PCMH Should Play Role as Health Insurance Cooperatives Are Established, Says AAFP

March 09, 2011 04:00 pm News Staff

The AAFP is urging HHS to incorporate the patient-centered medical home, or PCMH, model into the Consumer Operated and Oriented Plan(www.gao.gov), or CO-OP, program as the agency gears up to help individuals or companies interested in establishing nonprofit health insurance cooperatives.

"As HHS develops the CO-OP program over the next few years, HHS should carefully consider the important relationship between enrollees and a strong provider network, especially in rural or medical shortage areas," said AAFP Board Chair Lori Heim, M.D., of Vass, N.C., in a letter(2 page PDF) to Steve Larson, director of the HHS Center for Consumer Information and Insurance Oversight.

The CO-OP program is the result of the Patient Protection and Affordable Care Act, which calls on HHS to offer assistance in establishing nonprofit health insurance cooperatives. The cooperatives, which will be subject to state regulations, will provide insurance coverage on state insurance exchanges, as well as through individual and small-group markets. Plans qualified under the CO-OP program must operate with a strong consumer focus and are required to use any profits to lower premiums, improve benefits or improve the quality of health care delivered to plan members.

Academy Members Sit On CO-OP Advisory Board

Three AAFP members serve on the 15-member advisory board for the Consumer Operated and Oriented Plan, or CO-OP, program, which will make recommendations to HHS about grants and loans to establish CO-OP insurers. They are

  • David Buck, M.D., M.P.H., of Houston;
  • David Carlyle, M.D., of Ames, Iowa; and
  • Michael Pramenko, M.D., of Grand Junction, Colo.

"An increased focus on physicians whose practices serve as a patient-centered medical home will result in increased CO-OP enrollee access to preventive care, better coordination of the care they need to manage chronic diseases and appropriate care for acute illnesses," said Heim.

Data from PCMH demonstration and pilot projects around the country have shown significant potential for increasing quality and controlling costs, Heim noted.

She cited data from various PCMH projects, including the Geisinger Health System ProvenHealth Navigator, which has demonstrated a greater than 7 percent reduction in total costs, a 16 percent to 24 percent reduction in hospital admissions and a 30 percent to 40 percent reduction in emergency room visits in the initial years of the demonstration. Another PCMH initiative -- Community Care of North Carolina -- estimates a savings of nearly $1 billion in Medicaid expenditures in just six years, according to Heim.

Heim emphasized that reducing growth in health care costs is just one of many benefits of the PCMH. "Data from several medical home demonstration and pilot programs show decreased mortality rates, improved participation in preventive and screening services, and better control of blood pressure and cholesterol levels," she said.

"Patients receiving care in a patient-centered medical home are active participants in their own health and are cared for by a family physician who leads the practice team, coordinating all aspects of the patient's health. These efforts improve the patient's quality of life and prevent costly hospital admissions."