Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of seven national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment
The work of the FFM project was overseen by a committee comprised of representatives from the sponsoring organizations: the American Academy of Family Physicians, the American Academy of Family Physicians Foundation, the American Board of Family Practice, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors, the North American Primary Care Research Group, and the Society of Teachers of Family Medicine.
The resulting 2004 “Future of Family Medicine” report called for changes in the U.S. health care system, such as "taking steps to ensure that every American has a personal medical home." The American Academy of Family Physicians (AAFP) Board of Directors had adopted the following policy statement, which offers a succinct definition of "personal medical home:"
"The American Academy of Family Physicians believes that everyone should have a personal medical home that serves as the focal point through which all individuals -- regardless of age, sex, race or socioeconomic status -- receive acute, chronic and preventive medical services. Through ongoing relationship with a family physician in their medical home, patients can be assured of care that is not only accessible but also accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians."
The Colorado Academy of Family Physicians (CAFP) has also embraced the personal medical home concept. “The model provides an easy-to-use point of entry into the health care system, coordinates ongoing, comprehensive medical care that is appropriate and consistent with the patient’s needs and values, and places the patient at the center of all choices concerning their care,” says CAFP President Larry Kipe, MD. “The personal medical home structure supports the patient establishing and maintaining long-term relationships within the medical team, while utilizing health information technology and other innovations to provide seamless and timely access to all essential care.”
NCQA Offers Evaluation of Patient-Centered Medical Homes By Kent Voorhees, MD
In the Winter 2008 CAFP News I wrote about how “The Value of Providing a Medical Home May Help Family Physicians.” That article listed the Joint Principles of the Patient Centered Medical Home, which include: 1) care is provided by a personal physician to provide first contact, 2) a physician directs medical practice, 3) care is oriented toward the whole person – caring for all of the patient’s health care needs or arranging care with other qualified professionals, 4) care is coordinated and/or integrated, 5) quality and safety are important features, 6) enhanced access to care is available, and 7) payment should recognize the added value the patient-centered medical home provides. These are all elements that are typically provided through a Family Medicine practice. Although most Family Physicians provide these elements, national parameters and standards have been developed by NCQA (National Committee for Quality Assurance) which can lead to your practice being certified as a Physician Practice Connections – Patient Centered Medical Home (PPC-PCMH) practice. Once insurance companies validate the value of providing a medical home, they may require that your practice be certified to qualify for additional payment for providing this added service.
I mentioned in my last report that there is a pilot project being led by United Healthcare to study the benefits of care provided through a medical home. This pilot project will be conducted over 24 months and be done collaboratively with other insurance companies in both Colorado and Florida. If the results of this pilot project indeed show what is expected – that care provided through a medical home is of higher quality and saves costs – then it is expected that the insurance companies would roll this out and compensate practices an additional payment above fee for service to practices that provide a medical home. I will attempt to describe this evaluation process as developed by NCQA.
NCQA, an organization that helps to establish standards by which insurance companies monitor quality care, has established physician recognition certification for a number of specific areas including: back pain, diabetes, cardiovascular disease and stroke, and physician practice connections (use of information technology). This enhanced recognition can lead to enhanced payment or referrals from insurance companies. A Physician Practice Connections – Patient Centered Medical Home (PPC-PCMH) is a new certification that has just come out this year, which includes a scoring method to rate what level of a medical home your practice provides with different levels of qualification. This scoring method may be used by insurance companies in the future to determine if you qualify for additional payment. By understanding the score of your practice you can also understand what it would take to improve your scoring. It is important to point out that although you can obtain NCQA certification now, it is still being worked out by insurance companies how they intend to handle this, and may take time before a decision is made to compensate practices additionally for providing this and what scoring level is required. Although it is a work in progress, it is important to understand what is being discussed nationally that may impact your reimbursement and practice in the future. You can read more about NCQA certification by going to the website www.ncqa.org and clicking on “Patient Centered Medical Home.”
