Patient Care Access News

Aiming for Success in the Patient-Centered Medical Home Model

Healthcare organizations that adapt to patient needs tend to be more successful in patient-centered medical home models.

patient-centered medical home

Source: Thinkstock

By Sara Heath

- Evolution and adaptability are essential for healthcare organizations aiming to thrive in patient-centered medical home (PCMH) models.

As the healthcare industry continues to change, organizations need to be ready to address changing needs and introduce new strategies that will create better care for patients, according to Tom Leyden, Director of Value Partnerships at Blue Cross Blue Shield of Michigan (BCBSM).

Leyden should know. After all, BCBSM is celebrating nearly ten years as leaders in the PCMH assessment space. In that decade, Leyden and colleagues have observed which best practices lead to more success in PCMH designation.

But understanding the PCMH has not always been easy, Leyden recalled. BCBSM’s focus on the PCMH began in 2007 after the organization’s leadership reviewed the National Joint Principles of a Patient Centered Medical Home care model.

These joint principles offered great insights into the ultimate goals for PCMHs, Leyden said, but didn’t offer details about how provider organizations can create extended care access or link to community services, two components of care that often lead to PCMH success.

READ MORE: Patient-Centered Medical Homes Support Primary Care, ACO Success

“For the first couple of years we worked with the provider community to come up with a transformation program where we defined what the future state would look like,” Leyden recalled during an interview with

“Through our Blue Cross Pay-for-Performance Program, we actually started rewarding physicians across the state for transforming their practices via the implementation of PCMH procedures that they were putting in place.”

By 2009, BCBSM began its PCMH evaluation process.

“We started evaluating practices based upon how much transformation they had put in place in their offices, around these patient-centered principles,” Leyden explained. “Half of the analysis was based on how much the practice transformed the care delivery. The other half was based on what that looks like in regards to claims experience or the actual cost and quality of healthcare.”

For example, BCBSM looked at HEDIS quality scores for inpatient utilization. What do organizations’ emergency department (ED) utilization rates look like? What about high-tech and low-tech radiologies?

READ MORE: How Do Patient-Centered Medical Homes Support Patient Engagement?

As practices continued to advance their services offerings and provide higher-valued care to BCBSM members, Leyden and his team rewarded PCP practices with PCMH designation.

When organizations obtain that designation, Blue Cross Blue Shield Michigan pays them differentially based on having higher-quality care. A primary care provider in the program can earn up to 150 percent of the BCBSM fee schedule for having proven that they deliver higher quality care.

Eighty-five percent of all primary care physicians in the state of Michigan participate in the pay-for-performance (P4P) program and have been subsequently PCMH designated by Blue Cross, meaning patients living in the 81 of 83 counties with PCMH designated providers have ready access to high-quality and coordinated primary care, Leyden explained.

In the ten years BCBSM has been evaluating organizations, it has learned that those who are agile and can transform with the evolving needs of their individual patient populations and the industry at large will be most successful.

For example, the BCBSM PCMH program is beginning to reflect the need to care for patients at-risk for opioid misuse.

READ MORE: Do Patient-Centered Medical Homes Boost Chronic Care Management?

“Tapping into our 10-year-old PCMH program, we were able to work with the provider community to say, ‘how can a patient centered medical home better serve an at-risk population who are suffering from opioid addiction?’”

BCBSM’s PCMH program now has policies in place that call for registration to the Michigan prescription drug monitoring program (PDMP) and creation of controlled substance agreements. Controlled substance agreements put in place expectations and recommendations for patients who are prescribed a long-term controlled substance – pain management patients receiving an opioid, for example.

In making those changes, BCBSM sees nearly 56 percent of its practices with a controlled substance agreement protocol. Additionally, 67 percent of practices have used Michigan’s PDMP.

Partnering with program participants is critical for accomplishing those goals, according to Lisa Rajt, MSW, Health Care Manager of Value Partnerships at BCBSM. It is certainly important for provider organizations to remain adaptable in the ever-changing healthcare environment. But equally important is BCBSM’s ability to measure that adaptability.

Rajt said BCBSM regularly convenes with provider organizations to better understand the program’s next direction.

