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Spreading Innovations in Health Care Delivery

This website, endorsed by Maryland’s Stakeholder Innovation Group, offers a glimpse at how many of Maryland’s health care providers and community organizations are working together to improve care delivery.

We urge you to use this site to share innovative programs and practices that improve the health of Maryland’s communities.

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CareFirst Patient-Centered Medical Home (PCMH) and Total Care and Cost Improvement Program Array (TCCI)

  • What are the objectives of the program?

    Improved care coordination, Improved health outcomes, Reductions in health disparities, Reduced readmissions, Increased use of preventive and primary care, Reduced utilization of post-acute care, Reduced transitions from post-acute care/long-term care, Reduced avoidable utilization, Reduced spending

  • Please provide a brief description of the program:

    As the region's largest private payer, CareFirst undertook the Patient-Centered Medical Home ( PCMH ) Program at the start of 2011 as a way to tackle the continuing steep increases in health care costs occurring in its service area which includes Maryland, the District of Columbia and Northern Virginia. In the years since, the company has added a range of other supporting programs known as the Total Care and Cost Improvement ( TCCI ) Program Array. The PCMH Program is the core of the larger TCCI Program Array. The PCMH Program rewards Primary Care Providers ( PCPs ) for providing, arranging, coordinating, and managing quality, efficient, and cost-effective health care services for individuals enrolled in health benefit plans issued or administered by CareFirst. The PCMH Program seeks to build a sound foundation for long term initiatives in primary care, continuous quality improvement and lower Member use of high-cost hospital services. The CareFirst TCCI Program Array along with the core PCMH Program provides care coordination at crucial junctures along the care continuum. The program includes 20 distinct components focused on areas including behavioral health and substance use disorder, complex case management, pharmacy coordination and home-based services, and others. These specialized programs are available to members under the care of participating PCMH physicians and broadly to all CareFirst members. In the PCMH program, PCPs are divided into panels consisting of between 5 and 15 PCPs. Participating PCPs are incentivized in three different ways to address quality and cost outcomes. First, all PCPs are paid an ongoing Program Participation Fee equal to a 12 percentage point supplement to their professional fee payments from CareFirst, unless they fail to meet a certain threshold of quality and engagement scores. Second, PCPs are paid fees to maintain care plans (in addition to regular visit fees) in active oversight of registered nurses assigned to their practice through the PCMH Program. No fees are paid without direct PCP involvement in the development and activation of a care plan. Care plan activities are subject to strict standards regarding the selection of care plan candidates, documentation and actionable care plan content as well as achievement of member consent and other elements. All care plans are developed by care coordination nurses that are recruited, trained and supervised by the PCMH Program team. They are then placed under the clinical supervision of the PCP practice to which they are assigned. Payment to PCPs for care plan development and maintenance occurs only when they are developed and maintained according to Program standards. All care plans are peer reviewed by experienced nurses in the Program for quality and actionabilty. Third, Panels may earn an Outcome Incentive Award (OIA) for achieving better than target overall cost and quality outcomes for the attributed population in each Panel. The OIA is analogous to a shared savings payment. This payment is critical to motivate PCPs to achieve improved results and undertake the additional workload of care coordination and practice transformation. This third category of value based payment is the most significant of the three value based components in the Program. Outcomes/Results on Panel performance are continually measured and reported throughout each calendar year and paid through a fee supplement to PCPs in winning Panels over the next year. The average OIA for a typical winning Panel is in excess of 40 percent of their usual fees from CareFirst. When the three categories of value-based payments are combined, a typical winning Panel can expect to earn supplemental income from CareFirst that exceeds 50 percent of their standard fee income from CareFirst. The average winning PCP typically receives over $40,000 in additional income from CareFirst for their value-based results. In a typical year, approximately two thirds of all PCP Panels receive all three components of value-based payment.

  • What is the primary source of funding for the program?

    Most of the funding for the program is through rates billed by providers and is accounted for through the premium dollar. In addition, the program also received a federal Health Care Innovation Award through CMMI to provide the program's services to the Medicare population over 3 years.

  • Is this program operated as part of HSCRC's Care Redesign Amendment?


  • Which Center for Medicare and Medicaid Innovation (CMMI) category does (or would) the program fall under? Choose the best match.


  • What are the major components of the program?

    Care coordination/management, Patient assessment tools, Care transitions, Patient education/coaching/self-management, Multidisciplinary care teams, Patient care plans, Interventions to address social determinants of health, Protocols/agreements with care partners, Telehealth/connected patient technologies, Risk stratification

  • What types of organizations participate in the program?

    Physicians office (primary care), Home health care, Behavioral health provider (e.g., mental health and/or substance abuse), Non-clinical setting

  • Which population(s) does the program target?

    Privately insured, Individuals with multiple chronic conditions, Frail/disabled, Younger adults, Children

  • How many patients have participated in the program to date?

