Based on provider and payer feedback, the revised program will feature annual check-ins and reporting instead of the current program's three-year recognition cycle.
When the National Committee for Quality Assurance (NCQA) releases the 2017 iteration of its Patient-Centered Medical Home (PCMH) recognition standard in April, Marc Mayer, DO, president and medical director at Avenel-Iselin Medical Group, a multispecialty healthcare practice with more than 12 physicians in Iselin, New Jersey, will be excited to see major changes.
Mayer's practice first received NCQA PCMH recognition in 2011 and re-upped its status to Level 3 in 2014. He calls both experiences "pretty intense" and hopes the adjustments in 2017 will provide consistency and clarity that the application submission and review process currently lack, he says.
NCQA's PCMH is one of several PCMH recognition programs in the country to ensure primary care practices live up to the promise of the patient-centered medical home. For NCQA, that means inspiring quality in care, cultivating more engaging patient relationships, and capturing savings through expanded access and delivery options that align patient preferences with payer and provider capabilities.
Today, 17% of primary care practices, or 55,000 clinicians, carry NCQA's PCMH designation, according to NCQA, an increase from 100 when it was first introduced in 2008.
NCQA's intent in creating the standard, which can take three months to a year to meet through documentation, was to "acknowledge a need to elevate the status of primary care in this country to make it more attractive for professionals to go into and to make it a more joyful practice," says Patricia Barrett, vice president of product design and support at NCQA.
In summer 2016, NCQA called for input on the next version of the standard and received 3,000 comments from participating organizations. Although they were "generally positive," Barrett says they proved a need to redesign the process, including how applications are reviewed, the availability of submission assistance, and more clarity in expectations.
Barrett expects the 2017 recognition program to eliminate the guesswork and confusion from the submission and review process. For example, multisite healthcare facility applicants will be assigned a relationship manager whom they can interact with via WebEx to ask questions and double-check requirements. Also, instead of a single review, the process will comprise three check-ins that afford applicants an opportunity to correct items and receive credits. "Recognition will no longer be one and done; it will be more of an ongoing evaluation process," she says.
Another notable change will be the flattening of levels from three to one, Barrett says, enabling a much clearer delineation between practices that are recognized by the NCQA and those that aren't. "Our goal is to get back to the core concepts of the medical home and make sure what we are asking for truly reflects those concepts," she says.
"I didn't agree with the levels in the first place," Mayer says; adding that it takes time to transform a practice, making Level 3 difficult to achieve. However, he is committed to pursuing 2017 certification. "We decided a long time ago that PCMH was the way we were going to get the practice in line for the future."
Getting Recognized
About 15 years ago, Avenel-Iselin began adding specialty care, including cardiology, podiatry, gastroenterology, urology, and nephrology. "We've grown from just a primary care provider to a primary care–based practice," he says, making the practice far more conducive to the recognition requirements of collaborative and coordinated care.
Mayer first applied for recognition knowing "insurance companies and Medicare were going to go toward this type of practice transformation for primary care," he says. "We wanted to be forward-thinking."
A clinical manager and an administrator head up the application submission and review process. "While it wasn't difficult to make the transformation to PCMH internally, we spent a lot of time documenting what we were doing," he says.
One area that Mayer has seen improvement in due to the NCQA PCMH process is team-based care. "We had it, but we weren't maximizing it," he says, adding everyone now works to the highest level of their degrees, including medical assistants, nurses, and front desk personnel.
"Nurses used to just take vital signs and put people in a room," he says. "Now they look for gaps in care, such as patients being due for mammograms, colonoscopies, and vaccines. In the past it was my job as the doctor, but on a busy day, I didn't always ask."
As the medical team starts to gather metrics on these coordinated care efforts, they are noticing significant improvements. For example, only half the patients who should have been getting colonoscopies were, and now that number has increased to 85%, Mayer says. "The nurse makes one click in the EMR system and the front desk personnel know to schedule the procedure," he says.
Getting Buy-in
Ann D. Brown, MD, FACP, vice president of practice transformation and innovation, Physician Alignment, at Methodist Le Bonheur Healthcare, which has more than two dozen primary care locations in the Memphis area, first started working with a subset of 11 practices to gain NCQA PCMH recognition in 2013.
"We looked at trying to transform all the practices at once," Brown says, but she found it more practical to hand-select and target practices familiar with population health. She persuaded physicians to participate by explaining PCMH as a tool that would help them remain in practice and help them enjoy practicing. She added that PCMH would spread some of the patient's care to the entire medical team with proper education, training, and participation.
To assist the primary care group practices, Physician Alignment hired an IT director for its EMR platform with the focus of creating reproducible and trusted data in line with NCQA PCMH requirements. "For primary care groups, we've had internal quality measures for more than three years. Our IT director was instrumental in creating the trust for our doctors in our data being valid. We also have a Quality Committee of primary care physicians who have a voice in measure performance review and measure development."
But as streamlined as internal data-gathering has become, Brown sees room for improvement on NCQA's part and is encouraged with the recognition redesign process NCQA is initiating this year. The primary care group practices received recognition under the more-difficult 2014 standards, and Brown is expecting that practices participating in NCQA recognition will be able to maintain their recognition after 2017 more easily, she says.
Brown says that the PCMH recognition process can be costly in terms of training and support, including employment of quality improvement coaches, and that the return on investment possibly won't be recognized for three to five years. However, CMS' Quality Payment Program may reward certain PCMH-recognized practices with favorable Merit-based Incentive Payment System scoring, including NCQA, she says. For these reasons, the practice transformation has to be about improving patient care, "not financially focused. It's the right thing to do," she says.
A Group Effort
Randy Pritza, MD, MMM, chief medical officer at Omaha, Nebraska–based CHI Health Clinic, a network of primary care and specialty services with 100 locations in Nebraska and southwest Iowa, has collaborated with other CHI providers on NCQA PCMH recognition, including Barry Hoover, MD, MBA, FACEP, vice president and chief medical officer at The Physician Network, a wholly owned subsidiary of CHI with 50 primary, specialty, and urgent care practice sites throughout Nebraska.
Pritza started the PCMH recognition journey in 2012 by creating a pilot clinic at one site. That site achieved Level 3 recognition in 2013, and it was just re-upped for the 2014 standard. He created a learning lab on how to get certified and on the benefits of the NCQA PCMH recognition. Likewise, The Physician Network was able to get eight clinics certified in 2015 and 2016. Both organizations have been working to expand their recognition pool and continue to share their transformation best practices with the greater CHI collaborative.
"We have an aggressive timeline to have the majority of our clinics certified," Pritza says, but had run into roadblocks each time NCQA updated guidelines for each of the levels. "It makes the bar more complicated and forces us to think how we're going to achieve our goals," he says.
Hoover says organizations should realize that the process could take longer and require more human resources than expected. "Make sure you've resourced the efforts around this journey well," he says. "It's more a long-distance race than a sprint."
"You definitely won't be able to turn it around in 30, 60, or even 90 days," Pritza says. "You're dealing with a culture change on how you deliver care that a lot of doctors just aren't ready for."
As for NCQA's PCMH evolution, Hoover is hopeful. "My personal sense is it's evolving in the right direction," he says. "However, it would serve them well to focus on things that have positive patient impact, more so than process issues."