By Maggie Van Dyke
During most of Thomas McCarrick's 27 years as a primary care physician, he rarely engaged with insurers. When he did, the talk was mostly about fee schedules. Then his Verona, N.J., practice, Vanguard Medical Group, joined a patient-centered medical home program developed by Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) in collaboration with the New Jersey Academy of Family Physicians and physician leaders.
That was the start of a beautiful provider-payer friendship. "Instead of looking so much at what we can get out of each other, we are now focused on what we can do together to improve patient care and reduce costs," says McCarrick.
Horizon provides Vanguard, as well as other medical groups in the program, with extensive operational and financial support, including a paid nurse to coordinate the care of high-risk patients, a care coordination fee, and shared savings payments for reaching outcomes-based benchmarks related to clinical quality, patient experience, and utilization.
Early results indicate that the medical homes are successfully meeting the program's dual quality and cost goals. For instance, in 2011, Horizon medical home members with diabetes had 8 percent better blood sugar rates than those not enrolled in medical homes. Medical home members also had a 10 percent lower cost of care (per member per month) in 2011, compared to non-medical home members, due primarily to 25 percent fewer hospital readmissions and 26 percent fewer emergency department (ED) visits.
For Vanguard's patients, especially those with complex or multiple medical conditions, the group's medical home conversion has transformed their lives. "Practically speaking ... my mom has not fallen," says Helen Kuryllo, caregiver to her parents who are patients at Vanguard Medical Group. "There have been no hospitalizations for either parent. The paramedics in town no longer recognize me on the street. Most important, there is close, consistent care."
See interview with Kuryllo: A Caregiver's View of a Medical Home
All of this began with a new type of working relationship between Horizon BCBSNJ and the participating physician groups. "From day one, what has made this program so unique is the collaboration?and it is absolutely a leading factor in why we've been able to achieve positive results," says Jim Albano, vice president, network management and Horizon Healthcare Innovations at Horizon BCBSNJ, which is the largest insurer in New Jersey.
Before launching its full-fledged medical home program, Horizon piloted the approach in 33 group practices with members who have diabetes. After getting its feet wet, Horizon transformed the diabetes pilot into a comprehensive medical home program that aims to eventually include all Horizon members in New Jersey. Launched in January 2010, the program-called the Horizon BCBSNJ's Patient-Centered Medical Home Program-currently includes more than 500 physicians and 154,000 Horizon members at more than 145 N.J. practice locations.
Like other medical homes, the Horizon model focuses on improving care coordination and encouraging patients to get needed preventive and wellness care. Following a population management approach, a lead physician and a team of caregivers regularly monitor patients' progress, engage patients to obtain needed tests and treatments, and coordinate care with other providers.
Reinvesting in primary care. Vanguard, a three-group practice, participated in Horizon's diabetes pilot and went on to become one of the first eight practices in Horizon's comprehensive medical home program. As part of this work, Vanguard achieved Patient-Centered Medical Home recognition from the National Committee for Quality Assurance (NCQA).
"We were trying to figure out how to do things better for our patients and to find opportunities to get away from the current fee-for-service business model in which we are basically just paid for office visits," says McCarrick. "Rising healthcare costs are causing insurance companies to keep a lid on our payments. This has left many primary care practices struggling to survive, and they can't invest in things that will make their practices better or offer competitive salaries to bring in newly graduated physicians."
New Jersey, in particular, is expected to bear the brunt of the looming physician shortage in coming years. The American Academy of Family Physicians has deemed the state a primary care desert caused in part by low primary care physician salaries and the decision of many New Jersey-trained physician graduates to practice outside the state.
By supporting primary care practices with its medical home program, Horizon hopes to achieve its own business objectives of higher quality, better patient satisfaction, and improved affordability for its members. "One of our core goals is to reinvest and re-energize primary care throughout New Jersey because a strong primary care doctor/patient relationship is key to helping individuals manage their health and avoid serious illnesses and hospitalizations," says Albano.