    As of January 2017, just under 1.2 million CareFirst Members were in the PCMH Program while all 3.2 million CareFirst Members are served by one or more programs in the TCCI Program Array.

  • In what Maryland jurisdictions do participating patients reside?

    Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert, Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Harford, Howard, Kent, Montgomery, Prince Georges, Queen Annes, Saint Marys, Somerset, Talbot, Wicomico, Worcester, Participation also includes non-Maryland residents

  • Briefly describe the staffing resources required to operate the program:

    CareFirst provides nurse care coordination services for the program, and also employs program consultants who review data and reports with PCPs. A robust data infrastructure is also essential to the program. The most noteworthy of staffing resources are the 250 registered nurse care coordinators who are assigned to PCMH practices and Panels. These nurse coordinators live and work in the communities in which their assigned PCPs practice and they become deeply embedded in day-to-day practice operations. This nurse field force is led by 20 senior nurses who provide leadership and oversight in the 20 sub-regions that constitute the broader CareFirst service area. Further, this field force is reinforced by 50 nurses that handle members who are not attributed to PCMH PCPs, 75 nurses who are stationed in area hospitals to assure appropriate transitions to post-discharge care, and 50 licensed behavioral health professionals who coordinate the mental health and substance abuse needs of members In addition, full claims data line item specific on every claim for every member - is provided to Panels for the entire range of services received by each and all of their attributed members regardless of where a service is rendered or by whom it is rendered. CareFirst employs over 30 Masters-trained Practice Consultants to help clinicians identify patterns in their data and develop action plans in response to the data analysis.

  • Briefly describe the key initial steps to implementation:

    1. Creation of a comprehensive online Member Health Record is maintained for each member showing all services, costs, quality measures, care plan notes and other data specific to each member that is longitudinally gathered over time and updated daily or monthly depending on the nature and source of the data. If a member is in a care plan, all nursing notes and written documentation is included as is all reconciled drug data. 2. Recruitment of Local Care Coordinators 3. Recruitment- All fully credentialed PCPs in good standing (about 4,400) in the CareFirst Regional PPO and HMO networks throughout the CareFirst service area were invited to join the Program on a voluntary basis. If interested, each was required to sign an addendum to their network contract with CareFirst. Each receives a participation fee of a 12% increase in fee-for-service payments. CareFirst now has roughly 90% of eligible PCPs in the Program. 4. Uniformity Across All Business Units -With the signing of the initial network of PCPs, the PCMH Program started its first day of operation on January 1, 2011, with approximately 650,000 Members who were attributed to the initial participating PCPs. This initial enrollment was principally derived from CareFirst's fully-insured population. Thereafter, a special effort was undertaken to gain the voluntary participation of large self-insured employer sand the Federal Employee Health Benefit Plan. All remain in the Program as of early-2018.

  • Are incentive payments to health care providers part of the program?


  • Which incentive type(s)?

    Shared savings, Bonus payments, Shared resources (e.g., IT infrastructure)

  • Does the innovation program qualify as a CMS Advanced Alternative Payment Model (APM)?


  • What are/were the expected results in improved outcomes, population health, and cost savings?

    CareFirst expected and continues to expect to see improved quality of care for members through the PCMH/TCCI program, as well as cost savings from averting higher cost care and from utilization of high value care.

  • Have expected results for improving outcomes and population health been met?

    Yes, expected results were achieved

  • Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:

    From the PCMH program's inception in 2011 through 2016, CareFirst members experienced, per 1,000 CareFirst Members in the CareFirst Service Area (which also encompasses DC and portions of northern Virginia): 15% fewer hospital admissions 13% fewer emergency room visits 6.2% fewer days in the hospital Likewise, key quality indicators for those CareFirst members under the care of a PCMH physician continue to show positive results when compared to members under the care of non-PCMH physicians. CareFirst members seeing PCMH providers in 2016 had, per 1,000 members in the CareFirst Service Area: 10.5% fewer hospital admissions 17.1% fewer days in the hospital 34.7% fewer hospital readmissions for all causes 9.8% lower cost per emergency room visit , Yes, expected results were achieved

  • Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:

    CareFirst's Overall Medical Trend a measure of annual total growth in health care costs averaged just 3.4 percent from 2013 to 2016, compared to an average of 7.5 percent in the five years prior to the inception of the PCMH program. In 2016, the PCMH program produced $153 million in savings measured against the expected cost of care for CareFirst members, bringing the total savings since the inception of the program to nearly $1 billion ($945 million.)

  • How to learn more (e.g., website URL)

    More information about PCMH/TCCI and the latest results is available here:

  • Please provide URLs to any published evidence (e.g., peer-reviewed literature, white papers, etc.)

    Cueller, et al. The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years. Gimm, et al. Medical Home Implementation in Small Primary Care Perspectives: Provider Perspectives. Afendulis, et al. Early Impact of CareFirst's Patient-Centered Medical Home with Strong Financial Incentives. CareFirst Common Model Pilot: Summary of Results (2012-2016).