More Texas Practices Improving Care With Patient-Centered Health Care Model
Practice Management Feature — January 2017
Tex Med. 2017;113(1):49-56.
By Joey Berlin
Dallas-area internist J. Shaun Murphy, MD, says patients can sense a change in his practice and its operations.
"They know when we're being aggressive about care," Dr. Murphy said. "They'll say things like, 'You've never talked to me so much about weight loss before, or 'You never talked to me about depression as much as you do now.' Most of the time, they are grateful for that."
Around mid-2016, Dr. Murphy's practice, Addison Internal Medicine, earned recognition from the nonprofit National Committee for Quality Assurance (NCQA) as a patient-centered medical home (PCMH). The PCMH model, which aims to transform primary care to reflect patients' needs and emphasize care coordination, is growing in popularity. NCQA said in November it had recognized more than 11,000 sites nationally as PCMHs.
Medical homes are supposed to represent a path where everybody's happy: Patients receive coordinated care, and care availability, focused on their personalized needs, reducing hospitalizations, and improving outcomes. Practices, in turn, reduce costs and can earn incentive payments from insurance payers for becoming a PCMH, if the payer sees the value in contracting with a medical home.
Achieving PCMH recognition may provide real benefits for patient care, but the journey is a difficult one, Dr. Murphy cautions.
"I'm not going to tell you it was easy. We hoped to do it in a year; it probably took us closer to two," he said. "But it was a good process, and I learned a lot. I learned a lot about my patients, how to take better care of them."
Principles of a PCMH
As of early November 2016, NCQA had recognized 11,844 PCMH sites in the United States, including 737 sites in Texas with 3,169 clinicians.
Dallas internist Sue Bornstein, MD, executive director of the Texas Medical Home Initiative, says many of the PCMHs in Texas are affiliated with large health systems in the state's larger cities, and many of Texas' military hospitals are medical homes, as well. But private practice physicians have been slower to embrace the PCMH model, Dr. Bornstein says. She notes larger practices have more resources to implement what NCQA requires for medical home status, and NCQA favors practices with a strong health information technology (HIT) infrastructure.
The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association collaborated on a 2007 paper "Joint Principles of the Patient-Centered Medical Home" that formalized the PCMH concept.
Among those principles were:
An ongoing relationship between a patient and a personal physician trained to provide first-contact, continuous, and comprehensive care;
- The personal physician leading a team of individuals at the practice level who are collectively responsible for patients' ongoing care;
- Whole-person orientation that cares for all the patient's needs at all stages of life;
- Coordinated and/or integrated care; and
- Enhanced access to care through such systems as expanded hours, open scheduling, and new communication options.
Several medical home recognition and accreditation programs now exist along with NCQA's, including programs for The Joint Commission and the Agency for Healthcare Research and Quality. However, practices don't have to attain formal recognition to become a PCMH.
NCQA recognizes three levels of medical homes, level three being the highest, depending on how many points out of a possible 100 a practice scores in its PCMH assessment.
What It Takes
Becoming a medical home requires a commitment to transformation. Practices may have to add personnel and may have to extend their hours. They also may have to alter significantly how they handle overall care. But Texas physicians who have taken the PCMH plunge say the impact on patient care has been positive and well received on the patients' end.
Texas Medical Association quality practice management consultant Yvonne Mounkhoune says an up-to-date electronic health record (EHR) system is essential for any PCMH, in part because of the need to report to other databases such as disease registries. In terms of personnel costs, Ms. Mounkhoune says physicians considering PCMH need to change their mindset.
"The visits that a doctor would normally have to do can now be done by other people," she said. "The doctor doesn't have to spend any time, really, speaking about nutrition. The doctor doesn't have to do the follow-ups for hypertensive medications; those people can be scheduled with a pharmacist. You have to think about it differently. It's not just that you have more [full-time equivalents] to pay for. They're going to be taking care of some of the work for you, and they're going to have some billable hours, as well."