Developing a playbook. The NCQA has spelled out specifics on what medical homes should look like (e.g., coordinated, integrated care). However, the down-and-dirty how-tos of operationalizing these standards are still a work in progress. As a result, Horizon and the initial eight physician practices that participated in the first phase of the medical home program spent a lot of time inventing-and reinventing-the necessary wheels.
"During our collaborative meetings, we worked together to fully comprehend the challenges that the physicians face as they transform their practices into medical homes," says Albano. "The dialogue has helped Horizon build a medical home program that is more gratifying for physicians and patients alike. While financial support is important, there is even greater value from collaboration. By consulting with physicians, nurses, and other stakeholders, we're better able to develop innovative tools and useful resources that practices can use to improve the quality of patient care."
McCarrick and other physicians from the initial eight practices met weekly with Horizon staff and members of a consulting firm. The participants were divided into six work groups that developed how-to approaches to key issues:
In addition, Horizon hosted monthly meetings between Horizon leadership and the eight lead primary care physicians.
From this collaborative work came the development of a patient-centered medical home playbook, which outlines best practices and offers various solutions on how to succeed as a high-functioning medical home. For example, the playbook covers the core components of establishing a medical home within the first 60 days.
A number of tools and resources were also developed to help the medical homes coordinate care, engage patients, etc. For example, one concern was how to communicate the concept of the medical home model to patients. "Together, we developed communication tools and resources, like letters, scripting, and starter kits, for practices to use in communicating with their patients," says Albano. "This targeted effort increased patients' understanding of the medical home program by 60 percent. This was an important first step to engaging and empowering patients in their health care."
Tackling the hard work. Because of its size and proactive leadership, Vanguard has managed to side step the financial problems facing many other New Jersey practices, says McCarrick. The practice already had an electronic health record (EHR) and a patient portal in place when it joined the Horizon program-essential technologies for a medical home that prides itself on care coordination and patient engagement.
Because of these and other advances, Vanguard was able to earn NCQA medical home recognition in just four months. However, McCarrick says the true transformation into a medical home takes much longer. "It took four months to work through the NCQA process-but that was just the NCQA process. That's different than having to build all the needed medical home processes and technologies from scratch. That's a huge amount of work, and it takes years to accomplish."
Vanguard is still fine-tuning various processes and procedures that are essential to a medical home, such as coordinating discharges with hospitals and improving patient access. "We get bogged down in practical problems that are not really addressed in the literature and often take a lot of time to fix," says McCarrick.
See related sidebar: Vanguard's Approach to Three Practical Medical Home Challenges
While all patients at Vanguard Medical Group receive coordinated care, some patients need a lot more attention than others. For this reason, McCarrick is very grateful for the full-time, fully paid population care coordinator that Horizon provided to his practice.
Currently, the population care coordinators within the Horizon medical home practices are either Horizon employees or employed by the practice and supported by Horizon, says Albano. In addition, Horizon is also supporting a 12-week training program for nurses who will work within the medical home practices. Horizon is expecting to train at least 200 care coordinators within the next two years.
Focusing on the sickest patients. The specially trained population care coordinators focus primarily on Horizon members who are considered the sickest 5 percent in the practice?and account for about 40 percent of costs.
"These are patients with significant comorbidities," says Janet Duni, RN, MPA, Vanguard's population care coordinator. "They are often not using healthcare services in the most strategic way, or they are overwhelmed by the complexities of seeing several specialists and have trouble self-managing their care. In many instances, there are opportunities to improve coordination of services and help patients better understand their diagnoses."
About 5,000, or 30 percent, of Vanguard's patients are Horizon members. Of these 5,000, about 150 are on Duni's "high-risk " list. "I'm in contact with 90 percent of the high-risk list no less than every three months, with a substantial subgroup receiving monthly or even weekly outreach," she says. "These are patients with sometimes complicated health histories, often with family or social problems as well. I try to understand the whole dynamic, which includes developing a relationship with spouses or caregivers. I touch these patient charts as often as I can, and have instituted a work flow to support that process. I try to ensure specialist reports are sent to our office and confirm that, if high-risk patients are not seeing us, they are being actively managed by their specialists."
