the team, the doctor focuses on the things he does best.

“They are all practicing at the top of their license. The goal is to create a different infrastructure in which the doctor can more effectively know the patient he’s touching and when he should be touching him. That useful information passes to the physician in real time or as close to real time as we can make it.”

Practices will be encouraged to take the team approach, says Fiaschetti. “In their offices they would have a care coordinator [often a nurse provided by Highmark] who could spend time with the chronically ill patients and get them the right level of care and the right education and coordinate their care more intensely. In exchange we will provide higher incentives to the physicians for better managing those patients based on certain quality parameters and based on certain cost parameters.”

Disease management

One thing that should work better is disease management, says Kaplan. “Doctors weren’t able to do disease management, so the insurers took on this task. But if a physician tells a patient, I’ll have a staff member call you tomorrow evening to remind you to take your medications so that this becomes a habit for you, then “The patient is more likely to pick up the phone. He’s less likely to do it if the insurance company is making a cold call. This takes time, and we need to better reward the physicians for his time. But we also need to have the infrastructure so the doctor can have a team that knows what the doctor wants for each patient. We know that we will have happier patients and we will actually have happier doctors.”

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