The Blue Cross Blue Shield PCMH model is shown above.
By Tom Lacock
Wyoming Medical Society
CHEYENNE – While the concept isn t new, the high profile afforded to Patient Centered Medical Homes (PCMH) by the Affordable Care Act is. PCMHs are being embraced by practices that say they have done this work for years, as well as public payers. However, they hope to be paid for their efforts through third party recognition. The concept has its detractors as physicians and practices say the process could be ironed out, and private payers still seem undecided on an exact formula to reimburse practices willing to make the leap to become a PCMH.
However, the theory that maintaining a medical home helps keep costs down for patients and payers alike seems universally agreed upon.
“To the extent that the PCMH is able to coordinate the care for our members, it should improve the quality of care, accessibility of care for our members and may improve the costs associated with providing care to our members,” says WINhealth CEO Stephen Goldstone.
What is a PCMH?
The National Committee for Quality Assurance (NCQA) is a non-profit dedicated to improving health care. It is also one of the leading organizations in the certification of PCMH s. It defines the PCMH as a way of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” It claims medical homes lead to higher quality and lower costs, and can improve patients and providers experience of care.
The Agency for Healthcare Research and Quality (AHRQ), a division of the US Health and Human Services Department, defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses five functions and attributes:
- comprehensive care (accountable for meeting the majority of a patient s physical and mental health
- needs, including chronic care and wellness);
- patient centered (relationship-based care with an orientation on the whole person);
- coordinated care (medical home coordinates care across all specialists, and hospitals), accessible services
- (open scheduling, enhanced in-person hours) and;
- quality and safety (evidence-based medicine and clinical decision support tools).
The concept suggests using a PCMH will result in less duplication of services and an emphasis on getting patients to the appropriate setting for their care. On its website, NCQA has a list of studies that supports the theory.NCQA has a list of studies on their webpage which support the theory. One 2012 study said PCMH-treated adults and children had 12 percent and 23 percent lower odds of hospitalization, respectively, and required 11 percent and 17 percent fewer emergency department services, respectively, than non-PCMH patients.
“PCMH is not a new model,” says Phyllis Sherard, PhD., of the Wyoming Institute for Population Health (Institute). “It was created in the 60 s by the AAP as a best practice for pediatric care. The model is still used in pediatrics, bit it has been slow to spread.”
The PCMH model organizes workflows so everyone in a clinic works to the top level of their license, meaning nurses aren t taking phone calls and physicians see patients. Terry Johnson, the practice manager for Babson and Associates in Cheyenne, said this requires more accountability by those in the clinic, but also makes workflow go smoother. He says Babson and Associates achieved Level III PCMH status in July of 2013 after starting the process in 2011 with facilitation supported by Cheyenne Regional and the Southeast Wyoming Preferred Provider Network. He said the PCMH model meant changes to the day-to-day duties of everyone in the office, which have been for the better. The clinic also promptly advertised their NCQA recognition and can claim the well-deserved “bragging rights” in their marketing materials.
“The restructuring of work flows and load has greatly improved the speed that care is delivered in our clinic,” he says. “The clinic is real-time with appointments; referrals and prescription refills. When the patients leave the clinic, office notes are signed off, referrals are completed, supporting notes are already sent and labs/x-rays are received and reviewed with the patients. We finish today s work today and allow our providers and staff to have better quality of life when they go home.”
How to achieve PCMH status
According to Greg O Barr, Director of Business Development for the Institute for Population Health, the $14.2 million Healthcare Innovation Award the Institute received was dedicated to expanding medical neighborhoods across Wyoming. Part of that effort involved helping practices to become PCMH s. Since 2012 it has helped 27 Wyoming clinics (representing 50 percent of primary care providers) attain a level of PCMH status, working through the nearly 168 areas where documentation is needed for NCQA recognition.
O Barr said the Institute offered PMCH transformation coaches, as well as gap assessments and modules to work with practices. Certainly, O Barr says, clinics can go online to walk through the process on their own, but he believes working through the Institute of Population Health can shave 15-20 months off the PCMH application period. Highly motivated clinics can achieve PCMH recognition in as little as 18 months, but 24 months is more realistic. While the Innovation Award ended June 30, 2015, the Institute is in the process of developing a pricing structure to enable them to continue to provide transformation assistance to the remaining 50 percent of primary care providers.
Maintaining any help available will be important to the future of PCMH in Wyoming as the process is lengthy. Johnson says among the practice community, the PCMH is known as the “paper centered medical home” because of the onerous process for accreditation. He says clinics seeking the classification can expect to provide evidence that they have implemented every requirement of a PCMH in order to secure recognition by the NCQA. He adds that any clinic attempting to attain PCMH status should prepare to have their every process dissected by NCQA.
Tonya Bartholomew, clinic manager for the Platte Valley Medical Clinic in Saratoga, says it took her 12-18 months to complete the NCQA application, which included uploading around 150 documents to support the application. She credited the community medical foundation in Saratoga for providing funds to hire a patient care coordinator at the clinic to perform care management, which she called the meat of the PCMH model. Even with help from the Institute of Population Health, there were challenges such as a lack of a clinic coach to extract documentation from the clinic s EMR. Wyoming s failure to develop and launch a statewide Health Information Exchange actually cost the clinic points towards its PCMH certification.
Goldstone says WINhealth has also gone through NCQA certification process, and while he considers NCQA certification a good validation measure, he agrees it is arduous and would like to see the process change its focus.
“These processes tend to be process-oriented – do you have a process in place for doing this or that?” he says. “For all of our benefit we need to become more outcome-oriented. Are we improving the patient population health we serve? Are we making healthcare affordable? We can t keep adding costs on top of costs unless there is some benefit on the other end.”