Fine-tuning risk. Identifying high-risk patients is an issue that many providers and payers are grappling with. Using a combination of science and art, Vanguard is "about 75 percent there in terms of fine-tuning risk," says Duni. She and the physicians in the medical group begin with a list of about 500 high-risk Horizon members at Vanguard, which the insurer develops using a claims-based risk assessment tool. The clinicians then fine-tune this list based on patient assessment, medical history, and use of medical services, among other factors.
"Horizon gives us a risk score on their members so we can actually look at those patients and decide if we agree with that score," says McCarrick. "Many times it turns out that a patient may have been in the hospital for an acute, self-limited problem, and once that problem is solved, the patient turns out not to be high risk. Conversely, we've had patients who have medical problems who are not captured in claims data very well, such as an elderly diabetic patient with cognitive impairment or a patient whose spouse is dying or recently died.
"EHRs are not typically set up to identify high-risk patients, he says. "There's no high-risk field that you can pull into your reports. So we had to develop a workaround. We are taking ICD-9 codes that we created and renaming them 'high-risk,' 'very high-risk,' and 'high-risk status post 30 days hospitalization.' This allows us to generate reports of our high-risk patients."
Vanguard also invested in a disease registry software tool that helps clinicians to identify patients who may need additional treatments, tests, or education. "It helps us better spot, for example, patients with cholesterol above a certain goal or blood pressure that is not controlled," says McCarrick. "It lets us drill down into populations of patients and actually pick out, for example, a subpopulation of diabetics with A1c hemoglobin levels greater than 8."
Maintaining high touch. Once high-risk patients are identified, the next challenge is keeping these patients "in our sight line" to ensure they are getting needed care and coordination, says Duni. To stay on top of patients, she uses a care planning tool, which was developed during Horizon's initial medical home planning meetings. Duni also uses a spreadsheet she developed that supports consistent tracking of appointments and outcomes.
"We are very concerned about having high touch with our highest risk patients. High-risk patients need individualized care plans, which may require weekly, monthly, or quarterly interactions. That can translate into phone contact, office visits, home visits, or assisting with coordination of services from other providers or community agencies."
In creating its medical home model, Horizon recognized the need to help primary care physicians pay for care coordination, which is not typically covered by Medicare or private insurance, says Albano. The care coordination fees are per-member-per-month fees on top of the practice's usual fee-for-service charges, he explains.
"We look at that payment as non-visit-based transformation support. A portion of the care coordination payment is dedicated to support a nurse care coordinator and the remaining support could be used to hire additional staff, improve technology, or develop other capabilities to improve care coordination," says Albano.
Participating practices can also receive an outcomes-based payment if they meet certain performance targets for clinical quality (e.g., percentage of pneumonia vaccines given to older adults), patient satisfaction, and utilization (e.g., percentage of hospital readmissions). Altogether, there are 18 targets that the medical homes are striving to achieve.
"We are moving from fee for service to fee for value," says Albano. "Instead of paying these practices for the volume of tests or treatments they perform, we are paying practices to get and keep their patient populations healthy in a cost-efficient way."
McCarrick believes the tide is starting to take a positive turn for primary care practices in New Jersey. In addition to the Horizon medical home project, the state is benefiting from a national medical home initiative sponsored by the Department of Health and Human Services (HHS). New Jersey was one of seven states selected to participate in the Comprehensive Primary Care Initiative, which will provide practices with monthly care management fees and shared savings.
"For us, the Horizon program has been a huge success, and I think it provides a path for other insurance companies to follow," McCarrick concludes. "I tend to be a glass-half-full guy, but I really do see a light at the end of the tunnel."
Quoted in this article (in order of appearance):
Thomas McCarrick, MD, is a primary care physician, Vanguard Medical Group, Verona, N.J. (firstname.lastname@example.org).
Jim Albano is vice president, network management and Horizon Healthcare Innovations, Horizon Blue Cross Blue Shield of New Jersey, Newark, N.J.
Janet Duni, RN, MPA, is population care coordinator, Vanguard Medical Group, Verona, N.J. (email@example.com).
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