In 2011 CareFirst BlueCross BlueShield, a plan offering coverage in Maryland, the District of Columbia, and northern Vir

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In 2011 CareFirst BlueCross BlueShield, a plan offering coveragein Maryland, the District of Columbia, and northern Virginia,implemented a patient-centered medical home (PCMH) program thatincluded enhanced payments for primary care practices, financialincentivesfor primary care physicians to reduce spending, and care coordina-tion tools to support improved care. The model, called the TotalCare and Cost Improvement Program, changed payments to primary carephysicians, increasing fees by 12 percent to compensate for extracare coordination and population management activities. The programalso established a one-sided system of shared savings, increasingfeesfor the following year if spending was below the target. Forexample, savings realized in 2012 would increase fees in 2013. Theincreases depended on the savings achieved by the panel, a qualityscore, panel size, and savings consistency over time. The increaseswere substan- tial, an average of 45 percent by 2013 (Afendulis etal. 2017).
How well did the program work? That is not clear. Afendulis andcolleagues (2017) conclude that savings were small and that manyphysicians were not fully engaged with the program. Cuellar andcol- leagues (2016) report savings of nearly 3 percent in 2013,largely driven by reductions in emergency department and hospitaluse. They conclude that “a PCMH model that does not requirepractices to make infrastructure investments and that rewards costsavings can reduce spending and utilization” (Cuellar et al. 2016,1382). The differences appear to be driven by analytic decisionsabout whether to analyze use of services by patients who switchedto PCMH practices during the first three years (Afendulis et al.2017).
The differing interpretations may not matter. In September 2017CareFirst issued a press release hailing “an historic slowing ofoverall medical cost growth” (CareFirst BlueCross BlueShield 2017).In 2016 CareFirst members seeing PCMH providers had hospitaladmission rates that were 10.4 percent lower and readmission ratesthat were 34.7 percent lower than those of patients receiving carefrom other providers. What changed? First, PCMHs had become a muchmore common approach to primary care by 2016. Second, in 2014CareFirst got a grant from Medicare to extend the program to coverMedicare beneficiaries. This change increased its clinical andfinancial effects.
The grant also allowed CareFirst to train staff in the PCMHpractices and to hire care coordinators, nurse case managers,consultants, pharmacy managers, clinical pathway specialists, andanalysts. Third, organizational change takes time, and three moreyears had elapsed.
Bleser and colleagues (2014) argue that becoming an effectivePCMH requires three things:
1. strong desire for change and a belief in the need forchange,
2. capacity to carry out performance improvements, and3. detailed understanding of current and best-practiceclinical protocols.
It is not clear that these elements were present during theearly years of the Total Care and Cost Improvement Program.Afendulis and colleagues (2017) report that physicians in theprogram were receptive to making quality improvements but were lessinterested in cost reductions. In addition, most were not familiarwith or interested in the shared savings incentives.
How did including Medicare beneficiaries change incentives?
How did the expansion of telemedicine services for Medicarerecipients help or hurt total cost and total improvement during thecoronavirus national emergency?