Patient-Centered Medical Home and Supporting Programs Contribute to Historic Slowing of Health Care Cost Growth

15 Percent Decrease in Hospital Inpatient Use a Key Factor

Washington, D.C. (September 18, 2017) - Now in its 7th year of operation, CareFirst BlueCross BlueShield’s (CareFirst) Patient-Centered Medical Home (PCMH) and complementary Total Care and Cost Improvement (TCCI) programs have contributed to an historic slowing of overall medical cost growth. 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. Contributing to the slowing of cost growth, is a 15 percent reduction in hospital inpatient admissions since the launch of the program in 2011.

CareFirst’s region-wide PCMH program is one of the nation’s most mature and established large-scale efforts that seeks to reduce costs while improving overall quality of care. Nearly 90 percent of all primary care providers (nearly 4,400 physicians and nurse practitioners) in CareFirst’s Maryland, District of Columbia and Northern Virginia service participate in the program.

“As a company, we have never experienced such sustained low levels of overall medical cost growth,” said CareFirst President and CEO Chet Burrell. “This trend is obviously encouraging, but even more so are the factors that make this slowing of cost growth possible. We were confident at the beginning of the PCMH program that, over time, this model would both slow cost growth and improve the quality of care. While there are always outside factors influencing such trends, our data clearly points to the positive impact of our PCMH and TCCI programs.”

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.) Fueling the savings are improvements in key quality of care measures for all CareFirst members. From the PCMH program’s inception in 2011 through 2016, CareFirst members experienced:

  • 15% fewer hospital admissions*
  • 13% fewer emergency room visits*
  • 6.2% fewer days in the hospital*

*Per 1,000 CareFirst Members in the CareFirst Service Area

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:

  • 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*

*Per 1,000 CareFirst Members in the CareFirst Service Area

The CareFirst PCMH program is structured around primary care providers organized into Panels – groups of 5 to 15 physicians – for purposes of coordinating the care of CareFirst members with the most pressing health care needs. As care giving teams, Panels can earn Outcome Incentive Awards paid as increases to their fee schedules based on both the level of quality and degree of savings they achieve against projections.

“Our experience has reinforced the fact that financial incentives alone are not enough to result in changes in PCP practices and behaviors that produce long-term results in bending the cost curve,” said Burrell. “Each year, our nurses and participating PCPs are now preparing 50 to 60thousand care plans for high-risk, high-cost members. That is augmented by our TCCI program which provides additional supports that span settings, provider types and geography to meet specialized care needs across a continuum of care. These types of capabilities are well beyond the means of many of our panels and independent PCPs.”

CareFirst’s TCCI program includes 20 distinct components focused on areas including behavioral health and substance abuse, 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.

“There is no doubt that our program has benefitted from consistency and stability,” said Burrell. “All our participating PCPs are operating under the same rules and provided the same tools and support. Approximately 75 percent of our participating panels have been in the program since its first year and nearly 34 percent have earned awards for meeting quality and cost targets in every year of the program.”

About CareFirst BlueCross BlueShield

In its 79th year of service, CareFirst, an independent licensee of the Blue Cross and Blue Shield Association, is a not-for-profit health care company which, through its affiliates and subsidiaries, offers a comprehensive portfolio of health insurance products and administrative services to 3.2 million individuals and groups in Maryland, the District of Columbia and Northern Virginia. In 2016, CareFirst contributed nearly $44 million to improve overall health, and increase the accessibility, affordability, safety and quality of health care throughout its market areas. To learn more about CareFirst BlueCross BlueShield, visit our website at or follow us on Facebook, Twitter, YouTube, LinkedIn, Instagram or Google+.