Success of PCMH Could Mean Expansion

Posted on May 10, 2012 by Kathleen Rand

Patient-centered medical home (PCMH) projects implemented by Independence Blue Cross (IBC) and BlueCross BlueShield of Tennessee (BCBST) have been so successful in improving patient outcomes and keeping medical costs under control that they are looking to increase the programs to more primary care physician (PCP) practices and into other therapy areas as well like behavioral health, cardiology and oncology.

Under the PCMH model, PCPs lead care teams to keep members healthy by using registries to track conditions and ensure that they receive needed care —essentially creating a hands-on approach. And physicians are also rewarded with a per-member per-month (PMPM) fee and other shared savings based on the health outcomes their patients achieve.

In fact, PCMH-focused practices will be eligible for shared savings beginning next year under the Affordable Care Act requisites. To illustrate, a practice with 1,000 chronic care patients could potentially net between $10,000 and $12,000 in shared savings and performance bonuses.

While the PCMH model incorporates many different elements, these five key points more than likely led to the success of the Tennessee Blues’ PCMH effort:

(1) Better access to physicians because of improved after-hours consultation and appointment scheduling for chronic care patients.

(2) Care coordinators at practice sites such as a licensed practical nurse – coordination is supported by total health management services and interactive reporting.

(3) IT infrastructure development to improve health information exchange and communication, resulting from a business stipend for IT efforts such as electronic health records and disease registries.

(4) Improving outcomes and performance measurement through metrics such as fewer emergency department visits and lower inpatient utilization, improving the financial management of healthcare for providers over the long term.

(5) Controlling cost efficiency through reporting to practices on utilization and cost metrics, and providing incentives to physicians through performance bonuses and shared savings.

These insurers realized that building a PCMH is a way to stabilize and grow the PCP network, boost patient outcomes, and improve access to care.

BCBST found that members enrolled in a PCMH had less emergency room utilization and lower inpatient admissions compared with non-PCMH members. It appears that PCMHs are proving a better pattern of utilization and cost efficiency due to the fact that patients are more engaged with their physicians and care coordinators.

Move Fast or Slow on Insurance Exchanges…

Posted on May 5, 2012 by Kathleen Rand

CEOs of health plans are in an interesting position as the Supreme Court deliberates the viability of the healthcare reform law and as the election approaches. That is to say, what approach should they take: should they plow ahead to get ready for the changes coming in 2014, or take their time with big decisions?

If the Supreme Court upholds the constitutionality of the reform law, Congress will be less likely to change or dismantle the law until after the elections. Therefore, it would make sense for insurers to move ahead now since the major changes such as insurance exchanges take effect in the beginning of 2014. Organizations need time to get ready for these exchanges and it would be too late if some sort of planning doesn’t take place imminently. Although not directly correlated to the insurers’ game plan but still pertinent to decision-making, another potential reason for not waiting for the Supreme Court and the election results is related to the states – states need to prepare for these insurance exchanges in order to get the subsidy payments tied in with the reform provisions.

However, some contend that insurers should wait – not jump into any costly decisions. They will have to consider getting subsidies for qualified beneficiaries from the government but that should not affect the timing of planning. The decision from the Supreme Court is less than two months away and then insurers will have 15 months after that to decide whether to even participate in the insurance exchanges. That is assuming that the exchanges are not overthrown and that the insurance reforms are kept intact – otherwise there would be very little motivation to be in the exchanges at all.

Healthcare Reform: Insurance Rate Battle Brewing

Posted on May 1, 2012 by Kathleen Rand

For the nearly two years, medical utilization has been lower. When combined with regulatory analysis, reductions in administrative expenses and more pressure on providers to improve effectiveness, many health insurers have been able to hold rate increases to single digits.

But that could change if utilization increases. Any rate increase could be met with much regulatory scrutiny. By June 1, HHS intends to publish state-specific thresholds for rate increases in the small-group and individual markets, and has been working with the National Association of Insurance Commissioners to determine what to look at when determining state-specific thresholds. In some cases, state thresholds could be higher than 10%.

The threat of federal rate review might have some health insurers calculating rate increases more carefully and negotiating lower reimbursement rates from providers more aggressively. It is possible that the new federal oversight might not have much of a direct impact on coverage costs, but could help to reveal the underlying medical costs, which is a factor in driving up premium increases.

Some believe that the additional level of federal oversight is redundant and will add cost to the product they want to moderate. They believe that rate review should be left at the state level. Last year, CMS’s Center for Consumer Information and Insurance Oversight (CCIIO) determined that seven states — Alabama, Arizona, Idaho, Louisiana, Missouri, Montana and Wyoming — lack the resources and/or authority needed to properly regulate the individual and small-group markets. In three other states, Iowa, Pennsylvania and Virginia, federal regulators can review only the small-group market while state regulators are responsible for the individual market. In some states, small-group insurance products had not previously required rate.

