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AUTHORS

Marci Nielsen, PhD, MPH

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J. Nwando Olayiwola, MD, MPH

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Paul Grundy, MD, MPH

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Kevin Grumbach, MD

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Contributing Author:

Lisa Dulsky Watkins, MD

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PAGE 2

ACKNOWLEDGMENTS

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Melinda Abrams, MS

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The Commonwealth Fund

Asaf Bitton, MD, MPH

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,QVWUXFWRU 'HSDUWPHQW RI +HDOWK &DUH 3ROLF\ Harvard Medical School

Mark Gibson

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Oregon Health & Science University

Bruce Landon, MD, MBA, MSc

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Beth Israel Deaconess Medical Center

Len Nichols, PhD

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George Mason University

Kavita Patel, MD

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)HOORZ (FRQRPLF 6WXGLHV The Brookings Institution

Mary Takach, MPH, RN

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National Academy for State Health Policy

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PCPCC STAFF

PCPCC BOARD OF

DIRECTORS

Marci Nielsen, PhD, MPH

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David K. Nace, MD, Chairman

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Amy Gibson, RN, MS

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Paul Grundy, MD, MPH, President

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Michelle Shaljian, MPA

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Douglas Henley, MD, Vice Chairman

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Andrew Webber, Treasurer

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Yuki Ueda

Errol Alden, MD

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Susan Edgman-Levitan, PA-C

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Hal C. Lawrence III, MD

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Harlan Levine, MD

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Marci Nielsen, PhD, MPH

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Graphic design and layout:

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PAGE 4

TABLE OF CONTENTS

EXECUTIVE SUMMARY

SECTION ONE

An Overview of the Patient-Centered Medical Home

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PCMH recognition programs

SECTION TWO

Summary of Cost & Quality Results

Methods

Results

Table 1. Peer-reviewed reports

Table 2. Industry-generated reports

Discussion

Table 3. Number and percent of studies reporting medical home metrics

The challenge of studying the PCMH

The right metrics

The right methods

SECTION THREE

The Future of Primary Care and the PCMH

The PCMH’s Role in Delivery System Reform

The foundation of high-performing Accountable Care Organizations

A hub for medical neighborhood

The payment reform imperative

All-payer or multi-payer payment reform

Employer and consumer engagement

Conclusion

APPENDIX A: PCMH Initiatives and Evidence since 2009

APPENDIX B: The Year in Review: Case Study Highlights

REFERENCES

PAGE 5

EXECUTIVE SUMMARY

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1. PCMH studies continue to demonstrate impressive improvements across a broad

range of categories including: cost, utilization, population health, prevention,

access to care, and patient satisfaction, while a gap still exists in reporting impact

on clinician satisfaction.

Total

Cost

Fewer Inpatient

Fewer

Improvement in

Improved

Increase in Preventive

Improvement in

Studies

Reductions

Fewer ED Visits

Admissions

Readmissions

Population Health

Access

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PEER-REVIEW/ACADEMIA

Reported

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outcomes

61%

31%

13%

31%

23%

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INDUSTRY REPORTS

Reported

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outcomes

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29%

14%

29%

14%

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• Improvements in population health indicators and increase in preventive services, such

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2. The PCMH continues to play a role in strengthening the larger health care

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SECTION ONE

AN OVERVIEW OF THE PATIENT-CENTERED MEDICAL

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PAGE 8

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rather, it is

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the capability

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sustain their

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improvements.”

PAGE 9

SECTION TWO

SUMMARY OF COST & QUALITY RESULTS

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cost &

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patient or clinician satisfaction DV FROOHFWHG YLD SDWLHQW VWDII DQG FOLQLFLDQ VXUYH\V

PAGE 10

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Table 1. Peer Review-Reported Outcomes 2012-2013, by location and by category

Location/Initiative

Cost & Utilization

Population Health

Access

Patient or Clinician

& Preventive

Satisfaction

Services

Alaska

Alaska Southcentral

• (' XVH IRU DOO FDXVHV

• ,QFUHDVH LQ SUHYHQWLYH

• ,QFUHDVH LQ DFFHVV WR

Foundation

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VHUYLFHV IRU DVWKPDWLFV

VDPH GD\ DSSRLQWPHQWV

Nuka System of Care³²

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LPSOHPHQWDWLRQ

DQG QRQ IDFH WR IDFH

Published:2013

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visits

Data Review: 1996-2009

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LPSOHPHQWDWLRQ

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DVWKPD GURSSHG

EHIRUH GXULQJ DQG

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High patient satisfaction:

