The shortage of primary care physicians, coupled with growing regulatory burdens and reduced job satisfaction, has many primary care doctors looking for ways to transform their practices. Concierge medicine has filled this need for some, but that model isn’t for everyone—plenty of doctors don’t feel comfortable charging an additional monthly fee to their patients.
The patient-centered medical home (PCMH), however, can deliver many of the same benefits in a way that fully supports a practice’s current patient base, and is starting to gather some momentum in the marketplace. What follows is an exploration of the PCMH, its benefits and challenges and strategies for implementation.
What Is a PCMH?
The PMCH model was born out of the pediatrics specialty, but in the last decade has expanded through pilot programs, demonstration projects and recognition programs created by the National Committee on Quality Assurance (NCQA), the Joint Commission and others.
Patient-centered medical home: “A model of care that emphasizes care coordination and communication to transform primary care into ‘what patients want it to be.’” (Source: NCQA)
Fundamentally, it’s a model based on teamwork: the primary care physician, the specialists and the patients themselves all function as a single team that works together to produce optimal results. As Maine physician Dr. Michael Clark of Lifespan Family Healthcare puts it, “We don’t buy insurance to get groceries, we buy it for the things we hope will never happen. Primary care is the one you shouldn’t be avoiding. So people should be incentivized to use it.”
Becoming a recognized PCMH is a significant undertaking. “If you ask most practices in America if they think they’re a patient-centered medical home, they’ll say yes,” says Peggy Reineking, NCQA’s director of clinical recognition programs. “But to really become a medical home, you need to go through a process of changing yourself from a traditional doctor-centered medical practice, and there’s a lot that goes into that.”
What Does It Take to Switch to a PCMH Model?
Achieving NCQA recognition takes far more than just collecting data and filling out forms. It requires a true transformation of your practice, which includes:
- Innovating constantly;
- Developing ways to measure key data and setting targets for improvement;
- Using Electronic Health Records (EHRs) in a way that fully capitalizes on their benefits;
- Communicating regularly and proactively scheduling follow-ups with patients;
- Expanding patients’ access to care; and,
- Coordinating patients’ entire care plans, including working with specialists, as needed.
Why Should Providers Consider Becoming a PCMH?
One of the biggest reasons to become a PCMH is to improve outcomes. In a 2012 review of PCMH initiatives around the country, the Patient-Centered Primary Care Collaborative (PCPCC) found that, across the board, PCMHs reduced emergency room visits, hospital admissions, inpatient bed days and readmission rates by between 10 and 50 percent. Glycemic control for diabetics, blood pressures for hypertensive patients, preventive care screenings and other measures all produced improvements.
Corollary to this, patient satisfaction goes up in a PCMH. In addition to the fact that patients are getting better care, many of the provisions of PCMH recognition are specifically designed to make doctors and/or medical information more accessible, including:
- Web portals giving patients better access to their medical information;
- Same-day appointments;
- Expanded after-hours access;
- The ability to handle more aspects of care remotely;
- Culturally and linguistically appropriate services; and
- Regular follow-ups.
But just as critically, physicians at patient-centered homes report significant gains in professional satisfaction. Though formal data on this is limited, the data that does exist—to say nothing of the substantial anecdotal evidence—seems to support that claim. Why? Because physicians finally are able to operate at their highest level of professional ability.
“There’s huge professional satisfaction when the team is taking care of patients, because everyone is functioning at the highest level of their training,” explains Dr. Charles Cutler, chair of the American College of Physicians (ACP) Board of Regents. “Physicians are taking care of complicated medical problems they’re trained to do rather than things that someone with a lower level of training could appropriately take care of.”
What Are the Requirements for PCMH Recognition?
If you decide to become a PCMH, the first step is to do a bit of self analysis. The NCQA offers a step-by-step guide that illustrates the requirements for receiving their recognition. Although they’re the market leader, there are several other certifying bodies, such as The Joint Commission and the Accreditation Association for Ambulatory Health Care, and a number of private insurers, employers and state entities—all of which have developed their own criteria.
Most certification bodies offer online resources to help you examine your practice’s current standing. A number of professional associations can also help with this. For example, members of the American College of Physicians can use the ACP Practice Advisor, a subscription-based software program that guides you through the process of transforming your practice.
The NCQA has six “must-pass” elements that practices must score at least 50 percent on in order to receive any level of PCMH recognition:
- Access During Office Hours;
- Use Data for Population Management;
- Care Management;
- Support Self-Care Process;
- Referral Tracking and Follow-Up; and
- Implement Continuous Quality Improvement.
Each element requires extensive documentation to go with your application. To pass Element 2 (Use Data for Population Management), for example, a practice must show that it conducts and documents a comprehensive health assessment of each patient that includes:
- Documentation of age- and gender appropriate immunizations and screenings;
- Family/social/cultural characteristics;
- Communication needs;
- Medical history of patient and family;
- Advance care planning (N/A for pediatric practices);
- Behaviors affecting health;
- Patient and family mental health/substance abuse;
- Developmental screening using a standardized tool (for pediatrics); and,
- Depression screening for adults and adolescents using a standardized tool.
