Amerigroup Unites Stakeholders in Quest for Higher Quality, Lower Costs
While politicians and courts continue to loudly debate the theoretical merits of various aspects of healthcare reform, a growing number of private stakeholders and industry organizations have quietly begun moving forward with concrete steps to transform the nation’s healthcare delivery system.
The Patient-Centered Medical Home (PCMH) is one of the innovative models gaining traction across the country as providers, payers and patients look at ways to work collaboratively to shift from a ‘sick care’ system to one that promotes wellness and delivers better outcomes and higher quality while reducing costs. By coordinating care and increasing investment on the front-end, this model aims to reduce or eliminate the higher costs associated with duplicated services, emergency care, hospital readmissions, and chronic disease management.
Billing themselves as “a different kind of health insurance company,” Amerigroup Community Care is one of the managed care organizations chosen by the state to provide coverage to TennCare recipients in the Middle Tennessee area. And it was here that Amerigroup launched its PCMH pilot program in 2010.
As of March 2012, Amerigroup had expanded the program to 45 PCMH sites with 548 participating primary care providers in six states covering 122,000 members, making it one of the larger PCMH programs nationally, according to the Patient Centered Primary Care Collaborative. Amerigroup officials noted the success of the program has led to plans to expand the PCMH model to additional practice sites and states during 2012.
William G. Runyon, MD, chief medical officer for Amerigroup Tennessee, is a driving force behind the PCMH program and oversaw the rollout in Middle Tennessee two years ago. “In our network, we currently have 18 patient-centered medical home primary care practices representing a little over 40,000 members,” he said, noting about 20 percent of Amerigroup Tennessee’s 200,000 members are enrolled in a PCMH model.
With an emphasis on prevention and wellness, the PCMH model typically incurs increased utilization on the front end as patients are encouraged to undergo health screenings, make sure immunizations are current and meet with physicians to ward off or control chronic conditions such as hypertension and diabetes.
“We absolutely anticipated that and were hopeful we’d see that,” Runyon said, adding the value proposition of the model as defined by increased quality and decreased costs typically doesn’t fully show up until two or more years after initiating the strategy.
Runyon pointed out, “It’s difficult for MCOs to make long-term commitments because the general thought is your patients come and go.” However, he continued, “The vision of our company is to be a different kind of managed care company. We acknowledged this is a very long-term commitment and outcomes will be over the longer term rather than the short term.”
Although he said it would probably be 2013 before more concrete results were evident, Runyon noted there was mounting anecdotal evidence pointing to the success of this type of model.
One Nashville practice already seeing results is the Metro Center Health Group. “Our partnership with Amerigroup has increased our efficiency and patient compliance, making us more effective in the communities we serve,” said Melvin Lightford, MD. “Thanks to the patient-centered medical home, our patients are able to get the access they need; we are able to better deliver the appropriate primary care preventive treatments and keep our patients out of the emergency room.”
In the case of his practice, Metro Center Health Group decreased its patients’ emergency room visits by 7 percent in the first half of 2011 compared to the same period in 2010.
At the core of the program is a collaborative agreement between payer, provider and patient to work together to break down the freestanding silos patients were left to navigate on their own in a traditional care delivery model. For providers, Runyon continued, not only does it require a willingness to realign long engrained perceptions but a commitment to fundamentally redesign their practice. “This is not work for the faint of heart,” he said with a laugh.
“If we think about the typical primary care practice, they tend to be more in the mode of waiting for the patient to show up rather than taking a more proactive approach,” he continued. With the PCMH model, the primary care practice becomes the team’s quarterback and actively helps patients move toward their health goals.
On the flip side, Runyon said, “The commitment we’ve made as a managed care organization is not to do what MCOs did for years … which is to keep providers at arm’s length.” Instead, he said, Amerigroup willingly provides the tools and resources to help provider partners succeed in this model.
The MCO engaged nationally recognized PCMH consultant TransforMED, a wholly-owned subsidiary of the American Academy of Family Physicians, to help with this initiative. TransforMED assists with training, practice assessment and subject matter expertise for Amerigroup’s local market medical practice consultants. In addition, Amerigroup provides practices with quality and medical cost management reports, has expanded the role of company nurses to become quality coaches, utilizes the practice consultants to facilitate ‘on-the-ground’ practice change, and integrated case managers with primary care practices to extend care management capabilities.
With a ‘knowledge is power’ philosophy, practices participating in the PCMH initiative receive monthly member listings of those assigned to their practice to prompt providers to reach out to members who have not yet scheduled an appointment. The daily inpatient census report gives practices a ‘head’s up’ to actively manage the discharge planning of members admitted to the hospital, and weekly ER reports serve as a red flag for providers to follow up with affected members to see if additional services are required. Other tools include a monthly predictive modeling report, monthly potential missed care opportunity report and quarterly medical cost management report.
“Developing very, very strong committed relationships … that’s, I think, really at the core of this. If you don’t have those relationships, it won’t work,” said Runyon.
In addition to developing ties with private practices across Middle Tennessee, Runyon said Amerigroup works very closely in Nashville with Matthew Walker, University Community Health Services and United Neighborhood Health Services, as well as with Primary Care and Hope Clinic in Murfreesboro. Another important community partner, he continued, is the Tennessee Primary Care Association.
“I am passionate about this. I get really excited talking about it,” said Runyon, adding that such conversations often lead to new partnerships. “I welcome people reaching out to me and having those kinds of conversations.”
Providers interested in learning more about the Amerigroup PCMH project or discussing the concepts behind implementing a patient-centered medical home, can contact Dr. Runyon at William.Runyon@Amerigroup.com.
Other Area PCMH Initiatives
A number of other patient-centered medical home initiatives are also underway in Tennessee.
Recently, the Tennessee Primary Care Association announced 17 Community Health Centers in the state were selected to participate in the Health Resources and Services Administration’s Patient-Centered Medical/Health Home (PCMHH) Initiative. Participants in Middle Tennessee include Matthew Walker Comprehensive Health Center, Tennessee Department of Health, United Neighborhood Health Services and University Community Health Services.
BlueCross BlueShield of Tennessee also partnered with multiple physician practices to launch a PCMH initiative last year. More than 25,000 BCBST members across the state were part of the initial program focused on prevention and primary care. The insurer is providing additional funding for health information technology, providing an on-site care coordinator for proactive outreach to patients, and investing in resources to help practices be successful in implementing the care model. Additionally, BCBST will reward practices based on quality and effectiveness.
“We are encouraged by the strong efforts and early results demonstrated by our medical home program,” said Kevin Raynor, manager of provider performance management for BlueCross. “This partnership is the first step towards a stronger, more integrated care system that delivers better quality, better costs and overall value for everyone.”
Fayetteville Medical Associates, Nashville Medical Group, Summit Medical Associates and Sumner Medical Group are among the Middle Tennessee participants. The large insurer anticipates continued expansion of the program. Thomas Lundquist, MD, BCBST vice president of performance and improvement, said in a webinar address last fall that the goal would be to give 50 percent of chronically-ill members access to a PCMH-focused practice by the end of 2012.
TAGS: Tennessee Primary Care Association, Matthew Walker, United Neighborhood, University Community Health Services, PCMH, Patient-Centered Medical Home, BlueCross BlueShield of Tennessee, BCBST, Summit Medical Associates, Nashville Medical Group, Fayetteville Medical Associates, Sumner Medical Group, Dr. Thomas Lundquist, Kevin Raynor