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DOO PHDVXUHV RI GLDEHWHV

•

RI SDWLHQWV VDLG

JURXS

FDUH

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•

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•

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VSHDN WR SK\VLFLDQ

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JURXS

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of Michigan Physician

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PAGE 11

Table 1 continued

Location/Initiative

Cost & Utilization

Population Health

Access

Patient or Clinician

& Preventive

Satisfaction

Services

National

Military Health System

For all patients:

• ,PSURYHPHQWV DFURVV

For all patients:

• 6WDWLVWLFDOO\ VLJQL÷FDQW

PCMH Initiative ³⁵

• IHZHU LQSDWLHQW

HLJKW SUHYHQWLYH

•

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LPSURYHPHQWV IRU

DGPLVVLRQV DQG

VHUYLFHV PHDVXUHV

XVH WKDQ FRPSDULVRQ

PHDVXUHV RI

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sites

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•

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FRPSDULVRQ VLWHV

GHFUHDVH DW :DOWHU

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For those with chronic

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conditions:

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FDUH YLVLWV

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• UHGXFWLRQ LQ 3034

FDUH FRQWLQXLW\ DW :DOWHU

WRWDO FRVWV

5HHG Y QRQ 3&0+V

For those with chronic

conditions:

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HQFRXQWHUV

•

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SKDUPDF\ FRVWV

•

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•

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• ,QFUHDVH LQ SKRQH

Administration Patient

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Aligned Care Team

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SHU

SDWLHQWV SHU

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IRU

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(PACT) ³⁶

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KHDOWK UHFRUG XVH

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ZLWKLQ KRXUV RI

RI SDWLHQWV HQUROOHG

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• ,QFUHDVHV LQ HOHFWURQLF

LQFUHDVHG

PHVVDJLQJ WR SURYLGHUV

IRU WUHQG

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SDWLHQWV SHU TXDUWHU

SULPDU\ FDUH YLVLWV

• ,QFUHDVH LQ VDPH GD\

WR SHU

SDWLHQWV

DSSRLQWPHQWV S

SHU FDOHQGDU TXDUWHU

• ,QFUHDVH LQ SDWLHQWV VHHQ

ZLWKLQ GD\V RI GHVLUHG

DSSRLQWPHQW GDWH

S IRU WUHQG

New Hampshire

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Health Initiative ³⁷

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LQ WUDGLWLRQDO

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PAGE 12

Table 1 continued

Location/Initiative

Cost & Utilization

Population Health

Access

Patient or Clinician

& Preventive

Satisfaction

Services

New Jersey

Horizon Blue Cross Blue

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• ,QFUHDVH LQ EUHDVW FDQFHU

Shield New Jersey Single

and costs did not

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Private Payer Pilot³⁸

VLJQL÷FDQWO\ FKDQJH

SHUFHQWDJH SRLQWV

KRZHYHU WKLV ZDV

RQ D EDVH RI

Published: June 2013

D VLQJOH \HDU VWXG\

Data Review: 2010-2011

DQDO\]LQJ HLJKW SUDFWLFHV

• ,QFUHDVH LQ QHSKURSDWK\

VFUHHQLQJV E\

SHUFHQWDJH SRLQWV RQ D

EDVH RI

New York

EmblemHealth High

•

IHZHU (' YLVLWV

• ,PSURYHPHQWV LQ %3

Value Medical Home

SHU \HDU VDYLQJ

FRQWURO

Initiative ³⁹

DSSUR[LPDWHO\

DQG EUHDVW FDQFHU

* randomized trial

(' FRVWV SHU SK\VLFLDQ

VFUHHQLQJV

SHU \HDU S

Published: June 2013

• 3K\VLFLDQV LPSURYHG

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HI÷FLHQF\ IRU DOO HSLVRGH

W\SHV E\

New York

WellPoint’s Single Health

Compared to control

• +LJKHU UDWHV RI +E$ F

Plan Model New York

group:

