Medical Home Monitor
Medical Home Monitor
November 1, 2010
Vol. III, No. 13

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Health Risks, IT Investment
  2. NCQA ACO Draft Criteria
  3. New Chart: Top Incentivized Health Programs
  4. Podcast: Embedded ED Case Manager
  5. Maryland Physician Incentives
  6. E-Survey: Tobacco Cessation
  7. Benchmarks: Medical Home in 2010
  8. Editor's Pick

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Medical Home Q&A's:
Health Risks, IT Investment

Medical Home Monitor

Health Risk Factors

Q: Which health risk factors are the most predictable and intervenable in future medical cost control with a positive ROI?
A: People with multiple conditions often have interacting factors. There are often social factors. Even though you can’t resolve the fact that someone does have diabetes and does have heart disease and something else, you can help that person make sure they have follow-up care and that someone reconciles their medications and helps to make sure that treatments for those conditions do not conflict with each other. Going forward, to affect medical cost, managing things like blood pressure and lipids for someone with diabetes helps, but ROI from these efforts is farther over the horizon.

Dr. Marcia Wade, senior medical director at Aetna Medicare.

For more strategies to assess health risk in the elderly, please visit:

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Investing in Health IT

Q: What kinds of IT staff should hospital and provider groups provide as the programs mandated by health reform unfold?

A: Both on the hospital and physician organization side, the investment in IT resources has not been sufficient to meet the technology demands that they’re facing now. Given profit pressures and margin pressures, making significant investments in building an IT organization may not be appropriate. They need to align themselves with organizations that can bring IT capabilities to the hospital organization and the physician organization. Tthere’s room for sophistication in terms of how the IT organization is invested in and built out within the provider side.

William Shea is a partner, health industry consulting, for Cognizant Business Consulting.

For more tactics to prepare for healthcare reform, please visit:

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NCQA ACO Draft Criteria Measures 10 Areas of Medical Home-ness
A core of primary care providers with medical home capabilities to deliver comprehensive, coordinated, patient-centered care is one of seven criteria for an accountable care organization (ACO) drafted by the NCQA.

To insure that primary care practices participating in ACOs provide patients/families with access to appropriate routine and urgent care, the ACO draft criteria will evaluate practice capabilities in 10 key areas:

  • Access during office hours;
  • Access after hours;
  • Practice team roles and responsibilities;
  • Use of evidence-based guidelines;
  • Care management;
  • Medication management;
  • Self-care;
  • Test tracking and follow-up;
  • Referral tracking and follow-up;
  • Quality improvement activity;
  • Identification of high-risk patients.

Besides primary care capabilities, the ACO draft criteria also includes separate standards for access and availability, care management, care coordination and transitions, patient rights and responsibilities, program structure operations and performance reporting.

The NCQA defines ACOs as "provider-based organizations that take responsibility for meeting the healthcare needs of a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capita costs."

How providers organize themselves as accountable entities is expected to vary based on existing practice structures in a region, population needs or local environmental factors. Some may include a full range of services including a variety of sub-specialists, hospitals, home care agencies, insurance products, etc. Others will be more narrowly constructed but maintain active relationships and formal contracts with providers across the spectrum of care necessary to meet the needs of their patients.

The NCQA is seeking public comment on the ACO draft standards, which were developed with the guidance of a multi-stakeholder ACO task force, until 5 p.m. on Friday, November 19.

To review the draft criteria, please visit:

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New Chart: Top Incentivized Health Improvement Programs
Financial and benefits-based incentives are offered for a host of health improvement initiatives. We wanted to see which health and wellness activities most often rewarded its participants with incentives.

View the chart at:

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HealthSounds Podcast: The Embedded ED Case Manager
Organizations should advocate for a case manager in the emergency room, says Toni Cesta, senior vice president of operational efficiency and capacity management at Lutheran Medical Center. Making the business case for an ED-embedded case manager, Cesta shares key targets for case management intervention in the ED and describes how the ER case manager is positioned to improve patients' transitions in care.

