January 2015 Newsletter

Highmark's PCMH Program: Reducing Utilization     

Results from Highmark's Patient Centered Medical Home (PCMH) program, which began over two years ago, has shown promising results thus far including lower emergency room use and fewer hospital readmissions. Currently, more than 300,000 Highmark members receive PCMH care at 300 medical practices.


Dr. Andrew Bloschichak, a senior medical director for Highmark Blue Shield and a family physician, highlighted the value of the program's outcomes in an op-ed from PennLive.com.


Notable PCMH achievement include:

  • Emergency room utilization is lower than the market by 15.7% (adult), 14% (Medicare Advantage) and 12.6% (pediatric care).
  • Readmission rates for commercial and Medicare Advantage members are lower than comparative market rates by 1% and 2%, respectively.
  • Prescription drug use is 6.6% lower than the market, and stable for adult care, while the market trend is increasing by 1.6%. Similarly, prescription drug use for Medicare Advantage members is 6.8% lower than the market, with the market trending slightly upwards at 1.4%.
  • Inpatient surgical utilization is 12% lower (adult care) and 9% lower (Medicare Advantage) than the market.
  • Inpatient medical utilization for Medicare Advantage members is lower than the market by 25.8%.
  • Nationally accepted measures of quality have improved by more than 30%.
CMS Announces Reimbursement Shift from Volume to Value

Medicare will rapidly shift to payments based on quality rather than quantity, according to a January 26 announcement.

By the end of 2016, Medicare aims to pay 30% of its fee-for-service dollars through alternative payment models such as Accountable Care Organizations (ACOs) or bundled payment. That goal rises to 50% in 2018.


Medicare also aims to tie 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reductions Programs. A minority of Medicare's payments are currently tied to quality or value.


A Health Care Payment Learning and Action Network will help expand alternative payment models into commercial, employer, and Medicaid programs.


To date, pilots of alternative payment models have saved Medicare $17 million. Hospital readmissions have decreased nearly 8%, translating to 150,000 fewer readmissions between January 2012 and December 2013. Quality improvement efforts saved 50,000 lives and $12 billion in health spending from 2010 to 2013.

PQRS Data Submission 

Deadlines Near


Physicians are highly encouraged to report 2014 data to PQRS to avoid a 2% penalty on Medicare fee-for-service payments in 2016.


Reporting deadlines are as follows:

  • Doctors submitting data directly from their EHR, a data submission vendor, or a qualified clinical-data registry -
    February 28, 2015.
  • Group practices - March 20, 2015.
  • Specialty board-related maintenance of certification - March 31, 2015.
PQRS data submission deadlines can be accessed here. A report report on the deadlines and penalties by ModernHealthcare can be accessed here.
Best Practices Spotlight

West County Health Centers, Inc., an exemplary practice profiled in Robert Wood Johnson Foundation's LEAP Initiative, has created a workflow to track incoming documents. This workflow template may help busy practices more easily track documents coming in and out of the practice.


A workflow document that assigns specific personnel to handle incoming and outgoing documents such as prior authorizations, disability forms, records release requests, lab denials, etc., can improve the flow of paper around the office and help establish accountability for the follow-up items.

In The Literature



A recent study published by the Journal of General Internal Medicine (JGIM) spotlighted PCMH-recognized practices that overcame challenges to teamwork related to goals, division of labor, communication, and systems.


Methods to improve communication include establishing common goals and "huddling" daily to reinforce responsibilities and discuss patient-specific issues. Incremental delegation of tasks and creation of electronic templates to ensure collection of appropriate information help lessen physician reluctance to delegate tasks to other team members.

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