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Tuesday Aug 12, 2014

Home Sweet Medical Home

Since the creation of the Patient-Centered Primary Care Collaborative(www.pcpcc.org) and the Joint Principles of the Patient-Centered Medical Home, in 2006 and 2007, respectively, we have seen a steady growth in the implementation of the PCMH in primary care practices. According to the 2013 AAFP Practice Profile Survey, 26 percent of family physicians report being in a recognized PCMH and 10 percent report that they have an application for PCMH recognition submitted and pending.

We also have seen an explosion of PCMH programs in health care systems, both public, and private. Today, most major insurance companies have implemented the PCMH at some level.  The PCMH was included in the Affordable Care Act, and as of June 2014, 47 states that have adopted policies and programs to advance medical homes in their Medicaid programs, and 30 states are making advanced payments to medical homes within their programs. The growth is something to be proud of, but we also recognize that many challenges must be overcome if we are to realize the full potential of the PCMH.

One complaint that we hear frequently is the difficulty and complexity of the recognition process. There are several organizations that have PCMH recognition programs -- NCQA, URAC, AAAHC, Joint Commission -- and there also are many state and insurance company-sponsored recognition programs. Although the AAFP is agnostic on these programs, we do recognize that NCQA is the dominant player in this market, and a majority of our members have chosen to participate in the NCQA PCMH recognition process. We continue to advocate among all of the recognition programs for standards that meaningfully represent the most important and effective principles of the PCMH and for application processes that are less cumbersome for family physicians.

The Academy recognizes that there is value in PCMH recognition, and such validation of practice capabilities is central to our advocacy efforts for increased payment for PCMH practices. Simply put, practices need to demonstrate transformation and the resulting improvements in processes and outcomes, not simply declare that they are doing so. However (and this is a big however) these recognition programs need to add value to patient care, be measurable, and most importantly be meaningful. This is where the AAFP is working hard on your behalf.

The AAFP met recently with representatives of NCQA to discuss its PCMH recognition program.  We expressed several concerns along three major themes:

  1. Cost -- The AAFP continues to be concerned that recognition programs are placing undue financial strain on practices. According to the 2013 AAFP Practice Profile Survey, 22 percent of family physicians found the expense of the PCMH recognition programs to be a substantial barrier. The costs are both the actual fee for the service, and the financial costs to the practice in the form of human resource allocations and lost revenue due to time spent away from patient care while completing the application. We also continue to express concerns that new forms of the recognition products are solely aimed at securing additional business and fees with little to no meaningful impact on the practice or patient care.
  2. Complexity -- The AAFP thinks that all recognition programs are overly complex. The Joint Principles included seven items, yet the NCQA process has more than 100 metrics -- this is a disconnect to put it kindly. According to the 2013 AAFP Practice Profile Survey, 54 percent of family physicians’ found the data and documentation requirements for PCMH recognition to be a substantial barrier, and 46 percent said the staffing demands to complete the application presented a substantial barrier. The AAFP continues to advocate for changes in the recognition process that place a greater focus on those key elements that have are demonstrable to improved patient care.
  3. Efficacy -- The early results on the efficacy of the PCMH are positive, but there are several studies that have raised some meaningful questions, particularly about the efficacy of the NCQA process. The PCPCC published a comprehensive analysis of PCMH programs nationwide. The Medical Home's Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013(www.pcpcc.org) clearly shows that the PCMH has been effective in reducing the overall costs of health care in some key areas and is improving the quality of care – especially for those patients with multiple chronic conditions. The AAFP continues to believe that the PCMH is impactful and will improve quality and lower the overall costs of health care as demonstrated in the PCPCC study, but there are areas that lend themselves to improvement in the PCMH transformation and recognition processes.

We will continue to work with the NCQA and others on refining and improving their recognition programs, especially in those areas outlined above. To their credit, the NCQA and others have been receptive to our concerns and open to our recommendations.

PCMH transformation is challenging and takes time (up to two or three years for some practices) and the benefits take even longer to realize. This is a work in progress and we applaud those practices that have taken on the hard work of transformation and continuous quality improvement. Today there are more than 500 PCMH initiatives or incentive programs nationally. This movement is growing and the foundation for both ACOs and future opportunities for value-based payment. The Academy wants family physicians to be positioned for success in the future health care environment.

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.