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PCMH ⁴⁰

•

IHZHU (' YLVLWV IRU

YHUVXV

Published: Sept. 2012

DGXOWV

IRU FKLOGUHQ

Data Review: 2007-2010

•

ORZHU ULVN

DGMXVWHG WRWDO 3030

FRVWV IRU DGXOWV

ORZHU IRU FKLOGUHQ

• /RZHU UDWHV RI

LQDSSURSULDWH DQWLELRWLF

XVH

Pennsylvania

UPMC Health Plan

•

IHZHU (' YLVLWV

• 3&0+ SUDFWLFHV

Medical Home Pilot ⁴¹

FRQVLVWHQWO\

•

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Published: Nov. 2012

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RI WKH QHWZRUN DFURVV DOO

Data Review: 2008-2010

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•

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IHZHU

•

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Rhode Island

Rhode Island Chronic

•

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• ,PSURYHPHQWV ZHUH

Care Sustainability

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SHU

PHPEHU

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Published: Nov. 2013

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Data Review: 2006 - 2010

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DGPLVVLRQV QRW

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PAGE 13

Table 1 continued

Location/Initiative

Cost & Utilization

Population Health

Access

Patient or Clinician

& Preventive

Satisfaction

Services

Utah

University of Utah

For the composite

Improvement in patient

Care by Design

scores based on team

satisfaction

Program⁴³

based care, 2 measures

of productivity and

• ([SODQDWLRQ RI FDUH

Published: Nov/Dec 2013

cost were statistically

Data Review: 2008-2011

VLJQL÷FDQW S

• &OLQLFLDQ LQVWUXFWLRQV

• 6WDII FRVW FOLQLFLDQ )7(

• /LNHO\ WR UHFRPPHQG

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• 2YHUDOO VDWLVIDFWLRQ

Improvement in clinician

VDWLVIDFWLRQ S

• 7LPH VSHQW ZRUNLQJ

• 5HODWLRQVKLS ZLWK

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Washington

Group Health

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•

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Cooperative

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PCMH Program ⁴⁴

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* spread of prototype model

SURJUDP

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to 26 clinics in Washington

LQFUHDVHV LQ VHFXUH

and Idaho

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DQG

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Published: May/June 2013

Data Review: 2008-2011

PAGE 14

Table 2. Industry-Reported Outcomes 2012-2013, by location and by category

Initiative

Cost & Utilization

Population Health

Access

Patient and

& Prevention

Clinician

Satisfaction

Alabama

BlueCross BlueShield

• )HZHU (' YLVLWV

Compared to network

• 2YHUDOO LPSURYHPHQW LQ

Alabama Medical Home

• )HZHU KRVSLWDO GD\V

avg., PCMHs had:

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Program ⁴⁵

•

KLJKHU UDWH

• (VWLPDWHG FRVW VDYLQJV

RI FRORUHFWDO FDQFHU

Published: Aug. 2012

PLOOLRQ

VFUHHQLQJV

Data Review: 2009 - 2011

•

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•

KLJKHU UDWH RI

DSSURSULDWH WHVWLQJ RI

FKLOGUHQ Z SKDU\QJLWLV

Connecticut

Connecticut Health

•

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• 0RGHVW LPSURYHPHQWV

Enhancement Program⁴⁶

ED visits

LQ DGKHUHQFH WR KHDUW

•

IHZHU VSHFLDOW\

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Published: Jan. 2013

FDUH YLVLWV

FKROHVWHURO DQG GLDEHWHV

Data Review: 2011-2012

PHGLFDWLRQ

•

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FDUH YLVLWV

•

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WUHQG JURZWK UDWH

Maryland

CareFirst BlueCross

•

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•

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BlueShield ⁴⁷

savings

VFRUHV IRU SDQHOV WKDW

• 3DQHOV HDUQLQJ

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Published: June 2013

Data Review: 2010-2012

incentives achieved

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incentives

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Blue Cross Blue Shield

•

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Michigan PCMH

visits

Program⁴⁸

•

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IHZHU

Published: July 2013

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ED visits

•

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sensitive ED visits

•

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DGPLVVLRQV

New Jersey

Horizon BlueCross

•

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BlueShield New Jersey

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PCMH Pilot

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Monmouth County

3&0+V

Public Employees ⁴⁹

•

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Published: Dec. 2013

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Data Review: 2012-2013

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PAGE 15

Table 2 continued

Initiative

Cost & Utilization

Population Health

Access

Patient and

& Prevention

Clinician

Satisfaction

Oregon

Oregon Coordinated

• IHZHU (' YLVLWV

LQFUHDVH LQ

Care Organizations

•

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(CCOs) Oregon Health

VSHQGLQJ

visits

Authority ⁵⁰

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Published: Nov. 2013

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UHDGPLVVLRQV

Data Review: 2012-2013

• LQFUHDVH LQ SULPDU\

FDUH VSHQGLQJ

Pennsylvania

Highmark Patient-

• IHZHU LQSDWLHQW

Centered Medical Home

DGPLVVLRQV

Pilot ⁵¹

•

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Published: Jan. 2013

• GHFUHDVH LQ WRWDO

Data Review: 2011-2012

3030 FRVWV IRU

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SDWLHQWV

•

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WRWDO 3030 FRVWV IRU

diabetics

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Discussion

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Table 3. PCMH Studies from August 2012 to December 2013 that report outcomes (by category and by

frequency)

Total

Cost

Fewer Inpatient

Fewer

Improvement in

Improved

Increase in Preventive

Improvement in

Studies

Reductions

Fewer ED Visits

Admissions

Readmissions

Population Health

Access

Services

Satisfaction

PEER-REVIEW/ACADEMIA

Reported

(n=13)

61%

31%

13%

31%

23%

outcomes

(n=8)

(n=4)

(n=1)

(n=4)

(n=3)

INDUSTRY REPORTS

Reported

(n=7)

57%

29%

14%

29%

14%

outcomes

(n=4)

(n=2)

(n=1)

(n=2)

(n=1)

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PAGE 19

SECTION THREE

THE FUTURE OF PRIMARY CARE AND THE PCMH

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The foundation of high-performing Accountable Care Organizations

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PAGE 22

MULTI-PAYER INITIATIVES: THE ROLE OF PAYMENT REFORM

VERMONT BLUEPRINT FOR HEALTH

Author: Lisa Dulsky Watkins, MD, Former Associate Director, Vermont Blueprint for Health

The importance of employers and payers investing in the PCMH model is critical because the extent to which

various payers - Medicare, Medicaid, commercial plans, and employers - are aligned around these payment

models is the extent to which true transformation of the US health care system is possible. These “multi-payer”

initiatives convince health care providers that the daunting task of redesigning their clinical practice is worth

the time, effort, and investment because a majority of their payer-mix supports the re-design. ⁷⁷

The Vermont Blueprint for Health ⁷⁸ is a striking example of the effectiveness of a successful multi-payer reform

effort. ⁷⁹ The statewide adoptions of the spectrum of this multifaceted program can be linked to a long-standing

willingness to cultivate collaborative relationships among the various stakeholders. This demonstrable public-

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theoretical to the implemented.

Over the last decade, Bipartisan support in the public sector had a profound impact on the credibility of Health

Reform. Republican Governor Jim Douglas and an increasingly Democratic State Legislature found common

ground on key aspects of reform, joined by a commitment to grapple with predictions of escalating costs and

increasing morbidity in the aging Vermont population. Initial Blueprint activity was seated at the Vermont

Department of (Public) Health, seen widely as a neutral convener of the disparate groups brought together.

Meaningful engagement of the private sector was essential. From the very beginning, commercial insurers,

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to participate in the myriad planning and advisory committees. Attention was paid to the need for national

recognition of practices as PCMHs, the scale of enhanced payments to the practices, the initial development

and payment of the locally based care coordination teams, respect for the internal business processes of the

participating insurers and accountability of the Blueprint to its funders regarding outcomes.

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implementation and evaluation strategies to be undertaken. Their commitment to voluntarily support the

Blueprint was evident. There are self-insured employers already participating in the Blueprint despite their

ERISA exemptions, and discussion with others as well as with private payers as the impact on cost and quality

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insurers,⁸⁰ but there remains the impact of the process undertaken in good faith.

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making the program “all-payer” through the lens of the practices and payers.

