Patient-centered care in primary care settings

Emphasis is on care management at the provider level

Blue Cross Blue Shield of Michigan is partnering with more than 8,000 physicians in about 80 physician organizations to develop better ways to manage the care of patients, with an emphasis on care coordination at the primary care level.

About 1,200 of the physicians have achieved the designation of a patient-centered medical home practice.

"We recognize that when the health plan provides care coordination, it's at a distance from the doctor-patient relationship. According to the patient-centered medical home model, care coordination that happens within the context of the patient-doctor relationship in a medical home is more likely to be effective, because the patients and doctors are more motivated," says David Share, MD, MPH, senior associate medical director for health care quality for the health plan.

The Detroit-based health care plan began structuring its patient-centered medical home initiative in 2004, when the health plan provided incentives for physicians to create shared processes of care and information systems and to use them to work with specialists to collectively take responsibility for a population of patients.

"We are always looking at ways to partner with the physician community to improve patient care. We recognize that physician organizations can't provide comprehensive care management without a system in place. We decided to offer the resources for doctors and patients to work together to manage patient care more effectively. Initially, we used our incentive money to support physician organizations in creating the infrastructure and information systems they need for new processes of care," he says.

Many of the features of the patient-centered medical home involve care coordination and care management, Share says.

Nurses in Blue Health Connections, the health plan's case management program, already coordinate care and follow up with patients at risk for chronic illness, those who have chronic illness, or those who have complex health care needs, Share points out.

The new initiative aims to move care management closer to the point of patient care with a goal of improving communication among patients and providers.

"We recognize that when the health plan provides care coordination, it's at a distance from the doctor-patient relationship. According to the patient-centered medical home model, care coordination that happens within the context of the patient-doctor relationship in a medical home is more likely to be effective because the patients and doctors are more motivated," he says.

The health plan has created specific transition codes (T-codes) that offer fee-for-service payment for specific procedures that involve care coordination, care management, or self-management training and support. One T-code for care management and self-management support is for telephone contact; the other is for in-person support.

The procedures may be provided by a variety of disciplines, including nurse case managers, social workers, nutritionists, diabetes educators, and respiratory therapists.

"If these professionals engage with patients about patient-specific chronic illness education, either in person or by telephone, the health plan will pay for it separately. This provides the medical offices with the resources they need to provide the services and expand their ability to provide care management," he says.

In the early phases of the initiative, the health plan provided funds to practices to help them get started. Ultimately, the majority of the extra services provided by the medical home will be paid for by reimbursement using the T-codes.

"Our plan is to support physician practices as they take responsibility for care coordination and self-management, which leads to better outcomes. To get from where we are to a truly patient-centered medical home model requires the physicians to do a lot of work that involves building new systems and hiring new people. It's part of the health plan's responsibility to support that creation of infrastructure. Once it's created and we start to pay for results and care coordination, we won't be paying as much for medical services," he says.

When patients have access to a primary care physician practice, which provides better care coordination and support for self-management, they can be expected to have a lower cost of care, fewer admissions, and fewer emergency department visits because they are getting timely, competent care, Share says.

"In the patient-centered medical home model, the case managers reach out and help the patients set goals based on their doctors' treatment plans. When patients forget to schedule regular visits, the case manager calls and reminds them. It all leads to better control and fewer complications," he says.

The health plan is beginning a new pilot project to develop a provider-delivered care management program, which shifts all care management services from the health plan to the physician office.

"This is taking the concept to the next level. If physicians have a comprehensive care management program embedded in their offices, they can effectively engage with at-risk patients to comprehensively manage their conditions," he says.

In the provider-delivered care management program, physician practices and the health plan will share data.

"We know from claims data which patients are at higher risk than average and can provide the practices with a list of people they can reach out to for care management. The doctor's office can send data back to the health plan and let us know who engaged and how. We will be able to reach out to our customers, the employer groups, and let them know if their employees are taking advantage of the case management services they contracted for," he says.

Having the physician office engage in care management will make the patients feel that physicians care about their conditions, he points out.

"When someone from a physician office calls a patient to follow up, it becomes a different conversation in terms of the human dimension than when someone from the health plan makes the call," he says.

"We know that being a patient makes you feel vulnerable. It matters if someone who is treating you cares about your health and doesn't just look at you as a number," he adds.

Five physician offices of various sizes and with different practice models are testing the provider-delivered care management program.

"We want to be able to examine the processes, how information is exchanged, and how the service varies and which staff are providing the services in different settings," he says.