Unusual partnership unveils next generation PCMH model
Last February, shortly after Brad Wilson took over as CEO of Blue Cross and Blue Shield of North Carolina (BCBSNC), he and UNC Health Care System CEO Bill Roper, MD, MPH, began discussing ways post-health reform to “move the needle” and truly make a difference in healthcare delivery.
“We came up with the idea to collaborate on a model based on the Patient Centered Medical Home (PCMH),” said Wilson. “Fast forward to Dec. 7, and we were able to stand together and cut the ribbon on Carolina Advanced Health. It’s up and operational, and has caught the imagination of many people. Bill and I have appeared jointly and have been invited separately in North Carolina and outside the state to discuss our collaboration. It’s created a lot of buzz and we believe it will result in higher quality of care at a lower cost.”
The Specialist Role and Other Curiosities
Important decisions that will emerge from the next generation Patient Centered Medical Home (PCMH) model at the new Carolina Advanced Health involve the role of specialists and sub-specialists.
“The primary care physicians who staff our clinic will determine and make necessary referrals,” said Brad Wilson, CEO of Blue Cross and Blue Shield of North Carolina (BCBSNC). “Since the clinic is affiliated with the UNC Health Care System, many specialty referrals will be made within the system. But the patient won’t be restricted to go there.”
Other important questions that arise from specialists: to what extent will this new paradigm of care disrupt or diminish the need for specialty referrals? And how will it impact the specialty community long-term?
“I don’t know the answer to those questions, but I do know that if the clinic works well, it will diminish the need for specialty referrals because that’s what a Patient Centered Medical Home is all about – a patient-centered engagement and involvement that lessens the need for specialty care,” said Wilson.
Some physicians are curious about the new concept.
“There’s skepticism among North Carolina physicians about whether this plan will really work, to deliver a higher quality of care at a lower cost, and maybe some of the skepticism even rises to the level of cynicism,” said Wilson. “We believe it will work. There’s enough medical evidence to back it up, that if you do it well and do it right, you can achieve that result. That’s our goal, and one of the reasons for doing this is to prove that proposition, and ultimately we will.”
A common question North Carolina physicians often ask Wilson about the model: exactly how do medical professionals make their money?
“Folks in this clinic are on salary, so the volume is irrelevant to their earnings,” he explained. “At the end of the year, if the evidence shows that higher quality outcomes have been achieved at a lower cost, then they’ll be rewarded in addition to their salary for their outcomes. So the focus is on making the patient as well as possible.”
Another common query: who decides the criteria by which to judge the clinical outcomes?
“The answer is that it’s been worked out under the leadership of Blue Cross and UNC and physicians of expertise,” said Wilson. “We looked to national colleges and academies of specialties and primary care, and those have been designed and put in place by medical professionals, not insurance professionals.”
Carolina Advanced Health, a new primary care physician practice that coordinates a patient’s care under one roof, takes the PCMH model to a new level. Established to help boost quality outcomes, streamline care and reduce medical costs, the new practice represents the next generation of the PCMH.
“This is just the beginning of what we hope will be a new era in personalized healthcare that leads to improved patient health, greater efficiency, and lower healthcare costs," said Roper.
Specifically, doctors, nurses and other health professionals at the practice work together to manage every aspect of patient care to help improve the patient experience. The collaborative approach, aimed at improved health and quality standards and a reduction of complications among patients, will help reduce medical costs in the national transition from production-based to value-based medicine.
“Establishing the new clinic didn’t have that many challenges or anything insurmountable,” said Wilson. “The first step was deciding that these two organizations would come together on this project. If you think about it classically, a health insurer and a major academic medical center typically don’t come together to build things. Once we decided we had the spirit and the will to work together and bring this to pass, the hard work started.
“Along the way, there were bumps in the road on very important issues like governance, how to pay providers working in the clinic, what kind of technology to employ, and how to handle specialty referrals. There were lots of important conversations. The key agreed-upon aspect of the project from the onset was that failure wasn’t an option. When we got to a tough place, we stayed together, kept working, and found a solution. Then we moved down the road. All the teams that were put together that brought this clinic into being did exactly that. The work got done.”
Carolina Advanced Health will serve up to 5,000 eligible BCBSNC customers, including up to 1,500 members of the North Carolina State Health Plan for Teachers and State Employees. The model was designed for adult patients ages 18 to 62 with chronic illnesses, such as coronary artery disease, hypertension, diabetes, obstructive lung disease, depression, and asthma.
“The reason we put parameters around the population is that this is an experiment, a laboratory, if you will, and we wanted to make sure we had a well-defined population that we could accommodate and not lose our focus trying to determine best practices,” said Wilson. “Of course, as we learn what’s working well, we certainly intend to translate that into other age categories and populations, and hopefully someone else will do this somewhere in America and be successful.”
Carolina Advanced Health patients will receive a range of services, including primary care, medication management and preventive care. The practice also streamlines the medical process, allowing patients to schedule multiple appointments on the same day, ask BCBSNC Customer Service claims questions onsite, and also pay bills and schedule appointments online.
When at capacity, Carolina Advanced Health will provide patients with:
- Primary care services
- On-site mental health support
- On-site nutritionist
- On-site pharmacy consultations
- On-site lab testing
- Case management and coordination of care for patients requiring hospitalization
- Group and educational visits
- Extended weekday and weekend hours
- State-of-the-art information technology
“As the core group grows, we’ll determine what other medical professionals, such as nurse practitioners, need to be brought in to serve that population,” said Wilson. “We plan to have an onsite pharmacy. We’re going to try to be as much of a one-stop shop as possible for patients being seen at the clinic.”
Plans for expansion have been tentatively noted in the long-range outlook.
“By year 3, there should be sufficient experience with a critical mass of patients that we’ll understand and validate a lot of assumptions that have been made and then understand best practices and be in a position of scaling this up or replicating it in another part of the state,” said Wilson. “That would be the earliest. We believe by year five, evidence will be available that would put us in a position of making scalability, replicability types of decisions on a broader scale.”
BCBSNC and UNC Health Care System brought in an independent third party to review data and make independent judgments about the success and challenges of the clinic model.
“So when we begin to tell our own story, it will lend additional credibility,” he said. “We intend to publish the results and be completely transparent about what we’re doing and the outcomes we’re achieving so others will learn from it, avoid mistakes we’ve made and replicate what’s working well.”