Organization: CareFirst Blue Cross Blue Shield  

Innovation Type: Medical home supported by shared savings .

What They’re Doing: Private payer-directed medical home project with multiple provider incentives (shared savings, enhanced provider fee rates, and provider fee payments for coordinated care)

Clinical Innovation: Based on a three-year pilot program, CareFirst BlueCross BlueShield’s PCMH Program supports almost 3,500 primary care providers (physicians and nurse practitioners) as leaders of interdisciplinary teams to coordinate care for patients in Maryland, Northern Virginia and the District of Columbia. It is the nation’s largest private payer-directed medical home initiative. 

Supportive Financing Mechanism: Participating PCPs earn significant financial incentives for meeting specified care coordination, quality and efficiency targets, including:

• A 12% increase in provider fees for enrolling and actively participating in the PCMH Program.

• Additional professional service fees for developing care plans ($200) for select patients with certain chronic or multiple conditions and for managing and monitoring those plans ($100). These fees are paid in addition to (not in place of) existing office visit and other service fees.  

• Fee incentives based on long-term overall quality and cost improvements for their cohort of patients. PCPs can earn bonuses ranging from 40% to 80% over time and paid through additional fee schedule increases based on their engagement with their patients, the quality of care delivered to their entire cohort of patients, and aggregate costs of care compared to expected costs. 

Evaluation Type: Quasi-Experimental 

Evaluation Plan: Multiple measures, including quantitative metrics of illness burden (based on claims data), qualitative patient satisfaction surveys, cost data, and NCQA metrics. 

Patient Health and Cost Outcomes: Results expected by the end of 2012. 

Publications: none 

Target Population: Initial inclusion of interested providers, with goal to expand to entire coverage area.

Date of Implementation: Roll-out process launched January 2011 after completion of three-year pilot. Plan is fully operational.   

Contact: Brian Silverstein, M.D., Senior Vice President, Primary Care Medical Homes, brian.silverstin@carefirst.com,  Phone: 410-605-2473

Multimedia: Videos from CareFirst President & CEO Chet Burrell and participating physicians at www.carefirst.com/pcmhinfo

Where to learn more: www.carefirst.com/pcmhinfo