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of CMS as a payer was a critical problem in statewide implementation, Vermont leaders were instrumental in

the call for its involvement. The CMS Multi-payer Advanced Primary Care Demonstration, for which Vermont

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CONCLUSION

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PAGE 23

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PAGE 24

APPENDIX A: Summary of PCMH evidence by category and

organized by State/Location, with references, 2009-2013

LEGEND

&RVW UHGXFWLRQV

,PSURYHG DFFHVV WR FDUH

5HGXFWLRQ LQ (' +RVSLWDO

,QFUHDVHG SUHYHQWLYH VHUYLFHV

,PSURYHG KHDOWK

,PSURYHG SDWLHQW RU FOLQLFLDQ VDWLVIDFWLRQ

Location

Initiative

$ODEDPD

Blue Cross Blue Shield Alabama Medical Home Program

Medical Home Program Description %OXH &URVV %OXH 6KLHOG $ODEDPD $XJXVW

$ODVND

Alaska Southcentral Foundation - Noka System of Care

Ü3URFHVV DQG 2XWFRPHV RI 3DWLHQW &HQWHUHG 0HGLFDO &DUH :LWK $ODVND 1DWLYH 3HRSOH DW 6RXWKFHQWUDO

Foundation”

'ULVFROO HW DO The Annals of Family Medicine 0D\ -XQH

$ODVND

Alaska Native Medical Center

“A new model of health care”

$VLQRI Providence Business News 0D\

&DOLIRUQLD

Orange County, CA Health Care Coverage Initiative (HCCI) - Medical Services Initiative

“Impact of Patient-Centered Medical Home Assignment on Emergency Room Visits Among Uninsured

Patients in a County Health System”

5RE\ HW DO Medical Care Research and Review

&DOLIRUQLD

CareMore Medical Group, Urban Medical Group, Leon Medical Centers, Redlands Family Practice

“American Medical Home Runs,” 0LOVWHLQ $ *LOEHUWVRQ ( Health Affairs

&DOLIRUQLD

Blue Cross Blue Shield of California Accountable Care Organization Pilot

Ü%XLOGLQJ 7RPRUURZÚV +HDOWKFDUH 6\VWHP 7KH 3DWKZD\ WR +LJK 4XDOLW\ $IIRUGDEOH &DUH LQ $PHULFDÝ

%OXH &URVV %OXH 6KLHOG $VVRFLDWLRQ $XJXVW

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Colorado Multi-Payer Patient-Centered Medical Home Pilot

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8WLOL]DWLRQ $QG 4XDOLW\Ý

5DVNDV HW DO Health Affairs 6HSWHPEHU

Ü&RORUDGRÚV 3DWLHQW &HQWHUHG 0HGLFDO +RPH 3LORW 0HW 1XPHURXV 2EVWDFOHV <HW 6DZ 5HVXOWV 6XFK $V

Reduced Hospital Admissions”

+DUEUHFKW HW DO Health Affairs

&RORUDGR

Colorado Medicaid and State Children’s Health Insurance Program (SCHIP)

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Promising Results”

7DNDFK 0 Health Affairs -XO\

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HW DO Health Affairs

PAGE 25

APPENDIX A (Cont’d)

Location

Initiative

Connecticut

Connecticut Health Enhancement Program

Ü9 %,' LQ $FWLRQ $ 3UR÷OH RI &RQQHFWLFXWÚV +HDOWK (QKDQFHPHQW 3URJUDPÝ

7KH 8QLYHUVLW\ RI 0LFKLJDQ &HQWHU IRU 9DOXH %DVHG ,QVXUDQFH 'HVLJQ -DQXDU\

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Johns Hopkins University - Guided Care Program (Washington, DC and Baltimore, MD)

&ROXPELD

*XLGHG &DUH DQG WKH &RVW RI &RPSOH[ +HDOWKFDUH $ 3UHOLPLQDU\ 5HSRUW

/HII HW DO American Journal of Managed Care

)ORULGD

“Increasing access to health care providers through medical home model may abolish racial disparity in

GLDEHWHV FDUH (YLGHQFH IURP D FURVV VHFWLRQDO VWXG\Ý

/HH HW DO Journal of the National Medical Association

)ORULGD

Capital Health Plan

“Report from Tallahassee Memorial HealthCare on Enhancing Continuity of Care”

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Idaho

Blue Cross of Idaho Health Service

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%OXH &URVV %OXH 6KLHOG $VVRFLDWLRQ $XJXVW

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State of Illinois Medical Home Pilot

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5DQNLQ HW DO American Journal of Medical Quality,

