EmblemHealth Medical Home High Value Network Project

Region Within State: 
New York City and surrounding counties
Project Category: 
Insurer-Based
PROJECT STATUS
Target Start Date: 
Tuesday, January 1, 2008
Pilot/Demo Length: 
1.5-2 years

This project seeks to determine whether the provision of enhanced payment and support for redesign and care management results in greater transformation of supported practices to medical homes and better performance on measures of quality, efficiency, and patient experience than in comparison practices. The evaluation is conducted as a randomized controlled longitudinal study.

CONVENING ENTITY/PROJECT CONTACTS
Convening Organization Name: 
EmblemHealth
Primary Contact: 
William Gillespie, MD
E-mail: 
[email protected]
Phone: 
646/447-5797
Additional Contact
Name: 
Amin Hakim, MD
Judith Fifield, PhD
Phone: 
646/447-7505
860/679-3815
Participating Stakeholders: 

EmblemHealth; Ethel Donaghue Center for Translating Research into Practice and Policy at the University of Connecticut Health Center.

EXPECTED OR ACTUAL DEMOGRAPHICS OF PARTICIPATING PRACTICES
Number of Practices: 
38
Number of Participating Physicians: 
159
Physicians per practice: 
1-8
Types of Practices: 
Internal Medicine, Family Medicine
Health Plan Lines of Business Included: 
Commercia, Medicare Advantage, Medicaid Managed Care
Overall Number of Covered Lives: 
12000
Technology Characteristics at Start of Pilot: 

Estimated % of practices with practice management systems: >95%
Estimated % of practices with electronic medical record: 26-50%
Estimated % of practices with registry software: <5%

PRACTICE TRANSFORMATION SUPPORT (INCLUDING TECHNOLOGY)
Focal areas of transformation: 

Care Coordination
Increased Access
Information Technology (e.g., registries, patient portals)
Team Approach to Care

Services participating practices have added as a result of their participation: 

EHRs (but they are not a requirement)

Payment Model: 

Three-part payment model: 1) Fee-for-service; (2) Care management payment—equal to $2.50 pmpm for a practice that is fully functioning as a medical home with an eligible patient population of average care management need. The specific amount depends on the level of care management need of the practice’s population and the practice’s medical homeness score as determined by the PPC-PCMH survey and supplementary questions; and (3) Peformance-based payment - equal at maximum to $2.50 pmpm for each member that is identified on the practice’s member list. The specific amount earned by the practice depends on practice results on performance measures relating to quality, efficiency and patient experience.

PROJECT EVALUATION
Types of data to be collected : 

Clinical Quality—Clinical quality process and outcome data at the practice level using data based on HEDIS specifications and specifications used in the CMS Physician Quality Reporting Initiative.
Cost/Efficiency—Efficiency data using medical claims to produce a practice-level calculation of savings consisting of a risk-adjusted ratio of expected to actual episode costs.
Patient Experience/Satisfaction—Patient experience data to include measures of overall satisfaction, access, physician communication, and perceived ability to self-manage.
Qualitative process evaluation data—The evaluators are collecting qualitative process evaluation data through interviews with practice physicians and staff, as well as the staff implementing the intervention.
NCQA PPC-PCMH—Practices are completing the NCQA PPC-PCMH and sharing results with the independent evaluator.