Setting the dual intentions of improving the value of healthcare while enhancing compensation for its primary care physicians may seem like a formidable goal; nevertheless, CDPHP set out to do just that when it launched a two-phase pilot in 2008 to reform both the practice of primary care in its network and payment to these physicians.

Case Study in Physician Practice and Payment Transformation: The CDPHP Experience chronicles the clinical and financial journeys of this network model health plan, sharing practical strategies and lessons learned from this two part-process.

Illuminating Phase I, Bruce Nash, MD, MBA, and CDPHP senior vice president, medical affairs, and chief medical officer, describes how CDPHP met the challenge of developing a novel risk adjustment methodology that would drive a global payment combined with a significant bonus structure. The approach was successful in both attracting physician participation and encouraging future growth by medical students to enter primary care. Dr. Nash explains the motivation for the medical home pilot and presents preliminary findings from the three practices in the pilot cohort.

In Phase Two, CDPHP built its clinical transformation to a patient-centered medical home — renamed Enhanced Primary Care — around case managers embedded in physician practices. CDPHP's Lisa Sasko, MA, MBA, director of clinical transformation, and Charlene Schlude, director of case management, describe the expansion of the effort to 24 practices and share additional results from Year 2 of the effort.

They also share the business case for an embedded case management program to bring healthcare organizations to the new level of care required in today's healthcare delivery system, and describe the day-to-day interactions of embedded case managers with providers in a practice.

This 45-page report provides details on the following:

• Motivations for the CDPHP Medical Home project;
• Readying for practice and payment reform;
• Analyzing the risk-adjusted FFS model and the bonus models:
• The business case for embedded case managers in the physician practice;
• The role of case managers in delivering accountable care in the medical home;
• The impact of embedded case managers on hospital re-admissions, ER visits and care transitions;
• The operational and cultural issues critical to the success of the program;
• Results from the two-year analysis of the CDPHP program;
• Planned enhancements of the initiative;

Table of Contents

• Rewarding Primary Care Practice Reform with Physician Payment Reform
  • Motivations for Medical Home Project
  • Payment Reform
  • FFS Still Works for Certain Conditions
  • Risk-Adjusted Comprehensive Base Pay Bonus Payment Model
  • Preliminary Findings
  • Creating Even Larger Bonus Opportunities
• The Role of the Embedded Case Manager in Clinical Transformation
  • History of the Enhanced Primary Care Program
  • Steps to Practice Transformation and Payment Reform
  • Analyzing Savings in a Pilot Practice
  • Implementing Embedded Case Management
  • Incorporating the Triple Aim Initiative
  • Expanding Programs and Practices
  • 5 Criteria for Practice Selection
  • Impact of Practice Transformation
  • Stratification and Prioritization
  • Primary Day-to-Day Nurse Roles and Responsibilities
  • Reducing Gaps in Care
  • Case load and Schedules of an Embedded Case Manager
  • Collaboration with Pharmacies
  • High-Risk Populations and Dual Diagnosis Care
  • Identifying Desired Outcomes
  • Costs Associated with Embedded Case Managers
  • Outcomes and Lessons Learned
• Q&A: Ask the Experts
  Funding RN Case Managers
  • Training the First Nurse Case Managers
  • Productivity Benchmarks for Embedded Case Managers
  • Prehuddle Reviews
  • Cost Savings from Case Managers
  • Physician Incentive Models
  • Patient Risk and Acuity Levels
  • Case Management Certification
  • Relative Readmission Index
  • Evidence-Based Teaching Tools
  • Factoring in Observation Stays
  • Primary Care Partnerships
  • Payor Incentives for Case Management
  • Translating Model to Specialist Practices
  • Readmissions Metrics
  • Bon Secours Demographics
  • Prioritizing Case Management Resources
  • Case Management Outreach
  • MyChart Patient Portal
  • Payment Models
  • Skills for a Successful Case Manager
  • Hiring the Right Embedded Case Manager
  • Care Plan Management Tools
  • Health IT and EHRs in the Practice
  • CDPHP Demographics
  • Case Manager Communication Tools
  • ROI Methodology
  • Expanding the Touch of the Practics
  • Measuring Member Satisfaction and Service
  • Cost to Patients
• Glossary
• For More Information
• About the Speakers