“Building Community-Based Medical Homes for Children”

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CareFirst BlueCross BlueShield

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PLOOLRQ LQ 6HFRQG <HDUÝ

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Johns Hopkins University - Guided Care Program (Baltimore, MD and Washington, DC)

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/HII HW DO American Journal of Managed Care

0LFKLJDQ

BlueCross BlueShield of Michigan Physician Group Incentive Program

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HealthPartners

“Patient-Centered Medical Home Cost Reductions Limited to Complex Patients”

)ORWWHPHVFK HW DO American Journal of Managed Care, 1RYHPEHU

Ü7UHQGV LQ 4XDOLW\ 'XULQJ 0HGLFDO +RPH 7UDQVIRUPDWLRQÝ

6ROEHUJ HW DO The Annals of Family Medicine. 2011.

,V &RQVLVWHQW 3ULPDU\ &DUH :LWKLQ D 3DWLHQW &HQWHUHG 0HGLFDO +RPH 5HODWHG WR 8WLOL]DWLRQ 3DWWHUQV DQG

Costs?

)RQWDLQH HW DO The Journal of Ambulatory Care Management,

PAGE 26

APPENDIX A (Cont’d)

Location

Initiative

1DWLRQDO

Military Health System Patient-Centered Medical Home Program

Walter Reed National Military Medical Center (Bethesda, MD), Edwards Air Force Base (Lancaster, CA)

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+XGDN HW DO Military Medicine

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United States Air Force

Ü)<

0HGLFDO 3URJUDPVÝ

6WDWHPHQW RI /LHXWHQDQW *HQHUDO 'U &KDUOHV % *UHHQ Testimony Before the House Appropriations Committee,

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1DWLRQDO

Veterans Health Administration Patient Aligned Care Team (PACT) Program

“The Patient-Centered Medical Home in the Veterans Health Administration”

5RVODQG HW DO American Journal of Managed Care -XO\

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Integrated Delivery System”

.OHLQ 6

)XQG & The Commonwealth Fund

“Medical Homes Require More Than an EMR and Aligned Incentives”

6ROLPHR HW DO American Journal of Managed Care

1DWLRQDO

PCMH National Demonstration Project - American Academy of Family Physicians

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0RQWKV LQ WKH 3DWLHQW &HQWHUHG 0HGLFDO +RPH 1DWLRQDO 'HPRQVWUDWLRQ 3URMHFWÝ

-D«Q HW DO The Annals of Family Medicine

1HEUDVND

Blue Cross Blue Shield of Nebraska

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5HXWWHU Lexington Clipper-Herald $SULO

1HZ +DPSVKLUH

New Hampshire Citizens Health Initiative

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8WLOL]DWLRQ $QG 4XDOLW\Ý

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1HZ -HUVH\

Horizon Blue Cross Blue Shield Patient-Centered Medical Home Pilot

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'HOLYHU\ RI &DUH IRU &RXQW\ :RUNIRUFHÝ

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+RUL]RQ %OXH &URVV %OXH 6KLHOG RI 1HZ -HUVH\ $SULO

1HZ -HUVH\

New Jersey Family Medicine Research Network

“Principles of the Patient-Centered Medical Home and Preventive Services”

)HUUDQWH HW DO Annals of Family Medicine

1HZ <RUN

Institute for Family Health Patient-Centered Medical Home Program

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<HDU 7UDQVLWLRQ IRU D 1HWZRUN RI )HGHUDOO\ 4XDOL÷HG +HDOWK

Centers”

&DOPDQ HW DO The Annals of Family Medicine,

PAGE 27

APPENDIX A (Cont’d)

Location

Initiative

1HZ <RUN

WellPoint’s Single Health Plan Model New York Patient Centered Medical Home

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8WLOL]DWLRQ $QG 4XDOLW\Ý

5DVNDV HW DO Health Affairs 6HSWHPEHU

Ü,PSDFW RI 0HGLFDO +RPHV RQ 4XDOLW\ +HDOWKFDUH 8WLOL]DWLRQ DQG &RVWVÝ

'H9ULHV HW DO American Journal of Managed Care

1HZ <RUN

EmblemHealth High Value Medical Home Initiative

Ü4XDOLW\ DQG (I÷FLHQF\ LQ 6PDOO 3UDFWLFHV 7UDQVLWLRQLQJ WR 3DWLHQW &HQWHUHG 0HGLFDO +RPHV $ 5DQGRPL]HG

Trial”