When it comes to rising coverage costs, insurance companies are an easy target. Regulators are limited in what they can do to control rate hikes – until there is a more meaningful delivery system. That is to say, changing fee-for-service medicine into something like a value-based purchasing model.

Regardless of the federal oversight, rates will push higher over the next several years because there is no pressure on provider charges to decrease. The cost shifting that is occurring by hospitals to the commercial sector is because of the reductions in reimbursements from Medicare and Medicaid. A possible solution: governmental regulation of the hospital rates that are charged to commercial health plans.

BHM Healthcare Solutions is a healthcare consulting firm specializing in physician advisor, and financial management services for healthcare organizations. For a fee consultation call BHM at 1-888-831-1171 today!

Increased Support for Primary Care Initiatives

Posted on April 28, 2012 by Kathleen Rand

Pateints and providers fit better under medical home model.

Primary care is vital to improving care, promoting health and reducing overall system costs, yet it has been rather under-funded and under-valued in the past. A primary care practice is a key point of contact for patients’ health care needs. With healthcare reform, new ways have emerged to strengthen primary care by improving care coordination, making it easier for clinicians to work together, and enabling them to spend more time with their patients. Recently, healthcare providers have been investing in primary care.

Initiatives offered as a result of the Affordable Care Act, like Accountable Care Organizations and Patient-Centered Medical Homes will give doctors better means to work with and help patients. In fact, medical home concept has led to the introduction of a program which will allow organizations to seek specific accreditation, i.e., URAC PCHCH Accreditation program. Additionally, these programs ensure that providers can do the following:

Patient with serious or multiple medical conditions need more support to ensure they are getting the medical care and/or medications they need. Primary care practices that embrace the medical home concept will deliver intensive care management for these patients with high needs. By engaging patients directly, patient-centered medical homes and accountable care organizations can create a plan of care that uniquely fits each patient’s individual circumstances and values.
Because health care needs and emergencies are not restricted to office operating hours, medical homes must be accessible to patients 24/7 and be able to utilize patient data tools to give real-time, personal health care information to patients in need.
Primary care practices will have the ability to engage patients and their families in active participation in their care. Medical homes have the ability to centralize communication and enable providers and patients the benefit of a ‘whole picture’ approach – a patient becomes much more than a string of independent, unrelated symptoms.
Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients’ experiences with medical care. Medical homes and accountable care organizations will work with the patient and his/her family to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts.

Insurance Exchanges Pivotal to Reform Law

Posted on April 25, 2012 by Kathleen Rand

The success of the reform law could depend largely on how effective state exchanges are in determining eligibility and enrolling and retaining members. There is an idea of a ‘no-wrong-door’ enrollment system through which millions of people will go and have their eligibility determined in real-time and have a top-notch customer experience. In fact, in various states, members of the state exchange board are working with state and county agencies to redefine the eligibility and enrollment processes.

Some don’t believe that the exchanges will have an impact on coverage costs – there is an expectation that rates will come down once insurance exchanges are operational. That remains to be seen. And along with ensuring that the exchange directs people to the most appropriate coverage, exchanges also need to ensure continuity of care.

Fluctuating income could cause some people to shift between Medicaid and subsidized coverage. There does not seem to be much clarity as to the insurance exchange could ensure that someone who is in the middle of treatment doesn’t have to switch health care providers.

Some safety net providers, such as free clinics, community health centers and various grant-funded programs, will need to study commercial insurance because some of their Medicaid patients will gain coverage through the exchange.

As insurers strive to build these exchanges, providers will continue to focus on developing accountable care organizations and patient-centered medical health homes. How they will integrate in the marketplace will be interesting to watch as it unfolds.

ACO – The Basic Concept

Posted on April 23, 2012 by Kathleen Rand

Under the healthcare reform law, an Accountable Care Organizations (ACO) is a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the patients they serve with Medicare. The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries. The ACO is like a patient-centered medical home where the patient and providers are true partners in care decisions.

The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services:

Networks of individual practices of ACO professionals,
Partnerships or joint ventures arrangements between hospitals and ACO professionals, or
Hospitals employing ACO professionals, and
Other Medicare providers and suppliers as determined by the Secretary.

The law requires each ACO to include health care providers, suppliers, and Medicare beneficiaries on its governing board. The ACO must take responsibility for at least 5,000 beneficiaries for a period of three years, also suggested in the law.

The law links the amount of shared savings an ACO may receive to its performance on quality standards. The rule proposes quality measures in five key areas that affect patient care: patient/caregiver experience of care; care coordination; patient safety; preventive health; and at-risk population/frail elderly health.

The ACA sets out proposed performance standards for these measures and a proposed scoring methodology, including proposals to prevent providers in ACOs from being penalized for treating patients with more complex conditions.

