"Secret, secret, I've Got a Secret."
Some of you may recognize these lyrics from the 1983 Styx mega-hit "Mr. Roboto," but most of you probably are pondering its application to the AAFP and family medicine. My secret is this: the key to improved quality and reduced health care costs is -- wait for it -- primary care. I realize that few of you are shocked by this statement, but there are plenty of people in health care that are just now waking to this reality.
A couple of weeks ago, I had the opportunity to meet with the president and CEO of CareFirst BlueCross BlueShield, about that organization's patient-centered medical home program. CareFirst, which operates in Maryland, the District of Columbia, and northern Virginia, launched its PCMH program in 2011 with more than 2,000 primary care physicians and providers participating. Today, 80 percent of primary care physicians and providers in this service area participate in the program, and collectively they provide care to more than 1 million patients. Seventy-five percent of participating physician practices are solo, small and medium-sized physician practices.
The design of the CareFirst program is quite simple. Physicians are asked to align themselves with other primary care physicians to form panels that range in size from five to 15. CareFirst provides two forms of upfront financial support -- a 12 percent participation fee and a $250 payment for each care plan developed. In addition, CareFirst provides three types of administrative support -- care managers; data and analytics; and technical assistance via program consultants.
CareFirst does not require that the practices achieve third-party PCMH recognition, nor do they require that the panels form new legal entities to work together towards achieving shared savings. Physicians can partner with others in a virtual or cooperative way rather than through contractual alignment. In return, CareFirst asks each panel to assume responsibility for the total cost of care for their attributed patients by focusing on five key areas:
If the primary care panels control total costs of care as compared to their benchmark, they get to share in the savings. I know what you are thinking, the benchmark lowers annually, thus making it impossible to achieve continuous savings in the program. Well, that would be wrong. CareFirst does not lower the benchmark to reflect annual or cumulative net savings. It only adjusts the benchmark based upon the risk stratification of the patients attributed to the panel.
So, has it worked? In short, yes.
Since 2011, CareFirst has reduced its expected costs of care and slowed spending growth by an estimated $609 million. Additionally, CareFirst slowed its rate of growth from 7.5 percent in 2011 to 3.5 percent in 2014. In four years, the CareFirst PCMH program has contributed to a 19 percent reduction in hospital admissions, 15 percent fewer hospital days, 20 percent fewer hospital readmissions, and 5 percent fewer outpatient health facility visits. As a result, participating physicians who met quality and savings targets earned, on average, $41,000 in shared savings.
Physician participation and engagement in the program is high and holding. Since 2011, only 13 percent of physicians have left the program. Of that 13 percent, 82 percent retired. The remaining 18 percent were asked to leave due to a lack of participation, but 7 percent of those physicians subsequently returned.
Since 2011, 38 percent of the primary care panels have secured savings in all four years, and 32 percent have secured savings in three of the four years, debunking the so-called process bias theory that suggests savings are not sustainable over long periods. In fact, only eight panels, or 2 percent, have failed to secure savings at some point.
Following my conversation with CareFirst, I came away with five key points about the future of advanced primary care practices and the medical home:
I realize that this posting could facilitate some interesting comments, and I look forward to hearing your thoughts. I also realize that there are likely some shortcomings in the CareFirst program. However, the successes of the CareFirst program and others like it are becoming far more prevalent. This leads me to believe that the core functions of an advanced primary care practice are becoming more identifiable and replicable and are being paid differently and better.
Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy. Read author bio »