)L÷HOG HW DO Journal of General Internal Medicine -XQH

1RUWK &DUROLQD

Community Care of North Carolina (State Medicaid Program)

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Conditions”

-DFNVRQ HW DO Health Affairs $XJXVW

Ü$QDO\VLV &RPPHQWDU\ 'ULYLQJ 4XDOLW\ *DLQV $QG &RVW 6DYLQJV 7KURXJK $GRSWLRQ RI 0HGLFDO +RPHVÝ

)LHOGV HW DO Health Affairs,

Ü&RPPXQLW\ &DUH RI 1RUWK &DUROLQD ,PSURYLQJ &DUH 7KURXJK &RPPXQLW\ +HDOWK 1HWZRUNVÝ

6WHLQHU HW DO Annals of Family Medicine

1RUWK &DUROLQD

Blue Cross Blue Shield of North Carolina - Blue Quality Physician’s Program

“Blue Cross and Blue Shield Patient-Centered Medical Home Programs Are Improving the Practice and

'HOLYHU\ RI 3ULPDU\ &DUH &RPPXQLWLHV 1DWLRQZLGHÝ

%OXH &URVV %OXH 6KLHOG $VVRFLDWLRQ -XQH

1RUWK 'DNRWD

BlueCross BlueShield of North Dakota MediQHome Quality Program

“Patient-Centered Home Snapshots,” %OXH&URVV %OXH 6KLHOG $VVRFLDWLRQ -DQXDU\

Ü$QDO\VLV &RPPHQWDU\ 'ULYLQJ 4XDOLW\ *DLQV $QG &RVW 6DYLQJV 7KURXJK $GRSWLRQ RI 0HGLFDO +RPHVÝ

Fields, et al. Health Affairs

2KLR

Humana Queen City Physicians

“Senate Panel Looks at Innovative Health Care Strategies,” Kaiser Health News -XQH

2NODKRPD

Oklahoma Medicaid

Ü5HLQYHQWLQJ 0HGLFDLG 6WDWH ,QQRYDWLRQV WR 4XDOLI\ DQG 3D\ IRU 3DWLHQW &HQWHUHG 0HGLFDO +RPHV 6KRZ

Promising Results”

7DNDFK 0 Health Affairs -XO\

2UHJRQ

Oregon Coordinated Care Organizations (CCOs) Oregon Health Authority

Ü2UHJRQÚV +HDOWK 6\VWHP 7UDQVIRUPDWLRQ 4XDUWHUO\ 3URJUHVV 5HSRUWÝ

2UHJRQ +HDOWK $XWKRULW\ 1RYHPEHU

2UHJRQ

CareOregon Medicaid and Dual Eligibles

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.OHLQ 6

0F&DUWK\ ' 7KH &RPPRQZHDOWK )XQG -XO\

2UHJRQ

%HQG 0HPRULDO &OLQLF &OHDU 2QH 0HGLFDUH $GYDQWDJH 3DFL÷F6RXUFH 0HGLFDUH $GYDQWDJH

“Bend Memorial Clinic Reduces Hospital Admissions and Emergency Visits”

%HQG 0HPRULDO &OLQLF 3UHVV 5HOHDVH $SULO

PAGE 28

APPENDIX A (Cont’d)

Location

Initiative

3HQQV\OYDQLD

UPMC Health Plan Medical Home Pilot

“Results from a patient-centered medical home pilot at UPMC Health Plan hold lessons for broader adoption

of the model”

5RVHQEHUJ HW DO Health Affairs 1RYHPEHU

3HQQV\OYDQLD

Southeast Pennsylvania (SEPA) Multi-Payer Collaborative

“Multipayer patient-centered medical home implementation guided by the chronic care model”

*DEED\ HW DO Joint Commission Journal on Quality and Patient Safety

3HQQV\OYDQLD

PinnacleHealth

“PinnacleHealth Expands Patient-Centered Medical Home Model,” 3LQQDFOH+HDOWK 1HZV -XQH

3HQQV\OYDQLD

Geisinger Health System Proven Health Navigator PCMH Model

Ü5HGXFLQJ /RQJ 7HUP &RVW E\ 7UDQVIRUPLQJ 3ULPDU\ &DUH (YLGHQFH )URP *HLVLQJHUÚV 0HGLFDO +RPH 0RGHOÝ

0DHQJ HW DO American Journal of Managed Care 0DUFK

Ü+RZ *HLVLQJHUÚV $GYDQFHG 0HGLFDO +RPH 0RGHO $UJXHV 7KH &DVH )RU 5DSLG &\FOH ,QQRYDWLRQÝ

6WHHOH HW DO Health Affairs.

