Tuesday Feb 17, 2015
Creating A Medical Home is About Improvement, Not Checking Boxes
My medical home has a first name, and it’s not NCQA.
Eight years ago this month, the AAFP joined with the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) to publish the Joint Principles of the Patient-Centered Medical Home (PCMH). The Joint Principles were grounded in the AAP’s work on children’s medical homes established in 1967 and supported by the AAFP’s 2004 Future of Family Medicine project -- which called for every individual to have a medical home -- and ACP’s work to develop an “advanced medical home,” which started in 2006.
Through a process that originated in 2006, these four organizations developed a set of seven principles that described the characteristics of a PCMH. Those seven principles call for each patient to have an ongoing relationship with a personal physician in a physician-directed medical practice and team. The physician and the team are responsible for providing all the patients’ health care needs, coordinating care across all elements of the health care system, expanding access, and providing patient-centric care. The final principle states that payment should appropriately recognize the added value of PCMH to patients, caregivers and physicians.
The four organizations mentioned above, along with IBM, also founded the Patient-Centered Primary Care Collaborative(www.pcpcc.org) (PCPCC), and the seven principles continue to serve as the North Star for that organization. The Joint Principles have been cited in numerous academic articles, the Congressional record and functioned as the substance of several state and federal laws and regulations. Furthermore, they are the guiding values of hundreds of PCMH programs run by insurance plans across the nation.
The PCMH, unlike other practice models -- such as managed care -- was created by physicians and not by others for physicians. The Joint Principles embodied an approach to the practice of medicine that many physicians had used throughout their careers. In many ways, the PCMH reflected how physicians wanted to provide care for their patients and not how someone else felt they should do so. It was organic and originated from the physicians who would ultimately practice in the model.
The enthusiasm surrounding the PCMH was palpable in the years following, and many family physicians saw the PCMH and the Joint Principles as the path forward to a better health care system focused on patients and supportive of physicians' sincere desires to “get off the hamster wheel.” The AAFP and our partner organizations were thrilled that the movement was based on a set of achievable characteristics that appealed to physicians in all practice settings.
In recent years, ownership of the medical home has moved from the physicians and physician organizations that created it towards the quasi-government agencies that recognize the practices. As a result, physician enthusiasm for the model has waned -- to put it mildly.
Third-party recognition is important if it is supported by a business case in your practice or local market, meaning there are payment incentives available. The Joint Principles contained a recommendation that “all practices should go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the characteristic of the PCMH as articulated in the Joint Principles.” However, we never thought that this service would be provided only by, let’s say, the National Committee for Quality Assurance (NCQA). We envisioned a recognition process whereby an insurance plan or collection of insurance plans, a quality improvement organization, or a Medicaid program that was offering enhanced payments for PCMH would verify practice capabilities.
The AAFP remains agnostic on PCMH recognition programs. If you think your local market or practice business plan would benefit from recognition, then discuss with your local payers and/or pursue collaboration with any of the organizations that provide PCMH recognition programs such as the Accreditation Association for Ambulatory Health Care(www.aaahc.org) (AAAHC), URAC(www.urac.org), the Joint Commission(www.jointcommission.org), or the National Committee for Quality Assurance(www.ncqa.org) (NCQA). The process of becoming a recognized medical home should be collaborative and focused on the characteristics of the Joint Principles. It should not be a collection of chart extractions, screen captures and checklists. It should be focused on practice and performance improvement. It should not be a product you purchase -- or repurchase every two or three years.
In short, don’t consider PCMH practice redesign and NCQA designation as synonymous. This line of thinking has taken a practice redesign and patient care model once celebrated by primary care physicians and turned PCMH into a dreaded phrase in primary care. I encourage every family physician to transform your practice based on the principles of the PCMH. And, you should consider third-party PCMH designation if that is beneficial to your practice, but please free yourself from thinking that NCQA recognition is the only organization that can recognize you as a PCMH because there are others.
The most important activity for family physicians is providing high quality care to your patients, and I believe that practice transformation consistent with the characteristics of the PCMH will help you in this endeavor by focusing your practice on process improvement, quality improvement, team-based and patient-centric care, and reform at a pace that benefits your patients and your practice. The AAFP has a variety of resources to assist you. Our approach is to meet you where you are and assist you in transforming at your own pace. The PCMH Planner is the perfect tool because it has a full complement of resources and allows you and your practice to move at a comfortable pace.
Posted at 08:00AM Feb 17, 2015