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Medical Homes Lower Costs, Improve Quality 
Patient centered medical homes in the Philadelphia area have improved quality and lowered health care costs, according to recent studies by Independence Blue Cross (IBC). The studies compared 125,000 individuals receiving primary care in 160 Southeast PA medical home practices from 2008 to 2012 to individuals cared for in non-medical home settings.
Most notably, patients with diabetes cared for in a medical home had 21% lower total costs-driven by a 44% reduction in hospital costs-than their counterparts in non-medical home practices. IBC also found lower costs for patients with other chronic conditions. Quality-wise, medical home diabetes patients had 60% improvement in getting their LDL-cholesterol under control, and there was a 45% improvement in the number of patients with poorly controlled diabetes. Medical home patients also had half the gaps in cancer screenings as patients in other settings. In July 2010, IBC changed its payment methodology to reward primary care practices that are recognized medical homes by the National Committee for Quality Assurance and that improve their performance on a range of quality measures compared to their peers. The IBC changes built on the success of Pennsylvania's Chronic Care Initiative that started in 2008 and helped more than 150 primary care practices across the state improve diabetes and asthma care by implementing the medical home model. Other insurers in Pennsylvania, including Highmark, UPMC Health Plan, and Geisinger Health Plan, also are rewarding and supporting medical homes. Aetna is in the process of rolling out a nationwide medical home payment plan. IBC's findings add to the evidence that medical homes save money and improve quality. The Patient Centered Primary Care Collaborative recently released a compilation of this evidence. Key components of the medical home model are enhanced access and care continuity, population management, care management for high-risk patients, patient self-management support, referral tracking and follow-up, and continuous quality improvement. PA SPREAD has slides sets to assist practices with many of these change concepts, as does the Safety Net Medical Home Initiative.
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Accountable Care Organizations Emerging in PA 
Pennsylvania has a growing number of Accountable Care Organizations (ACOs), or groups of providers that agree to work together to manage and coordinate the health care of a defined population. In recent weeks, ACO efforts have been announced by Highmark and the Allegheny Health Network in western PA and by Abington Health, Aria Health, and Einstein Healthcare Network in the Philadelphia area.
These alliances were announced just as the federal government shared the Year 1 results of its Pioneer ACO initiative, which involved 32 ACOs nationwide caring for more than 669,000 fee-for-service Medicare beneficiaries. One of the Pioneer ACOs is in Pennsylvania-Renaissance Health Network, a physician-owned and managed network comprised of over 250 primary care physicians in Berks, Bucks, Chester, Delaware, and Montgomery counties.
All 32 Pioneer ACOs met the quality reporting requirements, 25 reduced hospital readmission rates, and 13 reduced costs, generating a gross savings of $87.6 million in 2012. Altogether, the Pioneer ACOs earned over $76 million in shared savings and quality-based incentive payments. Only two Pioneer ACOs had shared losses totaling approximately $4 million. In the Pioneer ACO program, participating ACOs assume both upside risk, where they share in any savings, and downside risk, where they share in any losses.
Medicare offers a shared saving program that includes no downside risk. ACOs can join the Medicare Shared Savings Program every January (applications are due the summer before). CMS anticipates having Year 1 Medicare Shared Savings Program results later this year. Keystone ACO, operated by Geisinger, is the only PA-based ACO in that program, although several ACOs based in neighboring states cross into Pennsylvania.
A series of slide sets and other materials from the ACO: Accelerated Development Learning Sessions in 2011 may be helpful for start-up ACOs, as might the Advance Payment ACO Model, which offers up-front payments to be repaid through future shared savings in the Medicare Shared Savings Program, and a report on Accountable Care Strategies from the Commonwealth Fund.
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Best Practices Spotlight
A key component of the PCMH is care manage- ment for high-risk patients. Here are some tips for embedding care management in your practice:
Balance supply and demand: Play with risk stratification methods to make the number of patients to be managed equal to the capacity of your care manager(s). A full-time care manager typically can care for 100-150 patients.
Focus on transition care: Ask your local hospital(s) to notify you when your patients are discharged, so your care manager can call them within 48 hours to be sure they have a follow-up appointment, have the right medicines, receive any social services supports they need, and know what to do in the event of complications.
Provide sufficient training on your EMR: Care managers are most successful when they can communicate with providers and practice staff via the EMR, document their interventions in the EMR, track patient visits, vitals, referrals, and test results in the EMR, and maintain a registry of high-risk patients in the EMR.
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In The Literature
Engaging Patients in Collaborative Care Plans Effective engagement of patients in their self-care requires a new mindset: dancing with patients rather than wrestling with them to adopt healthier behaviors. This paper offers tips on how to fit self-management support in your day, how to help patients identify and overcome barriers to their self-care, how to engage the practice team in supporting patient self-care, training that may be helpful, and using the EHR to support this effort.
Estimating the Staffing Infrastructure for a Patient-Centered Medical Home
Primary care practices that have implemented the Patient Centered Medical Home have incorporated a range of new staff and functionalities. This paper estimates 4.25 full-time equivalent (FTE) staff per provider in a PCMH practice vs. the current U.S. average of 2.68 FTE staff per provider, with an associated incremental cost of $4.68 per member per month. Nurse care managers, health coaches, and behavioral health providers were the most commonly added staff in a PCMH.
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