The Public Payer s Perspective
Dr. James Bush, Medicaid Medical Director for the State of Wyoming, helped develop a PCMH program for the state’s Medicaid program. He says for a physician or practice in Wyoming to enroll in the Medicaid PCMH program, they must sign a survey put out by the NCQA, pull continuity of care documents on at least 50 percent of the Medicaid patients they see in a month, and at least once a quarter submit clinical measures into a state level registry. Bush says the measures are the same being used for meaningful use, in hopes of not duplicating efforts where possible.
The payoff for practices participating in the state’s Medicaid program is a $3 payment per Medicaid patient per month whether the client has been seen that month or not. Bush says that number will likely increase as the program matures, as he expects the high-performing practices to receive $6 per patient per month in year two of the program, pointing out it is important to reward physician practices for improved care. Bush said the program rolled out in January 2015 and has four practices onboard with 29 others now eligible and going through some level of NCQA accreditation.
Bush says the metrics Medicaid is receiving are helping them to suggest prevention screenings to physicians. Based on the numbers Medicaid has received through PopHealth, 8,709 of 9,993 adults in Medicaid have received their tobacco use screening and intervention in the first quarter.
“I think the biggest thing we will be able to see is they will be able to track quality over time,” Bush says. “We were tasked with coming up with a system for value-based purchasing and rewarding quality medicine versus quantity medicine. You are being paid more for better care. That is very, very exciting and rewarding.”
The private payer perspective
Bartholomew said when her clinic was first approached about being a PCMH by the now defunct Wyoming Integrated Care Network in 2012, the pitch was simple – it is the right way to take care of patients and there would be an attempt to get payers to the table to discuss increased reimbursement to clinics who became PCMH s. The Institute agreed to take on that role, which Bartholomew said was still a work in progress.
Currently, WINHealth offers a per-member-per-month payment for patient management. WINhealth CEO Stephen Goldstone said he remembers discussing a system for compensation in 2013 with the Platte Valley Medical Clinic over dinner in Saratoga, roughing out a compensation plan on the back of an envelope. He said his company receives data from clinics such as Platte Valley in hopes of impacting changes in population health.
However, he said WINhealth isn t seeing much in the way of cost savings yet.
“At the end of the day, what will these do to improve the health of the population they serve?” Goldstone asks. “Just to add a patient management for a fee-for-service we already pay is adding to our costs, and we aren’t seeing the offsetting reduction.”
Dana Pepper manages population health and wellness at WINhealth and says the company wants to see data (through the PCMHs) on where clients seek primary health care, the better to make sure it is the appropriate avenue and, by extension, the least costly to WINhealth. She adds that practices, patients and insurance companies can all make positive changes with the appropriate data.
Blue Cross Blue Shield also pays on a per-member/per-quarter basis to physicians and clinics that are either NCQA-certified as a PCMH or those that take part in Blue Cross version of a PCMH, the MedicQHome program. According to Wendy Curran, the vice president of care delivery and communication, MedicQHome offers physicians the use of its MDInsight computer software, which reports patient data to both Blue Cross (for Blue Cross clients) and the clinic enrolled in the MedicQHome (for all patients). Curran says MDInsight helps physicians understand which of their patients would benefit from things like screenings and other preventative measures. Curran said the MDInsight tool also acts as a population management tool for NCQA certification and earns providers points toward that end. Curran also said many of their larger groups and self-employed clients are looking for ways to keep their employees healthier and have gravitated to the data the MedicQHome program provides.
“We think it is a good thing,” Curran says of PCMHs. “It incentivizes providers, and helps to coordinate care. It starts to move us away from fee-for-service payment system and towards something that rewards the providers who reward outcomes and quality measures. We believe the end result is potentially cost savings for us and our members.”
While Blue Cross Blue Shield pays PCMHs whether they are part of the MedicQHome or an accredited PCMH, she said her organization s clinical advisory group has discussed an interest in incentivizing further the clinics which have become accredited through NCQA and that is something that may happen in the near future.
Kris Urbanek of Blue Cross Blue Shield’s Provider Services said once they receive enough statistics, his firm might use the data to increase patient education in a specific medical issue, or offer additional resources to tackle the issue past care management. He said the hope for Blue Cross is to set the bar for compensation of clinics high enough to offer an incentive to participate and yet not too low that it won t modify behavior within the clinics.
What s next
Sherard says there are advantages beyond just patient care to a PCMH. She points out that patients are becoming more discerning consumers of health care as their insurance plans ask them to pay higher deductibles. The PCMHs focus on wellness and prevention should appeal to those trying to keep themselves healthy and out of the doctor s office. She also thought younger physicians might find working in a PCMH more attractive due to the physician-led multidisciplinary team approach to care, which offers them more time for work-life balance, and has the added advantage of helping to mitigate the physician recruitment and retention challenges Wyoming continues to face.
“Younger providers are reluctant to to be on call 24-7,”Sherard says. “They want a balance in their family and work life and take as many call as they want to. They are looking for a practice that has a care team that can help carry some of the low-risk patient load, allowing physicians to see the highest-risk patients.”
While there are issues with the process, it is hard to find someone who doesn t agree with the basic tenets of PCMH – give the patient one central place to receive their health care and have that place communicate with any other providers to coordinate care for that patient going forward.
“It is the right thing to do for the physicians, the clinics, and the patients,” Bartholomew says. “People aren’t falling through the cracks. There are communications systems and people are held accountable for their responsibilities. The processes are in place and it is understood who needs to do what. We are better advocates to our patients. They appreciate the level of care we are offering them.”
“The clinic was built on the some of the main core components of PCMH: superior access to care, providing individualized care, promoting wellness and chronic disease management with the assistance of interdisciplinary teams,” Johnson says.