TMA Practice Consulting offers members resources to help them attain PCMH recognition. (See "PCMH Help From TMA.")
College Station's Allied Pediatricians of Texas first became a level-one PCMH under an old practice name in 2011, then became a level-three PCMH about three years ago. Allied is part of a "practice without walls," a group of practices that have merged under a common tax identification number to pool their resources. Each practice in the group is a level-three PCMH.
This month, Allied Pediatricians planned to add a 10th practitioner to a roster that includes a team of three licensed vocational nurses (LVNs) who act as care coordinators, a key component of the medical home machine. Allied's Scott Schams, MD, says the LVNs' main job is largely to coordinate care for chronically ill patients.
"[They] do the referrals; they talk to a lot of the specialists, getting information, stuff like this. … They'll take a look at the schedules, make sure that we have all the things that are necessary for that visit for those chronically ill," he said.
Before becoming a PCMH, Dr. Schams says, the practice previously had some weekend hours on Saturdays and Sundays. But as part of its recognition process, the practice extensively polled its patients on what hours would best work for them. The survey revealed some illuminating things about their patients' priorities, which include Texas A&M football games, and how those priorities affected patients' desired availability of care.
"Because we're in Aggieland, it's really funny: They want us to be open in the mornings, but have two doctors [available] rather than one so that they can go to the Aggie football games," Dr. Schams said. "I'm not joking, because around here, when football's going on, we know that this place is empty no matter how sick your child is then. If we have a night game, we'll be busy all day when we're open on Saturday. If we have an afternoon game, the calls stop at 10:30 am. If we have a morning game, we're not going to get anybody at all."
Addison Internal Medicine became a PCMH with the help of The University of Texas Southwestern Medical Center, through which Addison had already joined an accountable care organization. The PCMH transformation changed the way the physicians at Addison Internal Medicine communicated with their patients, Dr. Murphy said, improving that digital dialogue with the capabilities of the practice's EHR. For example, patients can send their physician messages using an app on their phone. He says the data-keeping requirements allowed the practice to improve its diabetic care.
"They really had a focus on mental health, and I began to screen all my patients for depression, not just the ones I thought might be depressed, and was able to help and find a lot of people who I wouldn't have without using the tools," Dr. Murphy added.
Data show NCQA-recognized PCMHs have made strides in reducing emergency department visits and costs, according to a report NCQA released last October. (See "PCMH Successes by the Numbers.") Texas medical homes have seen positive results statistically and in more intangible ways.
Starting about three years ago, Hill Country Medical Associates in New Braunfels worked through local hospital Christus Santa Rosa to earn PCMH recognition. Christus was looking to cut costs, said Hill Country practice manager Doug Brandsma, and worked with Blue Cross Blue Shield of Texas to incentivize practitioners to transform their practices into medical homes. With help from grants Christus received, Hill Country achieved level-two PCMH recognition from NCQA.
"It was a unifying thing, so I think it was really a good thing for the office," said Warren Albrecht, MD, a family physician at Hill Country. "Plus, then the metrics of managing a diabetic, managing someone with coronary disease, managing a smoker — to get those nine doctors, different training, different ages, that have been working together but primarily as independent practitioners ... it was really good in getting us to work for common goals that were shown to be national and international guidelines on diabetes, on hypertension, on cholesterol management."
Hill Country hired a part-time person for population management early in the process and assigned a nurse to go over each patient's chart and contact the patients to encourage them "to get the different things that they needed to do to help us meet the metrics," Mr. Brandsma said.
The self-examination of the PCMH process can reveal opportunities for serious improvement. For example, Allied Pediatricians used the process to find a way to dramatically trim its unnecessary admissions. It realized one particular hospital accounted for 80 percent to 90 percent of its admissions, and in the physicians' view, most of those admissions were unnecessary. When they followed up with the patient at the hospital, the child wasn't seriously ill or injured.