The PPC-PCMH includes nine standards for medical practices to meet. Under each standard there are a number of elements with different scoring weights that add up to a total potential score of 100. Of the various elements, there are 10 elements listed as “Must Pass Elements,” and practices must specifically pass at least five of these elements. The levels of qualifying are: Not Recognized, Level 1, Level 2, and Level 3, with Level 3 being the highest. To achieve Level 1 a minimum score of 25 out of 100 must be achieved. It is not clear what level will be required to qualify for additional reimbursement from insurance companies. There is a charge for being certified by NCQA, which is based on the number of physicians in a practice, which can be found on their website. The following is the table of the NCQA Scoring method and explanation of levels.
Although this overview is brief and not intended to be a comprehensive description, it is intended to provide information on some of the new developments taking place nationally that will likely eventually have an influence over how you will be paid in the future and potentially how you practice. Formalizing certification of a medical home is intended to improve the quality of patient care, and certification can serve to demonstrate to the public that your practice indeed provides this higher level of quality. It is anticipated that in the future that insurance companies will provide additional compensation for this, but this is still in the evaluation phase.
The above charts were produced by the National Committee for Quality Assurance and can be viewed, along with additional information, at www.ncqa.org. To see the charts, click on “Patient Centered Medical Home” and then “PPC-PCMH Summary.”
How do you know when your practice is a Patient Centered Medical Home?
By Elizabeth Kraft, MD
In the quality arena, the adage goes: “What gets measured, gets monitored and what gets monitored, gets improved.” In the past several issues of CAFP News, there has been discussion about the patient centered medical home, or PCMH. In brief, the PCMH is a practice that has at its core an on-going partnership between a patient and the patient’s family and the physician. The personal physician leads a clinical office practice team and assists the patient in navigating the health care system with coordinated and integrated care processes. This includes the use of evidence-based guidelines, referral coordination, cross-cultural sensitivity and a platform of health information technology. The practice provides accessible, family-centered, continuous care in a whole person orientation.
While it seems apparent that family physicians are finally getting recognized for their efforts in having provided this integrated health care all along, especially for patients with chronic illnesses, how does one know what is a PCMH? How do you know when your practice is a PCMH? How do you describe what makes a PCMH and can you measure what you have described? Why do you need to measure what you do as a Family Medicine physician? And, if you are to measure yourself as a PCMH, if you find areas that need improvement, are you willing to devote resources to improve?
While the PCMH is not a new concept, the creation of a uniform set of measures applicable across all specialties has recently been put forth by a national organization called NCQA. On Jan. 2, 2008, NCQA (National Committee for Quality Assurance) released a set of measures that have been endorsed by the AAP (American Academy of Pediatrics), AAFP (American Academy of Family Physicians), ACP (American College of Physicians), and the AOA (American Osteopathic Association), called PPC-PCMH (Physician Practice Connections-Patient Centered Medical Home). Building on the joint principles developed by these primary care specialty societies, the PPC-PCMH standards emphasize the use of a personal physician; physician-directed medical practice; whole person orientation; systematic, quality and safety features; and coordinated care management processes with enhanced access.
These measures are organized into nine standards that serve to describe and to measure the intent of what a PPC-PCMH should consist of: access and communication, patient tracking and registry functions, care management, patient self-management supports, electronic prescribing, test tracking, referral tracking, performance reporting, and advanced electronic communication. A practice can apply to NCQA for PCMH recognition; this entails submission of documentation that validates that the practice includes these aspects as part of the routine delivery of health care according to their standards. There are three levels of recognition, based upon the total number of points scored. There are several of these standards that are called “must pass” -- those standards must be incorporated into a practice in order to be recognized as a medical home.
