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Friday Dec 13, 2013

The Path to PCMH: You May be Closer Than You Think

 Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the first post in an occasional series that will attempt to address the issues members raised -- such as how to get started with practice transformation and what resources are available -- during the panel.

My medical group recently received notification that all 11 of our sites had obtained National Committee for Quality Assurance (NCQA) Level 3 patient-centered medical home (PCMH) recognition. This represented the culmination of a two-year transformational process.

The results? Access to office visits for patients have improved, referrals to subspecialists are actively tracked and followed, and transitions of care between inpatient and ambulatory sites are becoming more seamless as we share essential clinical information. Proactively managing our entire population for chronic diseases through the use of a registry is moving the delivery of care away from simply episodic, office-based visits. Indeed, we have begun the journey to transforming our delivery of primary care.

As I reflect on the lessons learned from achieving certification, several things immediately come to mind. I, like many primary care physicians, was certain that I already was operating a PCMH. Only during the process did it become apparent that my practice was not truly patient centered. For example, before our transformation, there was no meaningful coordination of care, and tracking of tests and results was not robustly followed.

Another learned lesson involved obtaining NCQA recognition. Although the application process was personally enlightening in regards to care delivery, it was labor intensive and costly. The hours spent on this project -- not just by me, but by administrators, practice managers, office assistants, medical assistants and nurses -- were staggering. A question lingered throughout the entire process: Could I have possibly afforded the financial and time commitments to bring a solo or small-group practice to NCQA certification?

This is a question that echoes with many family physicians. Many small-group and solo physicians are operating their practices on the thinnest of margins. Concerns have been raised, such as how to survive an increase in overhead while achieving certification. Other concerns center on NCQA certification itself, because it is viewed as simply checking off the appropriate boxes and as not truly reflective of the real value of the "triple aim" of health system reform.

These are valid concerns our colleagues are voicing. Only one-fourth of AAFP members are practicing in a certified PCMH. The fee-for-service environment still is prevalent in all markets; however, new payment models that recognize those practicing in a PCMH are being introduced across the country.

A recent bipartisan, bicameral proposal to repeal the sustainable growth rate formula would replace it with alternative payment models aligned more closely with quality of care. Although this proposal is not yet a bill, it makes clear that future improvements in payment for primary care will involve a structured care delivery model such as the PCMH. Transformation may be critical to the viability of our practices.

Moving forward, the AAFP will continue to provide resources for members to help with the transformation process. For example, the PCMH Planner -- a step-by-step guide designed to help small practices transform -- will be available early next year. With new payment models emerging, now would be a good time for primary care physicians to educate themselves about PCMH  requirements. You might be closer than you think. Not all aspects of the PCMH require up-front money, and you probably already are doing many of them.

Practice transformation can be overwhelming, and physicians often wonder where to start. Begin by analyzing your practice. Then select one aspect of the transformation to implement in your practice and begin the process.

Evaluating your practice is a good first step, but evaluating your market also is important. Some payers are paying per-member, per-month fees (some better than others) and offering other incentives for patient-centered care. Do you know what's happening in your area? Have you asked payers what incentives they are offering for patient-centered care?

Some physicians struggle with how to meet the requirements of PCMH while still based in a fee-for-service world. Open-access scheduling is one aspect of the PCMH that can help boost revenue by keeping your schedule full and avoiding costly no-shows.

In addition, establishing components of team-based care in our practice made us more efficient and allowed us to increase visits. My personal visits have increased 10 percent compared to when we started the transformation process two years ago, and patient satisfaction quality scores remain high. I no longer do work that can be done safely and efficiently by other members of my team. 

Finally, remember that you aren't alone. TransforMED's Delta Exchange is a free resource for AAFP members. Join and learn from other family physicians in their journey to PCMH.

Every journey begins with taking that important first step. Are you ready?  

Michael Munger, M.D., is a member of the AAFP Board of Directors.

Posted at 01:27PM Dec 13, 2013 by Michael Munger, M.D.

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