Based on what it found, Allied decided to drop its privileges at that hospital. Dr. Schams says the practice's hospitalization rate dropped overnight, and its hospitalization days have dropped more than 90 percent since 2012.
Dr. Schams says while the PCMH process has its drawbacks, "it does give you the freedom to be able to measure things that you feel as a practice and forces you to have to use tools or develop tools in order to find quality improvement projects."
The majority of patients at Hill Country take the increased interest in their own care that PCMHs are supposed to generate, Dr. Albrecht says.
"I think most people appreciate the general physical exam, and they appreciate that we're concerned about keeping them healthy," he said. "And then they tend to be — not across the board, but tend to be — more interested themselves when you talk to them. They get a little more motivated."
The physicians who consider the medical-home model a success on the patient care front offer caveats to consider.
From her previous 13 years in a small internal medicine practice in Dallas, Dr. Bornstein knows how difficult it can be for a smaller office to add the personnel required for a PCMH designation. She notes while small practices have the advantage of being able to make process-changing decisions more quickly because of their shorter chain of command, their resources are more limited.
"It's a lean operation, and if somebody came to us and said, 'You can do all this, but you need to hire another person,' that's hard. I mean, it really is hard," Dr. Bornstein said. "I don't want to make everything sound like it's all about money because that just sounds so unimaginative. But that is a reality."
Insurance payers in other parts of the country have embraced the medical-home model and rewarded practitioners accordingly. Ms. Mounkhoune, who previously worked for the PCMH-recognized Carolina Advanced Health in Chapel Hill, N.C., says payers on the East Coast are often willing to enter into contracts that include payment incentives for becoming a PCMH.
That financial motivation isn't yet as forthcoming from payers in Texas, though, physicians say.
"If we had extra payments for what our coordination of services would be, we could do an awful lot more," Dr. Schams said. "Right now, payments [have] really restricted us from probably doing what we really want to do. … I would say economically, it has not helped us. And if the data [are] out there showing it to be work, payers are going to have to pay a little bit more per month in order to get those kind of services."
If the payers would do that, he says, health care costs would drop.
"If we got $3 to $5 per patient per month — in other words, between $48 and $60 more per patient per year — we would be able to do a lot of things, amazing things," he said. "That's not much when you consider that a lab might cost that much in the adult realm."
Stephen Watkins, Aetna’s director of network management in Texas, says the payer does have some arrangements for PCMHs in the state. He says Aetna offers PCMH practices a care coordination fee on top of their fee-for-service contracts, "as well as an opportunity to share in savings they achieve on an attributed population” based on how well they perform on cost and efficiency metrics.
"In our model, PCMH providers earn shared savings that are produced when hospital use is decreased, if they have also hit their quality targets," he said.
However, Mr. Watkins says Texas physicians "are still fairly fragmented" compared with other markets, "and few qualify for PCMH programs."
Dr. Murphy agrees that while becoming a medical home has been beneficial for patients, it hasn't yet become a financial boon.
"Cost-wise, I do think that at some point for you to get the good contracts, you're going to have to have PCMH certification. … I don't think it's true today, but if it's true next year, and you don't have it, it's not something you can just all of a sudden get," he said. "It really is a process."
The path to becoming an NCQA-recognized medical home is about to change, and NCQA says it will be a better, more streamlined one.
NCQA will have a new PCMH recognition process in place when it launches the 2017 redesign of its program on March 31. Michael Barr, MD, executive vice president of NCQA's Quality Measurement and Research Group, says the changes were based on research, focus groups, and stakeholder feedback about the current process, some of it critical.
The most recent recognition process and standards went into effect in 2014. The program redesign will have a new set of standards, which Dr. Barr said would be published as a pre-release version this month. The redesign will focus on the communication between NCQA and practices and reducing the amount of documentation practices have to submit while improving the submission process.