Across the country, there have been pilot projects supported by Medicare, Medicaid and, in some states, by employers and health plans. In Colorado, Senate Bill 07-130, passed into law in 2007, mandates that all children in public health programs, Medicaid and SCHIP, have a PCMH available to them. Work teams of representatives from Family Medicine, pediatrics, mental health, oral health, families, and specialty medicine have been developing standards to help define the principles of the medical home and, ultimately, to objectively identify a medical home in practices that serve Medicaid and SCHIP children. Alignment of these standards with those of NCQA, those that have already been worked on by national advocacy groups, as well as additional measures that accurately reflect practice activities, such as patient centered, culturally sensitive, and compassionate care, are being considered.
NCQA has four other recognition programs for practitioners/practices that recognize a patient-centered approach and deliver care in accordance with widely accepted evidence-based guidelines: the Diabetes Physician Recognition Program (DPRP), the Back Pain Recognition Program (BPRP), the Heart/Stroke Recognition Program (HSRP) and PPC (Physician Practice Connections).
The value of achieving recognition for these programs comes to a Family Medicine doctor in many ways: achievement of DPRP and HSRP may allow credit on portions of the Maintenance of Certification for board certification. Employers desire to have their employees select doctors based upon quality -- the NCQA recognition program and board certification are available proxies. For example, in the fall of 2007, in the CBGH (Colorado Business Group on Health) “Health Matters” publication, a guide for employers and employees to select a health plan, placed the photographs of those doctors in Colorado who achieved DPRP recognition. Another plus for Family Physicians is that organizations or health plans may offer extra cash to physicians for participating in pay-for-performance programs or medical home pilot projects.
The AAFP is gearing up to offer assistance to support practices in working toward these recognition awards. The AAFP's Practice Support Division, its Center for Health Information Technology, and TransforMED, a practice redesign initiative affiliated with the academy, are three resources members could use. In Colorado, CCGC, Colorado Clinical Guidelines Collaborative, has been working with practices through the IPIP (Improving Performance in Practice) with in-office quality coaches to assist practices in redesign efforts to treat chronic illnesses such as asthma and diabetes, along the planned or Ed Wagner’s chronic care model.
A good web page with many links is http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20080207ncqa-pcmh.html. Visit the CCGC website www.coloradoguidelines.org) to learn more about the IPIP project and how to apply to be an IPIP practice.
As there will be an ever increasing focus on quality measures at the practice and physician level, understanding what these measures and standards are and seeking to incorporate them will place your practice ahead of the curve.
Medical Home – Of course we want it, but what is it exactly?
Medical Home – it’s a term we are hearing everywhere these days—from professional journals to the Wall Street Journal to local papers across the country. Led by the patient’s personal physician, the medical home concept puts the patient at the center of an integrated health care team capable of addressing the patient’s every routine health care need. Purporting to improve patient outcomes while reducing costs, it is like motherhood, apple pie and a day at the spa rolled into one. Sounds great, right?
But what exactly is a medical home? What does it look like? How will you know one when you see one? A medical home is not a building or a structure. At the most basic level it is a method of health care delivery; a method surprisingly similar to the idyllic image of medicine that drew most primary care physicians into the field. Imagine a primary care physician playing quarterback and wearing the number 7, leading a well orchestrated team of highly trained staff, providers and specialists towards the goal of patient welfare, and you begin to see the potential of a medical home.
The concept began with the American Academy of Pediatrics many years ago and gained national momentum when the other national primary care societies (American Academy of Family Physicians, American College of Physicians, and the American Osteopathic Society) joined forces. Together they published “The Joint Principles of a Patient Centered Medical Home” (see box). AAFP has been a prime mover in bringing the concept to reality at the national level.
Working with the primary care societies, NCQA, the National Committee for Quality Assurance, developed a set of standards to measure “medical homeness.” Measures include:
Ease of access and communication;
Patient population tracking and registry functionality;
Proactive self-management support;
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Performance reporting and continuous quality improvement processes;
Test and referral tracking; and
Access to advanced electronic communication resources.
