Blue Cross Blue Shield of Michigan
Physician Group Incentive Program
Patient-Centered Medical Home
And Patient-Centered Medical Home-Neighbor Interpretive Guidelines
READ ME FIRST: Introduction
Everyone needs to read these into pages
THE ESSENTIAL FAQS ABOUT THE PATIENT- CENTERED MEDICAL HOME AND PATIENT-CENTERED MEDICAL HOME-NEIGHBOR PROGRAM
1. What is the Patient-Centered Medical Home and Patient-Centered Medical Home- Neighbor?
The Patient-Centered Medical Home (PCMH) is a care delivery model in which patient treatment is coordinated through primary care physicians to ensure patients receive the necessary care when and where they need it, in a manner they can understand. The PCMH-Neighbor model enables specialists and sub-specialists, including behavioral health providers, to collaborate and coordinate with primary care physicians to create highly functioning systems of care.
The goals of the PCMH/PCMH-N model are to:
Strengthen the role of the PCP in the delivery and coordination of health care
Support population health management, which uses a variety of individual, organizational and cultural interventions to help improve the illness and injury burden and the health care use of defined populations.
Ensure effective communication, coordination and integration among all PCP and specialist practices, including appropriate flow of patient care information, and clear definitions of roles and responsibilities
2. Why are there all these “capabilities?”
When BCBSM began developing its PCMH program in 2008 in collaboration with PGIP Physician Organizations (POs), it became clear that practices could not wave a wand and turn into a fully realized PCMH overnight. In early demonstration projects, practices began suffering from transformation fatigue, in some cases leading to disillusionment with the PCMH model.
In partnership with the PGIP community, BCBSM decided to develop 12 initiatives to support incremental implementation of PCMH infrastructure and care processes. Each initiative focuses on a PCMH domain of function and defines the set of capabilities that will enable practices to achieve the PCMH vision for that domain of function.
Initially, a 13th initiative was developed for electronic prescribing (domain 8), but then a separate e- prescribing incentive program was implemented, and e-prescribing was removed from the list of PCMH/PCMH-N domains. In the 2016-2017 version of the Interpretive Guidelines, domain 8 was resurrected to add capabilities related to electronic prescribing and management of controlled substance prescriptions.
3. Why do we need “Interpretive Guidelines?”
During the first round of site visits in 2009, we rapidly discovered that there were widely varying interpretations of nearly every term and concept in the PCMH model. We created the Interpretive Guidelines to provide definitions, examples, links to helpful resources, and to address questions regarding extenuating circumstances.
The Interpretive Guidelines continue to evolve, and in this version we arenow includeing “PCMH Validation Notes,” which are examples of the ways in which a practice may be asked to demonstrate that capabilities are in place during the site visit validation process. Please note that these are just illustrative examples; during the actual site visit a practice may be asked different or additional questions.
4. Why have new capabilities been added over time, and why are some capabilities being retired?
Although the PCMH/PCMH-N model was designed to be highly aspirational, it also continues to evolve based on new research and insights about the delivery of optimal health care. Each year, BCBSM conducts a comprehensive review of the Interpretive Guidelines, incorporating input gathered from the PGIP community throughout the year, and new capabilities are added as needed based on new findings.
Starting in 2017, capabilities are retired when they no longer require substantive time and or resources to implement, due to the evolution of practice transformation.
5. Who is responsible for reporting PCMH/PCMH-N capabilities to BCBSM?
Physician Organizations are responsible for reporting PCMH/PCMH-N capabilities to BCBSM. Capabilities can be reported online at any time, using the Self-Assessment Database. Twice a year, in January and July, BCBSM takes a “snapshot” of the self-reported data.
It is not acceptable for a PO to request that practices simply self-report their capabilities. POs must be actively engaging and educating their practices about the PCMH/PCMH-N model, andmodel and must validate all capabilities before reporting them in place.