Dr. Barr says applicants had told NCQA they were navigating a cumbersome, overly complex recognition process with too much documentation and too little information about how a practice had done until it received its final score. Also, researchers, policymakers, and payers said there wasn't a strong enough connection between the standards and demonstrated quality-of-care improvement. Right now, practices go through the recognition process every three years without having to demonstrate continued alignment to PCMH requirements in the interim.
"The three-year cycle between the initial recognition and subsequent renewals might contribute to the observation that some practices don't always continue to practice as a PCMH," Dr. Barr said. "Under the new process, after the initial recognition, a practice will need to check in with NCQA on an annual basis and submit a very limited set of information, performance data, and attest to ongoing PCMH activities."
In the new initial recognition cycle, practices will work with an NCQA representative to organize a schedule of check-ins with NCQA over a period of 12 to 18 months to support the practice's transformation to a PCMH. NCQA's redesign also will allow practices the option of submitting electronic clinical quality measures to NCQA to satisfy some of the PCMH requirements. Those measures are a subset of measures from the government's EHR incentive program that also align with measures for other federal programs.
"The PCMH requirements are based upon what we know to be solid, good practice essentials to person-centered care," Dr. Barr said. "We are doing our best to wring out any of the inefficiencies and other aspects of the program that caused undue frustration without watering down the requirements."
A Need for Change
Dr. Murphy says practices looking to become medical homes shouldn't be turned off by the undertaking in front of them. Many EHRs, he notes, now have built-in material geared toward meeting PCMH criteria.
"It seems very daunting at the beginning," he said, "but if you break it up into little pieces and just realize that every change you make isn't going to be a great change, to not get discouraged by that, you'll get it all done."
He recommends using the services of a PCMH coordinator.
"I realize it costs money, but I think it's money well spent," he said. "And I do think you need to dedicate probably a full-time person to really doing it well and appropriately. That's not something that [NCQA] is going to say you have to do, but realistically I think [it takes] at least one or two full-time employees and then the PCMH coordinator — not every day, but I would say a couple of hours of their time every month for probably a year. I think that's what it takes."
Dr. Bornstein says, in general, pursuing PCMH recognition is worthwhile for most practices. One of the valuable things about the NCQA model, she says, is the opportunity to learn quality improvement.
"You've got a couple of really bright people — it can be the front office clerk, the front office receptionist. Get a couple of people that are committed to their practice, and they now learn they have the power to change things. That's huge," she said.
She says medicine has to change its approach to meet the needs of an increasingly sick population.
"I honestly do think that practices historically have been very physician-centric," Dr. Bornstein said. "The schedule has revolved around what the physician wants. And whether we like it or not, that has to change. That's important. Team-based care is going to be essential moving into the future."
Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
PCMH Help From TMA
TMA Practice Consulting can provide physician practices with guidance toward attaining patient-centered medical home (PCMH) recognition through:
- Education regarding National Committee for Quality Assurance (NCQA) requirements and components of PCMH;
- Assessment of existing processes and operational procedures;
- Identification of improvement opportunities written in a bound report;
- Development of appropriate workflow processes;
- Ongoing support throughout the practice transformation; and
- Assistance with submission of documents for recognition.
To learn more, contact TMA Practice Consulting at (800) 523-8776 or by email.
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PCMH Successes by the Numbers
Last October, the National Committee for Quality Assurance (NCQA) released a report detailing the potential benefits of earning NCQA recognition as a patient-centered medical home (PCMH). Various studies found:
- PCMHs reduced the growth in Medicare outpatient emergency department visits by 11 percent;
- PCMH clinics reduced emergency department visits by Medicaid managed care beneficiaries by 70 visits per 1,000 members per year, and increased office visits relative to non-PCMH clinics;
- PCMH practices experienced nearly $1,100 lower average per-patient total Medicare spending; and
- PCMH practices reduced total annual health care expenditures per capita by $482.40.
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