To receive NCQA recognition as a medical home a practice must demonstrate it has the systems and tools in place to coordinate patient care across the clinical spectrum, while empowering patients to self-manage their chronic conditions and support their efforts to make good choices.
When Colorado Senate Bill 130 was signed into law last year the state pledged to provide the children covered by Medicaid and SCHIP, and their families, with continuous, accessible, and comprehensive medical and nonmedical services. A multi stakeholder task force is currently working to define the standards for a medical home for Colorado.
While physicians agree that they would like to provide this kind of care, the reality of today’s health care environment is a major deterrent. The proliferation of medical knowledge, the complexity and fragmentation of the health care system, the unpaid and overwhelming administrative demands on primary care, a compensation system that does not reimburse for coordinating care, and patients who change providers regularly because of insurance changes are all significant barriers.
For medical homes to achieve their potential, significant changes at the practice level and the health care system level are necessary. At the practice level, there needs to be:
An engaged, empowered health care team to actively collaborate with the physician to assure the delivery of evidenced-based guidelines at the point of care;
An electronic information system (either an EMR or stand-alone registry) to track patients for effective management of chronic conditions and preventive medicine;
An outreach system to identify and notify patients when care gaps occur;
A reliable process for providing self-management support; and
A system for reporting and reviewing performance measures to assure continuous performance improvement.
Colorado Clinical Guidelines Collaborative (CCGC), a grant funded non-profit coalition of over 50 health care organizations, can provide practices seeking NCQA recognition with the onsite technical assistance ( IPIP) to enable practices to establish the systems and processes required to be NCQA recognized. CCGC Quality Improvement Coaches are also fluent in the integration of effective, low-cost software programs like Reach My Doctor that enable practices to deliver on the concepts of a Patient Centered Medical Home. Reach My Doctor has robust registry functionality in addition to HIPAA-compliant electronic communication to facilitate coordination of care between providers, and an excellent patient portal that engages patients in the management of their chronic conditions. CCGC coaching helps practices to develop effective processes and the necessary infrastructure to be able to provide planned care efficiently and effectively to manage chronic conditions and preventive medicine.
For medical homes to be successful broad changes will be necessary at the system level as well. Structuring compensation and incentive programs to cover the costs of the staff and electronic systems necessary to deliver medical home levels of care are necessary if medical homes are to remain economically viable. Barbara Starfield, author of The Primary Solution, argues that primary care in general, and primary care offices that adopt the concepts embodied in the Joint Principles in particular, not only improve patient outcomes but also significantly reduce health care costs, and the savings need to be redistributed to the people doing the work – primary care providers. Aligning financial incentives to recognize the value of care coordination and proactive care management is an essential component of making medical homes a sustainable model.
Selected for a multi-payer medical home pilot project, Colorado will have the opportunity to offer a small number of Colorado primary care practices the opportunity to test whether practices that achieve NCQA Medical Home Recognition and receive enhanced compensation will improve outcomes and reduce costs. As of this writing, six health plans have agreed to provide enhanced reimbursement to the participating practices. These health plans include Aetna, Anthem-Wellpoint, Cigna, Humana, Rocky Mountain Health Plans and United Healthcare. The actual project design is still a work in progress. CCGC has been designated as the convening organization to implement the multi-payer pilot in Colorado.
For more information about in-office coaching or the Reach My Doctor software to implement the medical home please refer to www.coloradoguidelines.org or contact Allyson Gottsman at 720-297-1681.
Joint Principles of a Patient Centered Medical Home
Endorsed by American Academy of Family Medicine, American College of Physicians, American Academy of Pediatrics, American Osteopathic Association.
