Blue Cross Blue Shield of Michigan Experience with the Patient Centered Medical Home

1. Blue Cross Blue Shield of Michigan Experience with the Patient Centered Medical Home Michigan Purchasers Health Alliance September 17, 2009 Thomas J. Ruane, MD Medical Director of PPO and Care Management Programs truane@bcbsm.com

2. Early Development BCBSM initiated a pay for performance program titled the “Physician Group Incentive Program” in 2004 - funded by a 0.5% “contribution” as part of a 2.5% annual professional fee update - enrolled ten primary care physician groups - Focused on the principles of the “Chronic Care Model”

3. Early Development • PGIP Principles • Physician enrollment by groups • Facilitates measurement • Provides for broader infrastructure development • Organizes communication between BCBSM and physicians participating in the PGIP program • Focus on “organized systems of care” • Development of more uniform practice infrastructures • Program initiatives should apply across the entire practice population of the physician group, not just BCBSM membership • Evaluate total care of members, not just primary care performance • Substantial Locus of Control in the group practice • Strong physician participation in program development • Enrollment in a variety of initiatives rather than a single program structure

4. Growth of PGIP • Enrollment has grown to 36 state-wide groups of physicians comprising: • Over 7500 physician • Over 5500 PCPs • Nearly 1.8 million attributed BCBSM members • Incentive reward pool has increased from 0.5% of PPO professional payment to 3.5% of all BCBSM Michigan Professional payment – over $60M in 2009 • Initial focus on • Development of disease-specific registries for patient management and reporting – chronic care model • Increased generic prescribing • ePrescribing • Currently • Nearly 20 initiatives with inclusion of oncologists, ER physicians, hospitalists and (in 2010) Ob-Gyns and Cardiologists

5. PCMH in PGIP • Evolution of PCMH from the Chronic Care Model was a natural next step in practice development • PCMH concept has focused and energized the physicians in PGIP and physician leadership in Michigan • PCMH principles have become the organizing principles of practice development for the PCPs in PGIP

6. PCMH Implementation and Progress 2007 - 2009 • Jointly agreed upon 12 Domains of function (6 in 2008 and 6 in 2009) with defined documentation and milestones relating to 64 specific capabilities: • Patient provider partnership • Patient Registry • Performance Reporting • Individual care management • Extended access • Test tracking and follow up • Coordination of care • Preventive services • Specialist referral process • Linkage to community services • Self-management • Patient web portal

7. PCMH Designation 2009 • Agreed to review the performance of practice units designated by the PGIP groups • Agreed to recognize up to 20% of PGIP PCP practice units who were most advanced in developing and implementing PCMH capabilities as BCBSM PCMH practices • Agreed to provide an additional 10% payment for all office visit (evaluation and management) services in the PCMH settings • PGIP groups nominated practices • BCBSM program staff reviewed the self-reported PCMH progress for the nominated groups – later for all groups working on PCMH capabilities

8. PCMH Designation 2009 • Made site visits to a large proportion of nominated practices in early 2009 • Communicated regularly with PGIP group leadership on the progress of the designation process • Effective July 1, 2009 300 Michigan practices including 1200 physicians were designated as PCMH practices and began receiving supplemented payments

9. Lessons Learned • Collaboration is key • Highly engaged PCP leadership from across the state sharing experiences made progress possible • Incorporation of a variety of approached to all PCMH capabilities enriched the program • Genuine Practice Transformation is hard and slow work • Incorporate ideas and methodology from many sources: professional societies, NCQA, LEAN process redesign, IHI learning collaboratives, TransformMED, etc. • Strong Clinical and Programmatic Leadership and Significant Financial support are all Essential