Furthermore, any patient who has multiple doctors probably understands the frustration of fragmented and disconnected care:, duplicated medical procedures, lost or unavailable medical charts or having to share the same information over and over with different doctors. Accountable Care Organizations , like patient-centered medical homes, are designed to lift this burden from patients, while improving the partnership between patients and doctors. Doctors can provide better care because they will have better information about their patients’ medical history and can communicate with a patient’s other doctors. Medicare beneficiaries whose doctors participate in an ACO will still have a full choice of providers and can still choose to see doctors outside of the ACO. Patients choosing to receive care from providers participating in ACOs will have access to information about how well their doctors, hospitals, or other caregivers are meeting quality standards.

PCHCH Medical Homes More Prevalent

Posted on April 19, 2012 by Kathleen Rand

Model of PCHCH

URAC’s PCHCH Auditor Certification is offered to healthcare management organizations desiring to provide independent PCHCH practice assessment audits of healthcare practices. URAC PCHCH standards provide the essential foundation for providers, payers, and patients to collaborate in enhancing quality healthcare services across the continuum through shared accountability in a patient-centered health care home. URAC’s PCHCH Auditor Certification provides assurances to healthcare practices that their auditors are licensed, qualified and specially trained health professionals who understand the complexities of care coordination. The URAC PCHCH Auditor Certification requires URAC Core Accreditation, assuring that the auditing organization meets desirable standards of operation and quality management prior to performing practice audits. URAC provides the certified auditor with access to and training on tools that support verification that a practice successfully meets a baseline percentage of select URAC PCHCH essential standards.

Simultaneously, the Commonwealth Fund—a private foundation that aims to promote a high-performing healthcare system that achieves better access, improved quality, and greater efficiency—launched a four-year, $6 million initiative to help primary care safety net clinics become high-performing patient-centered medical homes. As a result, in May 2009, 68 health clinics in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania have agreed to transform the clinics into person-centered medical homes. In addition, five regional coordinating centers (RCCs) have been formed to oversee the clinic’s transformation efforts. The five RCCs were selected to participate in the demonstration project, and each partnered with about 15 preexisting safety net clinics in their state. These collaboratives will receive technical assistance on practice re-design topics such as enhanced access, care coordination, and patient experience. To be eligible for participation, partner clinics had to provide comprehensive primary care services, including preventive care and immunizations, ambulatory care, and other common services. However, clinics did not need to provide on-site mental health or dental care in order to be considered comprehensive. The RCCs receive funding from Qualis Health’s Commonwealth Fund grant.

It is anticipated that at the end of the initial grant period all 68 health clinics will be unequivocally recognized as models of excellence. The participating centers will receive training to support the health centers’ efforts to improve the coordination of information and care between primary and specialty care or community provider organizations; to use information technology to identify patients with unmet needs; to improve care for those with chronic conditions; and to systematically obtain feedback from patients for quality improvement.

Employers Are Anxious about Reform Mandates

Posted on April 17, 2012 by Kathleen Rand

Healthcare Compliance concern for employers

Most employers but especially those with numerous lower-paid employees are getting worried about the combined effect of upcoming healthcare reform law provisions that they fear would hurt their competitive position. While these employers do not seem to be planning to drop employee health coverage completely they are exploring strategies that could reduce the impact of the changes on them — and affect health insurers in the process.

Another concern for employers relates to the provisions requiring auto-enrollment in coverage for full-time workers. Both the administrative aspects and the reaction from employees who are having deductions taken from their pay without authorizing them is a viable source of apprehension. Furthermore, employers cite worry about both the requirement that plans must pay at least 60% of actuarial value for covered services and that all employees working more than 30 hours per week must be eligible for health coverage.

Consequently, employers may change their work-force strategy so that they have fewer employees working more than 30 hours per week and therefore requiring health coverage while others might consider making part-time workers eligible for the health plans of full-time employees. Generally employers don’t want to reduce health coverage, but they are prepared to lower the value if competitor employers do. 32% of employers plan to reduce spending on dependent health coverage.

Under the Affordable Care Act, employers have financial liabilities if their coverage is deemed not affordable or not meeting the minimum value. However, one problem the employers are facing in preparing for this is that the affordability and minimum-value concepts have not yet been adequately defined. Health coverage is deemed unaffordable if it costs more than 9.5% of household income. Employers of low-wage workers are concerned that if they made coverage affordable to workers under the 9.5% requirement, it might not be affordable to the employers. Additionally, employers fear that their employees may decide not to buy health coverage costing 9.5% of their income.

Again, in general, employers are not looking to drop coverage, but are very concerned with such requirements as coverage for part-time workers. Many of them are interested in developing a new insurance product for those workers that both is affordable and in compliance with the healthcare reform law’s requirements.

