Patient-Centered Medical Home CareFirst Pilot Program Update

1. Patient-Centered Medical HomeCareFirst Pilot Program Update Primary Care Medical Home Workgroup of the Maryland Health Quality and Cost Council April 6, 2009 Jon Shematek, MD Senior Vice President & Chief Medical Officer CareFirst BlueCross BlueShield

2. Contents • BlueCross BlueShield Pilots • The CareFirst PCMH Pilot • Background • Foundational Requirements • Program Design • Outcomes and Evaluation • Issues

3. Blue Cross Blue Shield Plan Pilots (as of February 2009) Pilots in planning phase for 2009 implementation Pilots in progress Pilot activity in early stages of development Multi-Stakeholder demonstration

4. Background • CareFirst Patient Centered Medical Home Pilot (2008-2010) • Planning process (2008) • RAND provided environmental scan, consulting services on design • BCBSA • PPCPCC • Focus groups…citizens, physicians, employers • Recruitment completed late 2008 • Implementation commenced January 2009

5. Two Year demonstration/pilot Program • 11 Primary Care Practices • 84 Physicians (61 IM, 17 FP, 6 Peds) • 13 Nurse Practitioners • Over 30,000 CareFirst Members • Over 150,000 patients • Intensive facilitation • Innovative funding support Confidential Information- Not for Distribution

6. Foundational Requirements • Joint Principles • 100% attestation by all practitioners in practice location • Personal commitment to participate by lead physician, administrator • NCQA PPC-PCMH Certification • Level II minimum requirement by 4Q2009

7. Practice Transformation • External consultant with track record in PCMH • Confidentiality • On site “Thorough Practice Assessment” • Focus on patient-centeredness, teams • Technology Needs Assessment • NCQA PPC-PCMH Certification facilitation • Conference calls, weekly, daily as needed • Quarterly Learning Collaboratives

8. Data Intermediary • Participation with third party data intermediary • EMR not required • Patient attribution (practice self-identifies) • Real-time registries • Point of service decision support • Gaps in care reminders • Continuous outcomes monitoring • Periodic reporting • No cost to practice • Applies to all patients in practice • CareFirst provides selected administrative data (dates of diabetes retinal exams, breast, cervical and colorectal cancer screenings) • CareFirst views aggregate data for its enrollees only

9. Population Care Opportunities

10. Patient Level Care Needs

11. Condition Specific Care Needs

12. Direct Financial Support • Care Coordination Fee set at $4 pmpm capped at $100,000 per practice as long as practice continues to maintain all requirements • Technology grants up to $100,000 per practice for CCHIT-certified EMR, additional technologies, electronic prescribing systems, patient portal development, participation in interoperable health information exchanges • Based on technology assessment conducted by independent third party • Outcomes awards in Year II up to $100,000 per practice

13. Outcomes • Diabetes • HbA1c testing, cotnrol • LDL testing, control • Retinal exam • Nephropathy screening • Coronary Artery Disease • Blood pressure control • LDL control • Beta blocker use • Aspirin • Hypertension • Blood pressure control • Asthma • Severity classification • Appropriate medications • Childhood Immunizations • DTaP, IPV, MMR, HIB, VZV, Pneumococcal, Hep A, Influenza • Adult Immunizations • Influenza-A, Pneumococcal • Body Mass Index • Tobacco Use/Exposure • Breast Cancer Screening • Cervical Cancer Screening • Colorectal Cancer Screening CG-CAHPS Survey Results NCQA PPC-PCMH Certification

14. Patient-Centered Medical Homes Open Questions • What is the impact of the medical home on quality, cost of care, patient and physician satisfaction? • Which aspects of this medical home pilot are sustainable? Which can reasonably be replicated? • How to provide funding for primary care practitioners and their teams, particularly in a self-insured commercial market? • What is the opportunity for medical homes in pediatric practices, small practices, rural practices? • How does the medical home address the entire continuum of care, including specialty and hospital-based care? • Most importantly, how does the person (patient) become aware of and participate in the medical home?