Personal physician
Physician directed medical team practice Whole person orientation Care is coordinated and/or integrated Quality and safety are hallmarks of the medical home including: care planning, evidence based medicine decision support tools, continuous quality improvement, patient engagement
Enhanced access to care: open access scheduling, e-consults
Payment for care management and care coordination as well as the staff and technology to support such management and coordination
Colorado Medical Home Pilot Project From Theory to Reality
By Jeffrey J. Cain, MD
DRUM ROLL, please…. The much talked about patient centered medical home is taking a giant step forward in Colorado, moving us from concept to reality. Intense planning has been under way for six months, selection and preparation of practices that will achieve medical home designation will begin this summer, and an actual pilot, including enhanced payment, is slated to begin in January. This is The Real Deal.
The genesis for the medical home stems to a large degree from physician leadership of the primary care societies, including strong engagement from AAFP, to take a proactive step toward addressing some of the major issues of our broken health care system. Instead of being victims, physician leaders have come forward with a solution based on the documented evidence that when patients are managed by primary care physicians, health outcomes are improved and costs are lower. That is the key premise behind the medical home concept – putting primary care back in as the quarterback of patient care to provide comprehensive, continuous, and coordinated care. The published work of Barbara Starfield, MD, MPH, shows this model improves quality and decreases costs. The evidence is strong enough that businesses and payers are willing to put significant financial resources on the table to find out if it can really work.
Two basic components make the medical home different from our current system: delivery system redesign and realignment of financial incentives. System redesign means moving care delivery from acute, episodic, and reactive care with responsibility solely on the provider, to planned proactive care delivered by a health care team, using data and performance measures to guide care decision and process redesign. Information support in the form of registry functionality, either as a part of an electronic medical record or a stand-alone registry, is essential. It is critical that patients have alternative access to the practices and that there be more efficient and reliable coordination of care among physicians providing care for patients. Realignment of financial incentives moves from acute episodic transaction based fees to include compensation for care management and extra incentives for demonstrating improved health outcomes.
Colorado has been selected to be one of several states to participate in a patient centered medical home pilot project. The Colorado pilot is being referred to as a “Multi-payer, Multi-state Pilot” to test the concept that a patient centered medical home (as defined by National Committee for Quality Assurance and supported by enhanced payment) does improve care and lower costs. At this point six payers (see inset) have agreed to provide support for the pilot in the form of enhanced payment for between ten and 15 practices that among them provide care to 30,000 patients covered by the six payers. Practices will be assisted in meeting NCQA Level 1 Medical Home designation. Enhanced payment will be in the form of combining a care management fee, RBRVS (resource-based relative value scale) fee for service, and a pay-for-performance arrangement for practices meeting or exceeding quality benchmarks.
To make the concept of a medical home sustainable over time and to spread it beyond the pilot, primary care needs to redesign the way we deliver care to be able to achieve the goals of improved health outcomes and reduced costs. In many cases this will require practice transformation to put the systems and processes in place to be able to efficiently and effectively manage a population of patients. We will need to be able to monitor our patients’ care according to evidence based guidelines and to be able to demonstrate with objective measures that the care that is being delivered is good quality care; i.e. at least 60 percent of my diabetics have good control of their Hemoglobin A1C ( less than 7)
Times are changing. The CAFP will be working with members to help them prepare to deliver on the expectations of the medical home and to be able to participate in the rewards. CCGC (www.coloradoguidelines.org) can offer grant funded in-office coaching and software support to help practices make some of the transformation that is necessary through its IPIP program. Now is the time to prepare, so Family Medicine will be ready.
Colorado Medical Home Pilot:
Follows the AAFP’s Joint Principles of the Patient Centered Medical Home
Utilizes the NCQA–Patient Centered Medical Home measurement tool
Denver Metro, with ability to spread along the Front Range
25,000-30,000 lives / 10-15 Physician Practices
Measurement of outcomes:
Cost
Quality
Provider
Patient satisfaction
Technical assistance to pilot practices to reach “Medical Homeness”
Enhanced payment in the form of
“Care Management Fee” (pmpm)
Standard RBRVS
Pay for Performance.
Participating Payers to date : Aetna, Anthem-Wellpoint, CIGNA, Humana, Rocky Mountain Health Plan, United Healthcare
