Pilot focuses on improving care for diabetic members

Program engages physician practices

Horizon Blue Cross Blue Shield of New Jersey and the New Jersey Academy of Family Physicians are collaborating on a pilot project aimed at improving the quality of care members receive through a pilot program testing the concepts of the patient-centered medical home.

Initially, the program will focus on patients with diabetes, with the goal of improving the clinical quality of care and reducing health care costs.

The patient-centered medical home pilot project was the outgrowth of a much broader series of discussions between Horizon Blue Cross Blue Shield of New Jersey and the New Jersey Academy of Family Physicians, according to Nicholas Bonvicino, MD, medical director at Horizon Blue Cross Blue Shield of New Jersey.

"We reached out to the academy in an effort to improve relationships with physicians in the network. After a long series of meetings, we began to talk about the bigger picture," he says.

New Jersey is heavily specialty-driven, with few physician residents going into primary care, he adds. Since many of the primary care physicians in the state are older practitioners, Bonvicino anticipates a shortage when they retire.

"The future of primary care as a specialty is a major concern for both the academy and the health plan. We believe that in order to have an effective and efficient delivery system where our members receive the care they need, we need a strong primary care foundation," Bonvicino says.

The current system of fee-for-service means that physician practices have to optimize the number of patient encounters that present billing opportunities in order to maintain sufficient revenues to run the practice, he points out.

"We, as a health plan, can't afford to raise our costs by paying primary care physicians more for the same services they are currently providing. The question we pondered is how to get more of the care reimbursement dollars into the hands of the primary care physicians in a way that rewards improved value," he says.

In the patient-centered medical home model, physician practices are transformed from being merely providers of services to being entities that not only provide service but take responsibility for coordinating all the care the patient receives throughout the health care system, Bonvicino says.

The health plan's pilot project focuses improving care for a population of members with diabetes.

"We chose diabetes because it is a disease entity that runs the gamut across many kinds of illnesses and specialties and can drive a lot of medical costs. It's a low-risk, high-reward place to focus," he says.

The health plan has a diabetes disease management program that is based on telephone interventions and mailings. However, Bonvicino believes that disease management based in a physician office may produce better results.

"Disease management should be more effective when the patient is engaged with the clinical physician. Our focus is not to create a competitive environment but to provide the best care possible to help the patients learn to manage their conditions. In the long term, we believe that as medical homes become more common, the focus of health plan-based disease management may change," he says.

The pilot is not just an ordinary chronic disease management program, Bonvicino points out.

Instead, the health plan is engaging physician practices in population management, rather than utilizing third parties to do disease management without involving the treating physician, he adds.

"We are supporting primary care physicians in providing more holistic care and becoming more engaged in promoting wellness and prevention and managing populations with chronic diseases. We know that care coordination for patients with chronic diseases offers the big opportunities for improving care and cutting costs, and we believe that interventions at the clinical level should produce better outcomes than telephone disease management," he adds.

Physicians participating in Horizon Blue Cross Blue Shield of New Jersey's medical home model have the opportunity to access reimbursement that isn't accessible in standard fee-for-service contracts, Bonvicino points out.

"In most cases, services rendered on behalf of the member by someone other than the physician or not in the face-to-face office setting are not recognized for reimbursement. The patient-centered medical home model is a win-win situation. The payer benefits because costs are lower. The quality of care and compliance improves for the member, and the primary care practice benefits because of improved finances," he says.

The health plan has agreed to pay a care coordination fee on a quarterly basis for every eligible member in the pilot to the primary care physician who is accountable for the care of the member. It's up to the individual physician practices how they set up the care coordination processes.

"We know that one model doesn't fit all. We are paying them to do care coordination in the manner they see best, whether it's e-mail consultations, hiring a diabetic educator, organizing instructive classes, or having a nurse case manager on staff. Each can decide what works best for them," he says.

The health plan will determine the overall cost of providing care for the diabetics in the pilot project and compare that to the cost of a control group of similar members who do not receive care in a medical home.

Other clinical quality outcomes measures, including HEDIS measures, determine if patients receive the best practices in care for diabetes.

"We are looking to see if, in the short term, we can develop cost-savings that can support the care management activities. We hope that at the end of the pilot period, we will be able to show improved outcomes in terms of clinical measures and total cost of care," he says.

When plans for the pilot project were rolled out in January 2009, only one practice in the state of New Jersey was recognized by The National Committee for Quality Assurance (NCQA) as a patient-centered medical home. The health plan and the New Jersey Academy of Family Physicians developed a 16-week program to help practices prepare for recognition as a patient-centered medical home.

Of the 34 practices that applied for the recognition, 32 were successful and seven practices reached Level 3, the highest level.

The pilot program went live in October 2009, with 5,500 members and 33 practices participating.

The health plan is collaborating with three major hospital systems in New Jersey to expand the medical home model in the future.

"We are aligning forces for care coordination and exploring what infrastructure it will take to move beyond just managing chronic conditions. For instance, we want to develop a way to provide referral support for patients who need specialty care, to transfer the process into the hospital emergency room, and work on the inpatient side to better coordinate discharge planning so the whole health system is integrated," he says.

The medical home pilot goes beyond traditional disease management, Bonvicino points out.

"We are optimistic that the transformation of a physician office to provide a lot of additional value will allow reimbursement commensurate with that value and, at the same time, preserve primary care," he says.