But small employers also now know that these employer mandates apply only to those with more than 50 workers – hence, employers may think long and hard before they hire that 51st worker.

Benefit of PCHCH Concept

Posted on April 14, 2012 by Kathleen Rand

We have discussed the goal of the “medical home” in the last few blog posts — improve primary care so fewer people need to go to the hospital. States experimenting with this nationwide movement say that when practiced by doctors serving Medicaid patients, it can enhance overall health conditions and consequently save billions of dollars in the long run.

But does it save money in the short term and help the financial management of healthcare organizations? Some studies reveal that patient-centered medical homes definitively showed real cost savings, even when not involved with a Medicaid program. Federal health officials are so convinced medical homes save money that they’ve offered to pay most of the bill for states to test them. Starting in 2013, states that pursue a variant of the concept, called PCHCH will get a 90 percent federal subsidy. Instead of applying medical home techniques to all patients, health homes would specialize in those with multiple chronic conditions, including mental illness.

By promoting disease management, patient education, electronic record-keeping and more personalized care, medical homes are intended to improve the lives of people with chronic diseases such as diabetes and asthma and help healthy patients prevent illnesses. Overall spending is supposed to shrink because a sharper focus on individual patients leads to fewer emergency room visits, hospital readmissions, redundant and expensive tests.

The overall sense is that the medical home model is really promising but does remain to be seen just how much money will be saved quickly. Medical homes that focus most of their resources on patients with complex cases, such as those described in the federal government’s health home program, will likely generate the biggest measurable savings. In contrast, when you look at a full panel of patients in a primary care medical home, there aren’t as many opportunities to improve care, and it’s harder to measure effects.

Whatever the studies may show, patient-centered medical homes are an undeniably appealing concept. When more emphasis is placed on primary care, health improves and overall costs go down. At least 41 states are now testing the medical home concept, and various healthcare management organizations are applying for PCHCH Accreditation which will enable PCHCH auditors to assists healthcare facilities to qualify as medical homes.

For doctors, the experiment can mean more money and the satisfaction of seeing patients do well. Instead of simply getting paid for each office visit, doctors are paid an additional monthly fee to provide better, more efficient care – a value-based purchasing extention of one of the facets of the Affrodable Care Act. And instead of handling all of their patients’ needs on their own, doctors are assisted by a team of care coordinators like caseworkers, psychologists and specialized pharmacists.

All of this takes time and money, but supporters say the results are worth it. An added bonus has been that medical homes attract more primary care physicians to the Medicaid program and, in many cases, participating doctors provide the same kind of enhanced care to all of their patients, so the entire community benefits.

Patient-Centered Medical Home – A Model

Posted on April 11, 2012 by Kathleen Rand

A Medical Home Model

The medical home model, or simply “medical home,” is built on the idea that patients should develop meaningful relationships with their family care physician. In a medical home, primary care is used to achieve better health outcomes, improved patient experience, more efficient use of resources and ideally, lower overall costs to the healthcare system.

The basic concept of a patient-centered medical home is simple – patients have continuous access to a primary care physician who provides comprehensive and coordinated care for the majority of their health needs. Ideally, a medical home would be responsible for acute care, chronic care, preventive services and end-of-life care. The medical home staff coordinates patient care with specialists, lab and X-ray facilities, hospitals, home care agencies and other healthcare professionals on the patient care team.

Now, with federal healthcare reform, medical homes are fundamentally changing the way care is delivered. There are programs that accredit organizations as a medical home such as URAC PCHCH Accreditation. And as healthcare reform continues to roll out, the prevalence of URAC PCHCH auditors will increase.

The following characteristics are important components of the medical home model.

Patient-centered

The primary care medical home model provides primary healthcare that is relationship-based with an orientation toward the whole person. Medical homes should attempt to provide care in a culturally and linguistically appropriate manner. The patient-centered medical home model recognizes that patients and their families are meant to be members of the team and that they are fully informed when making and carrying out care plans for the patient. Medical homes also support patients in learning to manage and organize their own care at a level at which the patient is comfortable.

Comprehensive care

In order for a medical home to provide comprehensive care, a team of care providers is essential. For example, physicians, advanced practice nurses, physician assistants, nurses, pharmacists, social workers, nutritionists, and care coordinators could all be a part of the “home”.

Some larger medical homes may bring together a diverse team of care providers in-house while smaller practices or those with fewer resources, such as those in rural areas, may build virtual teams by linking themselves and their patients to providers and services in their communities.

Coordinated care

The medical home is accountable for coordinating care across all elements of the broader healthcare system, including specialty care, hospitals, home health care and community services and supports. Care coordination is principally critical during transitions between various sites of care, such as when patients are being discharged from the hospital. Medical home practices also are aadept at communicating openly among patients and families, the medical home, and members of the broader care team.