Family health

Blue Cross partners with Evergreen Family Health for integrated primary care

Blue Cross partners with Evergreen Family Health for integrated primary care

Berlin, Vermont — Blue Cross and Blue Shield of Vermont and Evergreen Family Health are partnering to provide collaborative primary care programs. This arrangement allows for additional integrative primary care oversight and management that should result in higher levels of success for Blue Cross members who are Evergreen patients. In recognition of Evergreen Family Health’s commitment to excellence in care and collaborative reform, the practice is the first recipient of the Blue Cross Provider Innovation Award.

This partnership is testing the keystone of healthcare reform, linking shared risk and a care management payment per member per month to measurable patient quality results. Together, we will track four significant domains of patient health: uncontrolled diabetes; hypertension; FIT test for colorectal screening; and coding risk adjustment.
“This business aligns with what we are trying to accomplish in primary care for our patients. It has been a rewarding experience to think outside the box and see Blue Cross supporting our shared priority of quality metrics that actually improve patient health outcomes,” said Dr. Michael Johnson, Managing Partner of Evergreen Family Health.
“Our goal is to empower and support independent primary care practices. Evergreen has approached this work collaboratively and with a patient-centric attitude,” said Lou McLaren, Director of Provider Services at Blue Cross. “We have come together to address baseline quality outcomes with equal risk on both sides, while supporting the care management function of the practice. These three elements are the fundamental principles of health reform.
Quality measures have been carefully chosen to reflect improvements in patient health and reduced costs. In each, the goal is to make it as easy as possible for patient and provider to achieve success. These are areas of health care concern where we can do better to manage chronic diseases and common concerns.
For example, for people with uncontrolled diabetes, Blue Cross will support the practice by purchasing continuous blood glucose monitors for patients with poor blood sugar management. These are people who are not yet insulin dependent but who are actively managing their nutrition. With this intervention, the patient can see in real time how their body and blood sugar react to a double cheese pepperoni pizza. Often seeing is believing. The monitor, along with nutritional counseling, can help them make dietary changes they can see and feel. The goal of the practice is to achieve a 1 point drop in A1C blood test results, which can make the difference between the patient being a controlled diabetic versus an uncontrolled diabetic.
The concept behind the hypertension quality measure is similar. A home blood pressure cuff sends information directly to the practice in real time. Regular communication makes the patient more aware of their body’s blood pressure throughout the day and gives the provider a more regular overview of their patient’s health. Identified trends help the provider distinguish the best steps for care management, including medication adjustments.
The fecal immunochemical test (FIT) is an alternative to colonoscopy. The FIT test offers a less invasive, less risky and less expensive alternative to surgery. Due to its ease and convenience, the FIT test has much higher compliance among all populations. The test can be done annually at home, for people with an average risk of colon cancer. The American Cancer Society recommends that colorectal screenings begin for people over age 45. If the FIT test is positive, the provider will recommend a colonoscopy.
As a fourth measure of quality, the risk adjustment process provides Blue Cross with additional data to identify patients with chronic conditions and enable their provider to develop care management programs and prevention initiatives. to better serve them.
“We work every day to provide our patients with the best care possible. Care management is key to achieving quality outcomes for our patients,” said Pam Farnham, RN, and Clinical Nurse Manager for Evergreen Family Health.
Blue Cross intends to expand this program to additional primary care practices statewide in 2022.
“Our goal is to move from heavy administrative burdens to meaningful benchmarks,” McLaren said.
The program developed between Blue Cross and Evergreen serves as a springboard to support other primary care practices in our network and to ensure the best possible care for our members.
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Blue Cross and Blue Shield of Vermont is Vermont’s only nonprofit local health plan. For more than 30 years, the company has improved the health and well-being of Vermont residents by providing innovative plans for individuals, seniors and businesses. Our employees are dedicated to developing new ways to support high-quality care and programs and events that promote wellness. Blue Cross and Blue Shield of Vermont is an independent licensee of the Blue Cross and Blue Shield Association. For more information, visit


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