South Carolina Insurer Embraces PCMH Model of Care

BlueCross BlueShield of South Carolina has started rolling out patient-centered medical home, or PCMH, initiatives across the state after a medical home pilot project led to dramatic improvements in the care and treatment of patients with diabetes in the Charleston area during the past year.

The initial medical home pilot project that inspired the move was a joint venture between BlueCross BlueShield of South Carolina, or S.C. BlueCross; its subsidiary, Blue Choice HealthPlan of South Carolina; and Palmetto Primary Care Physicians, a large primary care practice in the Charleston area that includes 24 clinic sites and 50 physicians. The pilot project targeted 1,200 patients with diabetes.

Based on data from the 809 patients who were continuously enrolled in the project for 12 months, officials found that patients experienced 10.4 percent fewer inpatient hospital days and 12.4 percent fewer emergency room, or ER, visits when compared with figures from the previous year. Moreover, patients in the medical home had better control of their cholesterol and glucose levels and were able to improve their body mass index and their measures of potential kidney damage. These patients also had higher rates of completing recommended eye exams.

In analyzing the data, the organizations also compared outcomes for patients in the medical home pilot with a control group of patients with diabetes who were treated by other primary care practices in the Charleston area. Age and gender mix were similar for both groups.

The patients in the medical home group experienced 10.7 percent fewer hospital admissions than the control group, as well as 36.3 percent fewer inpatient hospital days and 32.2 fewer ER visits than the control group.

"We're delighted these patients saw improved health and better access to a complicated health care system," said Laura Long, M.D., vice president for clinical quality and health management for S.C. BlueCross, in an Oct. 25 press release. "We intend to move aggressively to roll out this approach around the state. The results convinced us that we need to get this out of the pilot phase and into practice."

S.C. BlueCross and BlueChoice HealthPlan also launched a second medical home pilot project for diabetes on July 1 in conjunction with the University of South Carolina Department of Family Medicine. The two insurers have since launched a third diabetes medical home project with Mackey Family Practice in Lancaster. In the meantime, Palmetto Primary Care Physicians and S.C. BlueCross recently expanded their PCMH program from patients with diabetes to patients with congestive heart failure.

Elizabeth Hammond, a spokesperson for S.C. BlueCross, said the PCMH pilot project has generated a great deal of publicity in the state, and several primary care practices have contacted the company about becoming medical homes. S.C. BlueCross asks these practices to apply for medical home recognition from the National Committee for Quality Assurance, or NCQA.

"As soon as that is in process, then we start working out a contract with (the practices)," said Hammond.

According to Kirt Caton, M.D., medical director of the PCMH for Palmetto Primary Care, the practice achieved a Level 3 medical home recognition from the NCQA, which is the highest level possible.

To ensure the success of the medical home pilot, S.C. BlueCross established a blended payment structure for the PCMH by paying practices a per-member, per-month fee for each medical home patient, while leaving the existing fee-for-service payment system intact. S.C. BlueCross also pays practices bonuses for meeting certain benchmarks with medical home patients.

Palmetto Primary Care physicians also work closely with nurse practitioners and physician assistants. In addition, Palmetto Primary Care hired three case managers to work with patients with diabetes across the system. The practice also hired a certified diabetes educator to help all of their patients with diabetes, including the medical home patients, learn more about their disease. Palmetto Primary Care also started an American Association of Diabetes Educators program.

"If a patient is diagnosed with diabetes, that patient is contacted within two weeks by a diabetic educator or a case manager," said Caton.

The case managers speak with the patients on a regular basis and provide continuity of care, making it easier to manage the patient's condition. The case managers also will try to find out why a patient's diabetes is uncontrolled -- whether it is because they are unable to keep their appointments or because they are having trouble with the cost of their medications. For their part, patients are more at ease with their disease in this type of arrangement, according to Caton.

The addition of a diabetes educator also has helped Palmetto Primary Care achieve good results in terms of improving patient adherence to medication regimens and getting lab work done, which results in better patient outcomes. During a three-month period, Palmetto Primary Care physicians tracked 54 patients who received education from the diabetes educator. They found that these patients experienced a 0.3 percent point reduction in their hemoglobin A1C levels without any adjustments to their medications.

"We proved that in a small population, (education) has a significant impact," said Caton.

He also attributes the success of the medical home pilot to the practice's electronic health records system, which is connected to two nearby hospitals.

"If a patient goes to the emergency room and has labs drawn that day, the next day it comes up on our electronic (health) record," Caton said. "We get a readout that the patient has been seen in the ER. The case manager is notified, and the case manager contacts the patient about what could have been done to prevent (an ER visit) in the future."

Not surprisingly, Caton says he's convinced that the medical home represents the way health care will be practiced in the future. "I think every disease state should and will be in the medical home model in the future," he told AAFP News Now.