UPMC Health Plan Partners Program and the Patient-Centered Medical Home

* The Pay for Performance Program (P4P) applies only to Family Medicine Physicians and Internists. In order to be eligible for P4P, the practice must be committed to developing a Patient-Centered Medical Home and must have 200 or more UPMC Health Plan members.

By Nicholas DeGregorio, MD, MMM, FACP. Dr. DeGregorio is UPMC Health Plan’s Medical Director for its Quality Department.

Primary care physicians are increasingly frustrated with the health care system for a variety of reasons. There are increased administrative and regulatory requirements and overhead is outpacing revenue increases. Payment incentives reward volume over value of services, and time spent outside of office visits coordinating patient care is largely unpaid. Physicians are being pressured to see more patients in less time. The current delivery system demands more for less without providing adequate support and erodes the physician-patient relationship. There is also pressure to remain current with the ever-expanding medical literature in an increasingly litigious society. As a result, there is serious concern that the future ranks of primary care physicians are threatened.

UPMC Health Plan developed the Partners Program to proactively deal with these issues. The Partners Program formalizes the Health Plan’s commitment to work in partnership with physicians to better support and meet the needs of members and network physicians. 

Key aspects of the program include:

• Personalized high-touch services for members and physicians
  
• State-of-the-art resources and online tools for members and physicians
  
• Reports and online access to key data and actionable information
  
• Engaging members in health promotion and wellness
  
• Specialized staff as part of a physician-directed care team, including:
  • Case/disease managers
    
  • Physician account executives
    
  • I.T., data, and systems specialists          
    
  • Health coaches
    
  • Health Care Concierges and Member Advocates                
    
  • MyHealth Advice Line, a 24 hour help line
    
  • Promoting and assisting practices in development of the Patient-Centered Medical Home Model
    
  • Improved alignment of payment  incentives through a quality incentive reward program, based on standardized measures of:*
    • Quality
      
    • Efficiency
    • Patient-Centered Medical Home standards, which are factored into the overall score

The Partners Program and the Patient-Centered Medical Home bring the physician-patient relationship back into clear focus and help to re-establish the role of primary care physicians at the center of care.

The Patient-Centered Medical Home is not an office or a building, but a concept. It is part of a greater overall strategy of partnering with physicians to provide more holistic, comprehensive, and coordinated patient care. This is an important concept because our current system of care has not provided optimal outcomes.The Patient-Centered Medical Home Model has the potential to improve outcomes by connecting the dots in a health care system characterized by abnormal variation among disconnected centers of excellence. 

Today’s Patient-Centered Medical Home Model focuses not only on improved management of disease, but also on wellness. And not just episodically, but over the lifespan of a patient. It places the patient and physician at the center of care with family members, community resources, and UPMC Health Plan playing supporting roles and sharing labor.

As a member of a Patient-Centered Medical Home, the patient has a personal physician to meet urgent, ongoing, and complete care needs. The personal physician leads a multidisciplinary care team that provides initial and long-term planned care with whole person orientation. The team helps to educate and motivate patients in their own care, encourages self-management, and is responsible for coordinating care and helping patients navigate the complex health care environment. The effectiveness in the model comes from support of a knowledgeable and prepared practice team and an informed patient. Importantly, the Patient-Centered Medical Home physician is not a gatekeeper, but rather an advocate, resource, and educator who helps to guide patients to make informed health care choices.

UPMC Health Plan has developed a functional assessment that defines three levels of Patient-Centered Medical Home: Basic, Intermediate, and Advanced. The levels are based on criteria in the following six areas:

• Patient access (expanded hours and other forms of communication)
  
• Coordination of care (education and assistance outside of face-to-face visits)
  
• Quality of care (according to standardized, evidence-based quality measurements)
  
• Efficiency (clinical and administrative)
  
• Patient satisfaction (by CAHPS and practice-specific satisfaction surveys)
  
• Technology (EMR, interactive websites, etc.) 

The Health Plan’s goal is to assess all network practices in 2008. Practices that participate with the Medical Home assessment in 2008 will receive 20 points in their overall quality incentive reward. In addition, UPMC Health Plan will recognize practices that are successfully moving toward becoming a Patient-Centered Medical Home.

Our health care system has problems that cannot be changed all at once. UPMC Health Plan is committed to working together in partnership with physicians to improve the health care experience for members and physicians one step at a time. The Partners Program and the Patient-Centered Medical Home concept are two important steps toward those goals. Your Health Plan representatives, physician account executives, network personnel, and medical directors will share more information about this program.

For more information about the characteristics and principles of the Patient-Centered Medical Home, visit the Provider section of our website at upmchealthplan.com and select “Links and Resources.”