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How a Collaborative Care Model Works

A Collaborative Care Model (CCM) uses a prospective, risk-adjusted revenue concept to fund proactive care for Medicare Advantage patients with an emphasis on high-risk conditions. Incentives are aligned between the payer, physician and patient. Physicians perform prevention and management of high-risk members instead of activity-based medicine.

A CCM emphasizes health risk assessment programs, clinical care coordination programs, and designated medical expense funding from revenue including shared savings with physicians and physician groups based on performance metrics. If a surplus remains after reconciliation with the medical expense fund, the physician group is entitled to a percentage of the surplus as determined by their success in meeting access, quality and administrative accuracy metrics in accordance with the terms of the contract agreement.

Performance Metrics

Performance metrics include access, quality and administrative/documentation accuracy. These metrics are intended to encourage primary care physicians to see patients early and often, coordinate all aspects of care and accurately code diagnoses at the time of the visit. Quality metrics include:

  • Breast cancer screening
  • Colorectal screening
  • Cholesterol management for members with heart disease
  • Diabetes renal monitoring, diabetes – A1C>9, diabetes cholesterol screening, diabetes treatment
  • Adult BMI assessment
  • High-risk medications
  • Adherence with oral diabetic medication
  • Adherence with hypertension medication (ACE/ARB)
  • Adherence with cholesterol medication (Statin)

Joint Operating Committee

On a regular basis, Florida Blue meets with physicians to exchange information and enhance the relationship between the health plan and the physician group. Areas that require actionable intervention are discussed to assist in improving the physician group’s performance. The meeting also includes marketing, network/contracting, medical management updates, education and any additional items from the health plan.

This document provides a general overview of the CCM program and is not all inclusive. The actual terms and conditions for the program are set forth in the applicable agreement between Florida Blue and the primary care practice who participates in the program.

FB PRV PROG 004 NF 122021