CEO Chet Burrell: Here’s how CareFirst designed a patient-centered medical home that saved it $1B

CareFirst building
Attaining provider buy-in was a major challenge in the early stages of CareFirst's patient-centered medical home program.

CareFirst CEO Chet Burrell knows a thing or two about how to execute a successful patient-centered medical home model.

After all, the insurer’s almost 7-year-old program has now saved it close to $1 billion, lowered hospital admissions by 11% and reduced readmissions by 35%. The PCMH program, CareFirst says, is “one of the nation’s most mature and established large-scale efforts to reduce costs while improving quality of care.”

So how did CareFirst do it? FierceHealthcare caught up with Burrell recently to find out.

Chet Burrell

From the CEO’s perspective, two factors were major drivers of the program’s success: Provider buy-in and a sophisticated use of data. To master the latter, CareFirst had to begin by tackling the former—and that proved to be one of the biggest challenges that the insurer faced.

At the program’s outset, primary care physicians “didn’t want to change anything, they didn’t really trust the data [and] they didn’t trust the supports that they got,” according to Burrell. And a substantial number didn’t want to pay attention to finances at all, thinking that it would be inappropriate for clinicians to do so.

RELATED: Healthcare executives on overcoming the barriers to payer-provider data exchange

Reversing these attitudes, Burrell says, wasn’t easy and required persistence.

“Over time, by being a partner, by working with them—and not doing things to them—by being consistent, by being patient, by explaining over and over again how it works, they came to understand,” Burrell says. “They came to trust the data [and] they came to trust nurses assigned to their practices.”

Now, he adds, “if you were to take the program away, I think they would be screaming all over the region.”

No downside risk helps physicians stay independent

One way CareFirst achieved physician buy-in was to design its PCMH program with no downside risk for providers. In other words, they are offered financial incentives to meet cost and quality goals but don’t face penalties when they fail to do so.

That allowed independent, community-based providers—who are usually not equipped to take on financial risk—to participate. This is important, Burrell says, because independent physicians generally achieve the best overall cost savings with comparable quality to their hospital-employed counterparts.

“If [a payer] were to place risk on them, they typically seek cover by joining a big hospital system,” Burrell says. “Our program helps them stay independent, and we have found that independence has led to greater freedom in judgment about when and where to refer, and that in turn drives [down] a lot of healthcare costs.”

Data was “absolutely critical” to success

Once enough physicians were on board, CareFirst had to supply them with the tools to succeed in managing the care of high-risk patients. In that effort, technology played an invaluable role.

The organization has more data than the holdings of the Library of Congress 300 times over, Burrell says. But it would be worth very little if the insurer didn’t take steps to make it actionable for physicians.

CareFirst accomplishes that by providing each panel of primary care physicians with “extremely extensive” data profiles that allow them to look at both overall patterns and to drill down to see information about individual patients—particularly those that are the sickest and most vulnerable.

Physicians can also they see how they perform compared to their peers. “And that, we found, has been incredibly motivating to them,” Burrell notes.

That data is also supported by a team of program consultants who work with each panel of PCPs to help them find and understand the most significant and actionable patterns.

“All of that has been absolutely critical to the success of the program,” Burrell says.

PCMH gives Burrell a “lasting legacy”

Burrell, who announced his retirement in October after a decade at the helm of CareFirst, says the drive to improve people’s access to care by lowering overall costs is far from finished.

In fact, he hopes that CareFirst can eventually build off a successful pilot that involved bringing Medicare fee-for-service patients into the program.

“The cost results were stunning, because the panels that were involved in the pilot basically held costs flat for Medicare three years running,” he says.

But a host of factors—including a change in administration, the rollout of the Comprehensive Primary Care Plus program and the onset of the Medicare Access and CHIP Reauthorization Act—prevented that effort from moving forward.

“In the environment, it became very difficult to get the pilot extended,” Burrell says. “But we would in a minute return to it if there was interest at the federal and state levels.”

Still, while Burrell presided over a lot of changes at CareFirst, the PCMH program is the accomplishment that stands out the most. He is especially pleased that the program now has a fully built-out infrastructure and well-seasoned management and support teams.

“We’re in a good place to have that carry on after I retire,” he says. “I think that has the greatest and most lasting legacy.”

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