Citing improved healthcare for about 200,000 patients, Horizon Blue Cross Blue Shield of New Jersey is trying to get more insured members and healthcare providers to participate in reforms aimed at improving coordination and bolstering preventive care.
An internal study made public last month touted positive results for about 200,000 patients participating in Patient-Centered Medical Homes (PCMHs), in which providers commit to working together with patients to improve their health rather than just treat them when they become sick.
PCMHs rely on “care coordinators” on each healthcare provider’s staff to work with patients to schedule appointments and tests, and monitor their health.
PCMH patients fared better when it came to diabetes control and cholesterol management, and had more breast-cancer and colorectal screenings than patients served by traditional medical practices, according to the study.
The PCMH patients also had lower rates of emergency room visits and hospital admissions, as well as a 4 percent lower total cost of care.
Horizon executive Joseph O’Hara said the study confirmed that the company is moving in the right direction in developing such programs, which now include more than 3,700 doctors in PCMHs, as well as 13 accountable care organizations (ACOs), which are larger organizations such as hospital systems that use care coordination to serve specific groups of patients, such as Medicare recipients. O’Hara is Horizon’s ACO program director.
The study results are being conveyed to insurance brokers and employers, who in turn will describe the benefits of PCMHs to workers, O’Hara said.
Horizon members can choose whether they want to participate in PCMHs or stick with traditional medical practices. However, members in some new plans are offered lower out-of-pocket costs if they use PCMHs, noted Carl Rathjen, Horizon’s manager for strategic relationships and external affairs.
Rathjen predicted that Horizon’s PCMH results will catch the eye of both Blue Cross Blue Shield organizations in other states and Horizon’s New Jersey competitors.
A major step in expanding the PCMH program will occur on January 1, 2015, when Horizon will join its fellow Blue Cross Blue Shield organizations in offering covered members access to patient-centered programs in other states. For example, an employee who has a Horizon plan because they work for a New Jersey-based company will be able to receive PCMH services even if they live in another state, while a New Jersey resident who’s a member of another state’s Blue Cross Blue Shield plan will be able to use Horizon’s PCMHs.
O’Hara said it’s a major decision for a healthcare provider or medical practice to become part of a PCMH, since they have to transform the way they provide care.
For example, they must commit to seeing patients on the same day they are called for an appointment; to use data provided by Horizon to manage the health of patients; and to keep track of patients who are coming out of the hospital, and to see them soon after they’re discharged.
These changes can lead to more frequent care in the short term for patients with chronic conditions like diabetes in the short term, but result in lower long-term costs as these patients get their conditions under control.
Dr. Marc Feingold, who operates a sole-practitioner primary-care office in Manalapan, said he already had a patient-centered approach when he started his practice more than four years ago after leaving a large group. He said the study results support what he has seen.
“I went into primary care medicine because I like treating people and preventing them from getting sick,” Feingold said. “This (PCMH) program parallels what I’ve always been doing.”
Feingold said the PCMH has provided higher reimbursements and funding to support his office’s care coordinator.
“It wasn’t that big a decision,” he said. “It was kind of what we were already doing already, we just had to get recognized for the work we were doing already.”
He said he’s been providing feedback to Horizon, while also learning from the insurer’s approach. Every member of his practice, from the office manager to the care coordinator, has put an emphasis on preventive care, scheduling appropriate health screening for patients who may have come in for an entirely different issue.
“When someone comes in for a cold they don’t want to hear that” they should get a colonoscopy, Feingold said.
“I think a big part of it also has to be patients, because patients have to buy into it because you can’t force you’re patients to do things that they don’t want to do,” said Feingold, adding that if a patient is a smoker: “I’m not going to follow them around and slap the cigarette out of their hands.”
While the decision to join Horizon’s program wasn’t difficult, Feingold said, he added that being a PCMH “is a lot of work on the doctor’s part, on the office’s part, and on the patient’s part – it’s not an office for every patient, because it’s a collaboration. It’s a team effort and I can’t help my patients more than they want to help themselves.”
But some providers who have spent years basing their practices on seeing as many patients as possible aren’t interested in or able to become a PCMH, O’Hara said.
“I think there are some folks who are stuck in their model,” he said.
While much of the focus on early care-coordination programs has been on primary-care practices, it’s also extending into specialist practices. Horizon is building a different program – known as “episodes of care” – with the goal of better integrating specialists into the full range of healthcare provided to patients.
In this program, a specialist is paid a set amount to provide a service, such as a knee or hip replacement, rather than paying separate amounts for pre-admission care, surgery, hospitalization and post-admission care.