Citing Cost Reductions, Highmark to Expand PCMH Initiative

John Commins, for HealthLeaders Media , January 24, 2013

Fiaschetti said the quality indicators would be designed around nationally recognized benchmarks, particularly as they related to chronic illnesses such diabetes and congestive heart failure.

"The overall cost will be around the total per capita cost per member and the incentives will be different," he says. "Physicians can earn more money for better care and overall there will be a huge return because we will eliminate emergency visits, unnecessary admissions and readmissions, all those things that raise costs and frankly aren't good for the patients."

"We hope the outcomes are better health for the patients at a lower cost for the patient and the system," he says. "We believe that there is a huge return on this and what it is going to take is a different approach, a much tighter alignment than we've had in the past. We will be exchanging much more data about services that have been provided to these members, data about clinical information around these members."

Adam Powell, a healthcare economist and president of Payer+Provider Syndicate, a Boston-based consulting firm, says Highmark's recent findings from its PCMH pilot are consistent with the positive results seen at Blue-sponsored PCMH initiatives in South Carolina and North Dakota.

"While the additional care coordination resulting from the expansion of the PCMH initiative will likely improve the quality of care, it is important to maintain a bit of caution about the potential cost savings," Powell wrote in an email exchange with HealthLeaders Media.

"Similar savings will only likely be seen in the recently added practices if the practices in the pilot were representative of typical practices contracting with Highmark. Furthermore, the benefits of PCMH are still a bit murky. A July 2012 report by [the Agency for Healthcare Research and Quality] found insufficient evidence to precisely determine the clinical and economic benefits of the PCMH model."

"Quantifying the benefits of PCMH has been hampered by variation in the way that it is implemented. Given that Highmark has approximately 5 million members, expanding access to PCMH to include less than 5% of total membership represents a conservative approach. The lessons learned from this modest expansion will help Highmark be successful in its quest to cover 75% of its members with pay-for-value arrangements by 2015," Powell wrote.

John Commins is a senior editor with HealthLeaders Media.

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