To listen to this HIN podcast, please visit:

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CareFirst BCBS to Pay Physicians More for Care Plans, Patient Engagement

Three types of physician incentives built into Maryland' CareFirst BlueCross BlueShield (CareFirst) primary care medical home (PCMH) program include added payments for development of care plans for select patients and for physicians' engagement with their patients.

Recently approved by the Maryland Health Care Commission (MHCC) and the first single payor medical home programin the state, the program has begun recruiting primary care physician practices throughout its Maryland, Washington, D.C., and northern Virginia service area.

Participating physicians can earn three types of reimbursement increases:

  • Upon enrollment, PCMH physicians receive a 12 percentage point increase to the current reimbursement fee schedule, agreeing to higher compensation for improved coordination of care;
  • New reimbursement fees for developing care plans ($200) for select patients with certain chronic or multiple chronic conditions and for monitoring progress on the plans ($100); and
  • Additional fees (up to an 80 percentage point increase) paid for physicians’ engagement with their patients, the quality of care delivered to the entire cohort of their patients, and actual aggregate costs of care compared to expected costs.
Participating physicians must form “panels” of five to 15 primary care physicians (PCPs). Panels can be formed by existing practices, and smaller practices can combine to form “virtual” medical panels – ensuring that primary care practices of any size can join the program. PCMH is voluntary, and physicians are not required to purchase EHRs or hire additional staff to participate.

"As few as 5 percent of all patients can account for more than half of all health care costs,” said Chet Burrell, CareFirst president and CEO. “These are patients with multiple chronic conditions, such as obesity and high blood pressure and Type 2 diabetes. Improving the coordination of care for these patients can have a significant impact in bending the cost curve for health care services."

CareFirst is also actively recruiting 18 regional care coordinators, RNs or seasoned healthcare professionals who will work with physicians in the PCMH program to help identify needs and plan care for patients that could most benefit from early intervention for chronic conditions.

Coupled with CareFirst’s HealthyBlue product portfolio, which financially rewards patients for living healthier lifestyles and accessing care through their PCP, CareFirst aims to shift the focus of healthcare in the reform era to patient wellness and minimize the risk of catastrophic and costly medical problems due to unhealthy behaviors.

For more information, please visit:

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HIN Survey of the Month: Tobacco Cessation and Prevention Programs
Cigarette smoking continues to be the leading cause of preventable morbidity and mortality in the United States, reports the U.S. Department of Health and Human Services. And CDC data indicates that cigarette-smoking related healthcare expenditures in 2008 in the United States totaled nearly $96 million, and that the employer bears a cost of $3,391 per smoking employee per year, including $1,760 in lost productivity and $1,623 in excess medical expenditures. What is your organization doing in the areas of tobacco cessation and prevention? Complete HIN's Survey of the Month on tobacco cessation and prevention by November 30 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

Complete the survey by visiting:

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Benchmarks in Medical Home Performance
Who belongs on the patient-centered medical home team? How do medical homes impact hospital readmissions and reimbursement? This executive summary of HIN's fourth annual PCMH e-survey in March 2010 offers insight from 156 healthcare organizations PCMH adoption, components of a medical home and the effects of this model in the healthcare industry.

To download this complimentary white paper, please visit:

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EDITOR'S PICK: Save 10% on This Week's Medical Home Resource

Guide to Patient-Centered Case Management

The 110-page Guide to Patient-Centered Case Management presents best practices in identifying, stratifying and monitoring individuals for case management and documents the returns generated by targeted case management interventions in place at Geisinger Health System, Community Care of North Carolina and other organizations. The Q&A chapter answers more than 50 questions on patient-centered case management.

  • Chapter 1: Overview
  • Chapter 2: Long-Term Complex Case Management
  • Chapter 3: Best Practices in Patient Contact
  • Chapter 4: The Embedded Case Manager
  • Chapter 5: Case Management In a Diabetes Medical Home
  • Chapter 6: Case Management in the Emergency Department
  • Chapter 7: Q&A

Use ordering code MHMP to save 10 percent on this webinar training by visiting:

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Contact HIN:
Editor: Patricia Donovan,;
Publisher: Melanie Matthews,;

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