Pennsylvania Chronic Care Initiative (CCI)

Program Location: 
Harrisburg, PA
Number of Practices: 
Payer Type: 
Partner Organizations: 
Pennsylvania Academy of Family Physicians
American College of Physicians
American Academy of Pediatrics
Independence Blue Cross
Highmark Inc

Reported Outcomes


The Chronic Care Initiative, a multi-payer, collaborative initiative involving public and commercial payers designed to train primary care practices in the PCMH model, has provided support to 171 practices treating over one million patients. Practices have been supported in their transformation through: 

  • practice facilitation to assist practices in their transformation activities; 
  • regional learning collaboratives gathered practice improvement teams together to provide education and tools needed for practice redesign; 
  • monthly performance reporting through a free, secure, web-based patient registry ensuring that each practice team can identify successes and opportunities for further improvement; 
  • practice-based care management to support the most high-need patients, and 
  • enhanced payments through supplemental per member per month payments and the opportunity to share in any generated savings. 

Working in concert with private sector partners, state government forwarded the PCMH concept in Pennsylvania through Pennsylvania’s Chronic Care Initiative beginning in 2009, including core components of primary and patient-centered care, innovations in practice redesign and health information technology, and changes to the way practices and providers were paid.

As cited in the State Health Care Innovation Plan, the Chronic Care Initiative was fully implemented across the four regions by October 2009 and included 171 practices and 783 providers serving over 1.18 million patients. The Chronic Care Initiative continues today, having demonstrated improved practice performance and still working with participating practices to achieve practice-wide transformation that produces further improved quality and patient experience, and reduced cost escalation. In 2012, Pennsylvania used the Multi-payer Advanced Primary Care Practice demonstration as a source of supplemental funding for the existing Chronic Care Initiative (CCI), which brought Medicare into the multi-stakeholder, public-private initative.

Payment Model: 

Under Phase II, practices receive per member per month (PMPM) payments from participating payers. The amounts of these PMPM payments will vary by initiative year and patient age. Phase II of the CCI began in January 2012. Approximately 54 practices from two of the previous CCI rollout regions (Southeast and Northeast) will be participating in Phase II. In conjunction with a change in administration, oversight of the program has moved to the Pennsylvania Department of Health. Pennsylvania was one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program. Medicare joined as a participating payer in Phase II of the CCI. Participation in MAPCP ended in December 2014. Also, the federal government provides federal financial participation (FFP) for the enhanced reimbursements that Medicaid managed care organizations and Medicaid fee-for-service pay to participating practices.

Practices will be eligible for shared savings payments that will take into consideration practice performance on key quality and cost metrics. As the PMPM amounts decrease from year 1 to year 3, practices will be eligible for greater shares of any savings. 

Fewer ED / Hospital Visits: 

JAMA Internal Medicine (June 2015)

  • By year 3, pilot participation was associated with:*
    • lower rate for all-cause hospitalization (-1.7)
    • lower rate for all-cause ED vists (-4.7)
    • lower rate for ambulatory-care sensitive ED visits (-3.2)
    • lower rate for ambulatory visits for specialists (-17.3)

* (per 1000 patients per month vs. comparison)

American Journal of Managed Care (February 2015)

  • Controlling for baseline differences, PCMH practices maintained significantly lower utilization for hospital admissions (P <.0001) and specialist visits (P <.01) for each year in the follow-up period. 
  • PCMH practices also saw 0.3 fewer admissions per patient in 2009, and 0.2 fewer admissions per patient in both 2010 and 2011.
  • Specialist visits were reduced by 12.3 visits per 1000 patients in 2009, and by more than 10 visits per 1000 patients in 2010 and 2011.
  • However, PCMH practices observed significantly higher utilization in ED and outpatient visits, though the adjusted difference in ED visits shrank over the period from 2009 to 2011 
Improved Health: 

JAMA Internal Medicine (June 2015)

  • Statistically significant higher performance in all 4 examined measures of diabetes care quality including: HbA1c testing, LDL-C testing, nephropathy monitoring, and eye examinations (vs. comparison practices)

JAMA (February 2014)

  • Postive trend in quality measures, with one reaching statistical significance 

Pennsylvania Academy of Family Physicians (2012)

  • Decrease the percent of patients with DM in participating practices who have an A1C measure of greater than 9% from 33% to 20% (target: <5 %). 
  • Increase the percent of patients with DM in participating practices whose BP is documented in the past year < than 130/80 mm Hg from 40% to 49% (target: >70%). 
  • Increase the percent of patients with DM in participating practices with LDL < 100 mg/dl from 38% to 50% (target: >70%).
  • Increase the percent of patients with DM in participating practices who have a self-management goal documented within the past 12 months from 33% to 62% (target: >90%).

Joint Commission Journal on Quality and Patient Safety (June 2011)

  • "After the first implementation year, PCCI noted significant improvement in diabetes measures, including HbA1c, and in cardiovascular risk factors, including blood pressure and cholesterol"
Improved Access: 

JAMA Internal Medicine (June 2015)

  • By year 3, pilot participation was associated with higher rates of ambulatory primary care visits (+77.5) per 1000 patients per month 
Cost Savings: 

American Journal of Managed Care (February 2015)

  • Total costs were significantly lower in PCMH practices during all 3 follow-up years (P <.05).
  • Relative to baseline, overall PMPM costs were:
    • $16.50 lower in 2009, a difference of 5.5%.
    • $13.00 lower in 2010
    • $13.70 lower in 2011 
  • This reduction was driven by significantly lower inpatient (P <.01) and specialist (P <.0001) costs among PCMH practices over all 3 program years.
  • The relative reduction in specialist costs was particularly pronounced: in 2009, adjusted costs for PCMH were 17.5% lower than those in non-PCMH practices.
  • While significant relative increases in ED PMPM costs (P <.0001) partially offset these reductions, PCMH practices did not experience a significant increase in outpatient costs despite the observed increase in outpatient utilization 
Increased Preventive Services: 

JAMA Internal Medicine (June 2015)

  • 5.6% higher performance on breast cancer screening (vs. comparison practices)
  • no statistically significant improvement in colorectal screening (vs. comparison practices)

Joint Commission Journal on Quality and Patient Safety (June 2011)

  • All practices in the group received NCQA status with a significant increase in patients meeting diabetes self-management goals, and preventive screening and treatments, including eye and foot exams, microalbumin screen, pneumococcal vaccine, smoking cessation, and aspirin, statin, and blood pressure medicine use
Other Outcomes: 

American Journal of Managed Care (February 2015)

The increased utilization of outpatient care is actually suggestive of further success for the PCMH model. By improving coordination of care, doctors may have been appropriately directing their patients to lower-cost, lower-intensity services, which acted as substitutes for costlier hospital admissions and other service. 

Physicians in the Pennsylvania managed care practices may be under-referring patients to specialist services, but these differences in specialty care may simply reflect regional variation in practice.  

JAMA (February 2014)

A 2014 study published in the Journal of the American Medical Association found that this program "was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs of care over 3 years."

Last updated September 2015
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