The Blueprint

How can an employer access PCMH services?

by Amanda Berra

We recently received an inbound inquiry from a Fortune 100 employer: "We have heard about this new care model called 'medical home' that could help us save money on healthcare costs, and is supposed to be better for patients. How can we get involved?"

Unfortunately, our research indicates that, at least for now, there is no simple answer to that request. Despite a rapid increase in medical home development nationwide, there is no often clear way for most corporations--even hospitals as employers-- to enroll their employees in a medical home today

As employers become more active in controlling health care spend and quality, and as providers spend more time talking about the PCMH with health plans or employers directly, it is critical for us all to understand the challenges that employers face and the questions they are likely to ask about the medical home.

No ready-made PCMH products from health plans--yet

It's a safe bet that health plans rolling out large-scale PCMH incentive and support programs are working toward the point where they could offer employers a medical home product, such as a narrow network of only medical homes. But although we hear that employers are querying plans about such products now, they are not ready yet. Not only are many plans still figuring out what their unique medical home support approach is, bottom line is that most markets do not have sufficient functional PCMH capacity to make a realistic narrow network of medical homes.

When might a given market might have enough medical homes to make a narrow network feasible? The most aggressive estimate we have heard from a plan so far has been "three years from today".

Direct provider partnerships are a possibility--if all the questions can be answered

Employers can and have partnered with local providers in PCMH pilots in a few high-profile cases. Best-case scenario is a market with a single dominant employer and a sole community provider--but most employers are not in that situation. And even employers and providers who do find themselves in that type of market still have a lot of questions to answer.

How distributed is the employer workforce?

The more distributed the workforce across states or regions, the more complex the PCMH analysis becomes--because all of the below PCMH questions must be answered for every location where a critical mass of employees exists.

Within a given market, what functional PCMH capacity exists or is coming on line?

The employer must have good intelligence about who the local providers are in each market where employees and families live in order to identify where PCMH capacity exists.

From a provider perspective, it might seem straightforward to identify a major local system with a PCMH investment, but this is not an easy task for most employers, who do not have a good grip on provider market trends. And if the market is fragmented, it can become extremely logistically challenging to identify and approach all the potential PCMH players.

What is the overlap between our employees' PCP usage and the market's existing PCMH capacity?

An employer must run the numbers to gain insight into patterns of utilization of PCP services across employees and families. Once that analysis is complete, if a majority of employees an families already use existing medical homes, that is excellent news. But outside of very geographically contained areas, in many cases the overlap between employees and existing PCMHs may be quite small--raising the question of steerage.

How do we steer our employees who are not part of existing PCMHs into the PCMHs?

It seems that all the variations on all the established patient-steerage methods, from education to incentives, have been used to date to try to move a particular population into the PCMH--with various degrees of success or failure.

The first question is whether the employees/families have physicians at all. If they are not currently using PCPs--more typical in some workforces than others--that scenario can be easier to manage than trying to disrupt employee/family relationships with an existing PCP. We ran across one employer that backed out of a PCMH pilot when its analysis revealed that its employees already had strong usage of (non-pilot-participating) PCPs. Patients who are unassigned may be more open to being invited into a practice, when the invitation comes packaged with persuasive information and/or incentives.

Even employees/families that have existing PCPs may still be open to switching, if the steerage method is effective--but here employers face a very nuanced and high-stakes process of figuring out the right combination of carrots and sticks. Even just among PCMHs, we have seen everything from pure education ("this is what a PCMH is, and here are a list of participating sites"), to incentives such as waiving costs or reducing co-pays for selecting the PCMH site(s). We have heard stories of both success and failure using all of these methods, for reasons that are too long to get into here, but which we will tackle in the webconference version of this blog post (see end of post for details).

The steerage question also links back to the capacity analysis, since it is not reasonable for an organization to put strong efforts--including incentives/disincentives--into steering patients toward a PCMH if capacity at the site(s) is limited. I.e., asking patients to switch, and then finding that the sites are not accepting new patients, is not a good outcome from an employer perspective.

Should our partnership with the PCMH include provider-facing incentives?

Because commercial medical home payment models are still emerging, there is no go-to, accepted way of reimbursing for the medical home, except in extremely broad strokes. That means a conversation with an employer will likely include discussion about designing PCMH incentives for providers, which will be new territory for most. Employers may need significant help on this from a health plan or other source of guidance, such as a consultant or a very well-prepared provider.

Now is the time to open the conversation

The door to employer-provider conversations about the medical home is now open, however, time is a factor. In addition to plans working on their own medical home products for employers, there is also an increasingly competitive third-party market for employer-facing case management and wellness services.

Because "medical home" is such a popular term, many vendors are beginning to offer services packaged as either supporting the aims of the medical home (without actually coordinating with providers), or even serving as a substitute for partnering with existing providers around the medical home.

Providers that do not seize the opportunity in a timely manner may find that local employers have already committed wellness or case management dollars to vendors offering medical home-like services

More information--including a NEW DATE

Originally scheduled for the end of June, we will be presenting full findings on "Employers and the Medical Home" this Thursday, July 14 from 1-2 eastern. It is free for all Medical Home Project participants.

We are always interested in more case studies. If your PCMH program has worked with an employer, or if your hospital/health system is working on steering its own employees and families to a PCMH, and if we have not already spoken with you about this, please e-mail me anytime, even after this webconference date has passed. We'd love to hear what you are doing and share what we have learned from other Medical Home Project participants.

Comments? Questions? Email me at berraa@advisory.com