To this end, costs can be significant, even prohibitive, depending on your practice’s situation. Documentation alone can require its own investment, as practices often hire a team member whose specific job is to collect and manage all of the required data.
Although you can qualify for the lowest NCQA level of PCMH without implementing an EHR system, an EHR can play a significant role in becoming a sustainable PCMH. But an EHR system can cost tens—even hundreds—of thousands of dollars. If you don’t already have an EHR in place and aren’t in a position to implement one, you may have a hard time meeting the criteria for recognition.
Many practices become frustrated with the regulatory burden when making the switch to a PCMH model, feeling that they’re spending more time tracking data and jumping through hoops than practicing medicine. But ultimately, they find that this is just part of the growing pains of transforming their practice.
“Doctors have to be more than just clinicians, especially if they want to be the leader,” says Reineking. “You have to run your practice like a business and turn it into a well-oiled machine.”
What Kind of Financial Incentives Do PCMHs Offer?
A big challenge physicians face when transforming their practice is that reimbursement structures simply aren’t yet set up for this model. Even in places where the state or private payers do offer a financial incentive for NCQA recognition, these stipends are just a few dollars per member per month (with few exceptions), representing a very small percentage of a practice’s revenue. In other words, you’re doing a whole lot of work without the promise for more money.
According to the National Academy for State Health Policy, 43 states have adopted policies and programs to advance medical homes as of April 2013, and they’ve put together an interactive map to help you find them. Note that the certification program you select will have implications on these incentives, since most of these programs specify the specific certifying body that they’ll recognize. (Most of them use NCQA, which is how they became the market leader.)
What Are the Challenges of Becoming a PCMH?
Perhaps the biggest hurdle of transition to a PCMH model is transforming your practice’s leadership and teamwork. Dr. Bruce Bagley is interim president of TransforMED, a consulting company that engages with medical practices to help them become a patient home. He says that the difficulty of making the change is what usually surprises people the most.
“When your nurse practitioners and your physicians assistants and your billing staff have been doing something for years, it’s hard to break out of that, and it’s a major barrier,” he explains. “People need to rethink what their part in healthcare might be. When we see places with one excuse for inaction after another, lack of leadership is the missing ingredient.”
Dr. Clark says that teamwork is the most critical part of transforming a practice to a successful PCMH model. “That’s our special sauce, it’s the team,” he emphasizes. PCMH experts point out that this process requires shifting from a “doctor as the hero” model to one that empowers every member of the team to operate to the fullest extent they are legally and professionally capable.
“For a chronic condition, my team is empowered to order tests, and if gaps occur they can talk to other specialists, so a lot of work is done before I see [the patient],” says Dr. Clark. As Dr. Reineking puts it, “It doesn’t take an M.D. to order a pap smear.” Shifting these sorts of tasks to other team members is a big part of what produces the drastic increase in professional satisfaction mentioned earlier, as both doctors and other staff are fully engaged and driving the team forward.
The most important piece of advice, however, is to ask for help along the way. “You can’t do it alone, and shouldn’t feel like you’re alone,” says Vermont pediatrician Dr. Jill Rinehart. Leverage the experience of those that have made the switch before you in order to make a successful transition. Recognize that it will take time to completely switch to a new model, and that missteps and setbacks are a natural part of the process.
Are PCMHs the Future of Healthcare?
Although we haven’t reached a tipping point yet, it seems inevitable that new practice models like PCMHs are the direction in which medicine is headed. According to a white paper published by athenahealth, “the term patient-centered medical home appears in the Affordable Care Act [ACA] more than 80 times.”
The ACA also introduced Accountable Care Organizations, which are essentially PCMHs on a larger scale. More and more state organizations and insurers are offering incentives for PCMH certification, and employers are jumping on board, too, since PCMHs reduce absenteeism and presenteeism (poor performance due to health-related issues in the workplace). Given the vast improvements in outcomes, as well as the data suggesting that costs to payers are break-even at worst and 20 percent lower at best, it’s only a matter of time before that tipping point is reached.
Naturally, NCQA is at the forefront of this. According to Dr. Reineking, NCQA used to receive 20-30 application submissions per week. Now it’s closer to 100, and if there’s a major deadline coming up, such as for a state Medicaid program, this number can reach 500.
NCQA is now on its third generation of qualification standards, with the next set coming out in 2014, and is piloting a Patient-Centered Specialty Program that applies the same principles to specialty providers. In 2010, The American Academy of Family Physicians (AAFP) had 14.5 percent of its members achieving some level of PCMH recognition—two years later, that number had grown to 24.4 percent.
As such, it’s not a stretch to assume that PCMHs may become the standard in the near future. Dr. Jennifer Lail, an associate professor at Cincinnati Children’s Hospital Medical Center who has spent most of her career advancing this movement, sums it up nicely:
“We cannot ignore the fact that 17.3 percent of our GDP in 2010 was on [healthcare] spending and we were 37th in the world in outcomes, that the number of children with special complex medical needs is growing all the time, and the accountable care models are here. It’s going to take a lot of time, and payment reform will be absolutely essential, but insurance companies and states are recognizing that if they want practices to make this transformation, then they have to help them financially do it. So I’m hopeful.”