6. Can we report a capability in place as soon as the practice has the ability to use it? Or what about when one physician or member starts using it?
No and no. Any capability reported to BCBSM as “in place” must be fully in place and in use by all appropriate members of the practice unit team on a routine and systematic basis, and, where applicable, patients must be actively using the capability. Some examples the field team has seen of capabilities that should not have been marked in place are:
Patient portal capabilities reported as in place: Practice has patient portal implemented, but no providers or patients are using it.
After hours/urgent care capabilities reported as in place for specialty practice: urgent care centers are identified in the PO’s PCMH brochure the practice is giving to patients, but specialty practice says they don’t use urgent care and do not counsel patients about how to receive after hours/urgent care, but instead direct patients to the ED.
7. The PCPs in my PO are very familiar with the PCMH model, but our specialists hardly know what we’re talking about. Some of them think they should be their patient’s medical home, not the PCP. What should we do about this?
It is critical that prior to reporting PCMH-N capabilities in place, POs ensure that both allopathic and non-allopathic specialists are aware of and in agreement with the PO’s documented guidelines outlining basic expectations regarding the role of specialists in the PO and within the PCMH/PCMH-N model, including:
Commitment to support the PCMH/PCMH-N model and the central role of the PCP in managing patient care and providing preventive and treatment services, including immunizations
Willingness to actively engage with the PO to optimize cost/use of services
Collaboration with PCPs and other specialists to coordinate care In addition, POs should:
Visit specialist practices to determine which capabilities are in place and actively in use. (The only exceptions would be those capabilities that are centrally deployed by the PO, such as generation of patient alerts and reminders.) POs should also ensure that specialist practices are aware of, and in agreement regarding, which PCMH-N capabilities are reported as in place for their practice.
Hold forums and visit practices to educate the specialists and their teams about the PCMH-N model, and, importantly, emphasize the need for specialists to actively engage with the PO and their PCP colleagues to optimize individual patient care management and population level cost and quality performance. Please remember that the point of the PCMH-N program is not to reward specialists for capabilities that just happen to be in place; the purpose is to enable POs to engage specialists in the PCMH-N model, with the goal of building an integrated, well-coordinated medical neighborhood.
As of 2017, if the field team finds during the course of a site visit that any of these elements are missing (e.g., the practice does not understand or support the PCMH/PCMH-N model, has not been visited/educated by the PO, is not aware of which capabilities have been reported in place, etc.), the field team reserves the right to suspend the site visit and take other remedial steps as deemed appropriate.
An innovative incentive program through BCBSM that brings together physician organizations from across Michigan, to encourage information sharing about various aspects of health care. Program participants, including both primary care physicians and specialists, collaborate on initiatives designed to improve the health care system in the state.
An organization that partners with physicians or is a group of physicians that works with health plans on contracts and other mutual interests (i.e. incentive programs, transition programs, etc.) of their organization.
An organization that partners with physicians and hospitals in order to obtain payer contracts and to further mutual interests (i.e. incentive programs, transition programs, etc.) within integrated delivery systems.
An organization that is 50% owned by physicians and 50% owned by the Health System to negotiate payer contracts, assist with health plan enrollment, and provide guidance and support in mutual interests that promote evidence based care and overall well being of their customers "the patient".
Twice a year (summer and winter) BCBSM requires PO/PHO to conduct assessments for PGIP participating offices which include review of office demographic information, office technology and PCMH initiative implantation within the office. This data is linked to PCMH nomination, PCMH designations and PGIP incentive monies.
The identification of a practice within the PGIP program.
An office in PCMH nomination status is requesting review by BCBSM for PCMH Designation. An office can be nominated through their PGIP participating PO/PHO during the BCBSM Winter SRD submission.
Total number of "current" patients in the practice.
Total number of patients in the denominator with whom conversations have been held and partnerships established at any point in the past
Claim payments based on quality and utilization scoring determined by the health plan. (Quality based payment structure)