CareFirst Patient-Centered Medical Home - Maryland

Program Location: 
Annapolis, MD
Payer Type: 
Carefirst Blue Cross Blue Shield
Private payer based

Reported Outcomes


As the region’s largest private payer, CareFirst undertook the Total Cost and Care Improvement (TCCI) and PatientCentered Medical Home (PCMH) Programs at the start of 2011 as a way to tackle the continuing steep increases in health care costs occurring in its service area which includes Maryland, the District of Columbia and Northern Virginia. 

CareFirst's PCMH program is designed to provide primary care providers with a more complete view of their patients' needs and of the services they receive from other providers so that they can better manage their individual risks, keep them in better health and produce better outcomes. The program requires greater provider-patient engagement and it meaningfully compensates providers for that engagement.

At the start of 2015, more than 4,300 primary care providers (primary care physicians and nurse practitioners) were participating in CareFirst’s PCMH program. Primary care providers (PCPs) are organized into Panels – groups of 5 to 15 physicians – for purposes of coordinating the care of members who have chosen them. As care giving teams, Panels can earn Outcome Incentive Awards (OIAs) based on both the level of quality and degree of savings they actually achieve against projections.

Payment Model: 

12 percentage point increase added to current fee schedule

• New fees for developing care plans for select patients with certain chronic or multiple conditions that put them at risk and for monitoring progress against those plans

• Additional fee schedule increases (up to an 80 point increase) based on providers’ engagement with their patients, the quality of care delivered to their entire cohort of patients, and actual aggregate costs of care compared to expected costs.

CareFirst calculates that its risk-adjusted PMPM cost is $254. Performance varies among the panels and is divided into quartiles of $228, $246, $265 and $295. 

Fewer ED / Hospital Visits: 

CareFirst Industry Report (July 2015)  evaluation of the 4th year of the program. Service area includes Northern Virginia and DC

  • Since the beginning of the program in 2011, PCMH members have had*:
    • 19% fewer hospital admissions
    • 15% fewer days in the hospital
    • 20% fewer hospital readmissions for all causes
    • 5% fewer outpatient health facility visits
  • In 2014 alone, PCMH members experienced*:
    • 5.1% fewer hospital admissions
    • 10.7% fewer days in the hospital
    • 8.5% fewer hospital readmissions for all causes
    • 12.5% fewer outpatient health facility visits

CareFirst Press Release (July 2014)

  • 6.4% fewer hospital admissions*
  • 8.1% fewer hospital readmissions for all causes*
  • 11.1% fewer days in the hospital*

* results per 1000 CareFirst members

Improved Health: 

CareFirst Press Release (June 2013)

  • 3.7% higher quality scores for panels that received incentives
  • Quality scores for PCMH panels rose by 9.3% from 2011 to 2012
Cost Savings: 

CareFirst Industry Report (July 2015)  evaluation of the 4th year of the program. Service area includes Northern Virginia and DC

  • Health care costs for CareFirst members in a PCMH were $345 million less than projected in 2014
    • this is an improvement over 2013 data when costs were $130 million less than expected
  • Since 2011, medical costs for PCMH members have been $609 million less than expected
  • Approximately 84% of provider panels earned Outcome Incentive Awards (OIA) based on quality and degree of savings they achieved
    • An average award, in addition to a particiaption fee, amounted to $41,000 -$49,000 in increased revenue

CareFirst Industry Report (July 2014)

  • In all, the PCMH Program has saved $267 million in avoided costs when measured against the projected cost of care from 2011 to 2013

CareFirst Industry Report (June 2013)

  • average of 4.7% savings for primary care panels that received an Outcome Incentive Award
  • $98 million in total costs savings 
Other Outcomes: 

CareFirst Industry Report (July 2014)

  • 11.3% fewer outpatient health facility visits
Last updated March 2019
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