“I think from my perspective, [the secret to our success] is the strong, collaborative relationships that we have with the primary care providers,” she told “And just how intimately involved they are in crafting every aspect of our program. At every point, we solicit their feedback, we create work groups.”

This partnership is essential to making sure the PCMH designation process truly facilitates actions that are important to patients.

“We review implemented capabilities every year, and we always solicit feedback from the provider organization community, either directly or via our field team,” Rajt said. “This is to make sure that we're truly capturing the concerns and the interests of the provider community; to make sure that the guidelines are as reflective as possible of the current state of practice and what the physicians really need to transform their practices.”

Ultimately, BCBSM rewards primary care practices for changing their procedures and putting in capabilities to better assist plan members.

Increasingly you're going to have to look at how the primary care physician office is able to best meet the needs of at-risk population,” Leyden explained. “So senior citizens, people with opioid addiction, people in lower socio-economic strata. People on anti-coagulation medicine or other things that can put them at an increased risk.”

Delivering on some of the core promises of the PCMH – such as extended access to care or deeper patient-provider relationships – is also helping providers meet the ever-changing needs of their patient populations, Leyden added.

“One hundred percent of our members have 24-hour phone access to clinical decision makers in our PCMH model,” he said. “Every member who's going to a patient centered medical home can call their practice any hour of the day, any day of the week, with questions about areas of health concerns that they might have.”

The benefits of that extended access are twofold, Leyden explained.

“It saves our members from going to the ER at 3 a.m. because their child might have croup or what-have-you,” he noted. “It gives the patient peace of mind to know that yes, they do need to go to the emergency department. Or, no, what they're seeing is normal, but their PCMH-designated doctor is going to make time for them first thing tomorrow morning to come in.”

Regular phone access to a primary care physician also cuts down on avoidable ED visits, Leyden added. For example, PCMH designated practices have nearly 20 percent lower rates of avoidable ED visits because patients can mitigate their issues over the phone or through extended primary care hours.

Additionally, better access to primary care has also decreased inpatient ED admissions for chronic illnesses that have been exacerbated. This has enormous cost benefits to BCBSM.

And more time for relationship-building, which is a built-in element of the PCMH designation and P4P payment model, allows for better healthcare agenda-setting.

“We call it the patient provider-partnership,” Leyden said. “There's a conversation that we reward the doctors for having with the patient, about the role of the patient and the role of the physician and how can they best access services from the physician in a PCMH model.”

For example, PCMH designated physicians are paid to discuss expectations for calling about care concerns. Providers are also expected to discuss healthcare goals with patients. Understanding a patient’s preferred trajectory of care, as well as what she values in her health and life, can eliminate inefficiencies and deliver more cost-effective care.

These discussions not only save time and money, but also foster a better sense of patient activation, making it more likely that a patient will adhere to a care plan.

“It's about having a care team in place,” Leyden stated. “A variety of individuals, all working at the top of their credentialing. A physician working the top of their credentialing, the nurse, a care manager, a social worker, perhaps a dietician. This is fundamental for us to continue to expand the PCMH Program with an eye towards reducing costs even further and providing the best care possible.”

Success in the PCMH model knows no limitations, Leyden added. While some in the healthcare industry may believe only bigger institutions can be successful in developing new care models, that is a misconception. As noted above, 81 of the 83 counties in Michigan have a PCMH-designated primary care provider. Those PCPs span from independent doctors to clinics owned and operated by larger, academic health systems.

“It's not just a University of Michigan or Henry Ford Health System, or another large health system, that is able to transform their PCP practices into a PCMH designated practice,” Leyden said. “Our experience over 10 years is that as long as physician practices have the dedicated support of an organization to help them guide through the transformation process, any practice despite size or geographic location can transform their care delivery to provide improved quality healthcare.”

Rajt agreed, noting that adaptability – not the might of a PCP’s ownership – is key to PCMH success.

“I think the providers that really thrive in our program are the ones that are committed to change and to transforming their practices,” she concluded. “Initially the investment may be considerable in terms of time or resources. But the payoff, at least as far as we've heard from participating providers as well as their patients, can be tremendous. The providers may have more time to see patients. They may be able to practice in a way that's more satisfying for them. And then of course the patients get better care.”


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