3HQQV\OYDQLD

Independence Blue Cross - Pennsylvania Chronic Care Initiative

“Patient-Centered Medical Home Snapshots,” %OXH&URVV %OXH 6KLHOG $VVRFLDWLRQ -DQXDU\

3HQQV\OYDQLD

Highmark Patient-Centered Medical Home Pilot

“Highmark to expand patient-centered medical home efforts to improve care and health outcomes for

members”

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5KRGH ,VODQG

Rhode Island Chronic Care Sustainability Initiative

Ü(IIHFW RI D 0XOWLSD\HU 3DWLHQW &HQWHUHG 0HGLFDO +RPH RQ +HDOWK &DUH 8WLOL]DWLRQ DQG 4XDOLW\ 7KH 5KRGH

Island Chronic Care Sustainability Initiative Pilot Program”

5RVHQWKDO HW DO JAMA Internal Medicine 1RYHPEHU

5KRGH ,VODQG

Blue Cross Blue Shield of Rhode Island

“Patient-Centered Medical Home Snapshots”

%OXH&URVV Blue Shield Association -DQXDU\

6RXWK &DUROLQD

Blue Cross Blue Shield of South Carolina, Palmetto Primary Care Physicians

“Patient-Centered Medical Home Snapshots”

%OXH&URVV %OXH 6KLHOG $VVRFLDWLRQ -DQXDU\

7HQQHVVHH

BlueCross BlueShield of Tennessee

Patient-Centered Medical Home Snapshots,

%OXH&URVV %OXH 6KLHOG $VVRFLDWLRQ -DQXDU\

7H[DV

BlueCross BlueShield of Texas

Ü%XLOGLQJ 7RPRUURZÚV +HDOWKFDUH 6\VWHP Ý %OXH &URVV %OXH 6KLHOG $VVRFLDWLRQ

7H[DV

WellMed Medical Group

“Case Study of a Primary Care-Based Accountable Care System Approach to Medical Home Transformation”

3KLOOLSV HW DO The Journal of Ambulatory Care Management,

PAGE 29

APPENDIX A (Cont’d)

Location

Initiative

8WDK

University of Utah Care by Design (CBD) Program

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7UDQVIRUPDWLRQ 3UHOLPLQDU\ )LQGLQJVÝ

'D\ HW DO The Annals of Family Medicine

8WDK

Intermountain Healthcare Care Management Plus Program

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HW DO Health Affairs

9HUPRQW

Vermont Medicaid

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Promising Results”

7DNDFK 0 Health Affairs, -XO\

9HUPRQW

Vermont Blueprint for Health

Vermont Blueprint for Health Annual Report 'HSDUWPHQW RI 9HUPRQW +HDOWK $FFHVV )HEUXDU\

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%LHODV]ND 'X9HUQD\ & Health Affairs

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)LHOGV HW DO Health Affairs

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Regence Blue Shield Intensive Outpatient Care Program with Boeing

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Group Health Cooperative

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HW DO The Annals of Family Medicine

Ü,PSDFW RQ 6HQLRUV RI WKH 3DWLHQW &HQWHUHG 0HGLFDO +RPH (YLGHQFH )URP D 3LORW 6WXG\Ý

)LVKPDQ HW DO The Gerontologist

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0H\HU + Health Affairs,

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&ROHPDQ HW DO The Annals of Family Medicine

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)LHOGV HW DO Health Affairs

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0F&DUWK\ HW DO The Commonwealth Fund -XO\

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*LO÷OODQ HW DO American Journal of Managed Care

PAGE 30

APPENDIX B. The Year in Review: Case Study Snapshots

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Michigan (statewide), 3 million patients

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UPMC Health Plan

Pennsylvania, 23,390 patients

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Oregon Health Authority Coordinated Care Organizations (CCOs)

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