Defining the Patient-Centered Medical Home

About a decade ago, family physician Ramona Seidel left her position as family medicine director at a large multi-specialty practice to explore a different style of practicing. "I wanted to be able to spend more time with my patients, and I wanted to have increased transparency,” she says, noting that she also wanted to help her patients “get through the maze of care coordination” and help them understand her role as “more than just an urgent-care kind of provider."

To focus on those goals, Seidel opened up a solo practice in Arnold, Md., in 2003. Though the model of care she embraced didn't yet have a widely recognized name, today it's known as the Patient-Centered Medical Home (PCMH) - and it's picking up traction across the country.

In fact, the medical-home model is quickly becoming the "new normal" at pediatric and primary-care practices, says Susanne Madden, president and CEO of The Verden Group consulting firm.

"This is the way care is evolving," says Madden. "To really not tackle the Patient-Centered Medical Home, I think, is to sort of leave yourself on the sidelines while the rest of the industry moves by."

But getting in the game is not easy, says medical practice consultant Ewa Matuszewski, cofounder and CEO of Medical Network One, a Rochester, Mich.-based physicians' services organization. "One of our favorite comments is that to transform into a PCMH is like eating an elephant," says Matuszewski. "You bite into it one bite at a time." Here's a closer look at the requirements for transitioning to a medical home, and some tips for determining whether it's the right move for your practice.

Finding solid ground

The most widely recognized medical-home program is set forth by the National Committee for Quality Assurance (NCQA), a nonprofit organization dedicated to improving healthcare quality. To achieve NCQA recognition (as Seidel has done) practices must demonstrate the ability to provide six elements of care. These elements include improving care access, coordination, and quality. For more information on the six elements, see sidebar: "PCMH Recognition Criteria."

While it's not easy to become a medical home - Madden estimates it can take anywhere from four to 12 months for a typical fee-for-service practice to transition to the style of practicing laid out by the NCQA - it's worth serious consideration. "Frankly, I think what will happen is the payers will start paring payments based on who has Patient-Centered Medical Home recognition status and who does not, and what that means is that if you haven't achieved that recognition, you're likely to be on the chopping block for rate cuts pretty soon," says Madden, who is also cofounder of Patient Centered Solutions, which helps practices achieve NCQA recognition. "It's not just about taking advantage of incentives, but making sure that you are really solidifying your position in the marketplace going forward," she says.

Prerequisites

The good news is that any primary-care practice has the ability to successfully transition to the medical home, though practice size is linked to different transition challenges and opportunities, says family physician Terry McGeeney, president and CEO of TransforMED, a nonprofit subsidiary of the American Academy of Family Physicians that specializes in helping practices transition to medical homes. Smaller practices may find it easier to get staff on board, for instance, while larger practices may have better access to helpful resources, such as EHRs. Regardless of practice size, strong leadership, effective communication, and a team mentality are all a necessity to successfully transition, says McGeeney.

Cost concerns

Another prerequisite is funding. Practices pay an initial fee to obtain a PCMH survey tool license and a fee to apply for NCQA review and recognition. In total, such costs range from about $500 to $4,000 depending on a practice's size and number of locations. "The rest of the investment pieces really come in the form of time and energy that is spent on actually transitioning ...," says Madden. That time and energy includes:

• Staff time. A successful transition requires a lot of planning and monitoring of progress, says Madden. "If you're putting it on the shoulders of one or two [staff members], you want to make sure you're giving them five to eight hours a week to really get through all of this," she says.

• Staff additions. Medical homes provide patients with more access to care than typical fee-for-service practices, such as extended evening or weekend hours. To expand access, practices may need to hire additional staff such as physician assistants and nurse practitioners, says McGeeney.

• Tech tools. An EHR is a necessity if a practice wants to become a "mature" medical home, says McGeeney. "You can implement a lot of the attributes of a PCMH without an EHR," he says. "For example, you could function as a team, you could expand your access, you could do some disease [management] best practice, but if you really want to get into some of the sophisticated attributes of medical home, like proactive population management ... you can't do that without the technology."

Payback

Despite the upfront costs, many practices experience long-term revenue benefits from becoming a medical home, says McGeeney. One reason is that all staff members work "to their highest level of license," meaning doctors focus only on what requires a physician's license, nurses focus only on what requires a nurse's license, etc. "... You have to redefine everyone's roles in a practice to make it as efficient as can be," says McGeeney.

Improved efficiency, of course, leads to higher revenue, and in some cases, downsized staff. As noted, however, some practices may actually need to add staff to expand access. But keep in mind that while these staff members cost money to employ initially, they are "revenue generating" in the long run, says McGeeney.

Another revenue boost is no-show reductions. That's because in medical homes, 60 percent to 70 percent of the daily schedule is open to same-day and next-day appointments, says McGeeney. Since patients are accommodated more quickly when making appointments, they are more likely to show up. "We have some data that show with no new money from the outside, practices at the end of one year of medical home [participation] saw their revenue increase by $40,000 per doctor," says McGeeney. That's "because your no-shows are going down, your doctors are able to see more complex patients, and you're adding nurse practitioners to the practice, which generate revenue."

Reimbursement rewards

Another revenue perk? Some payers are providing special incentives to NCQA-recognized practices. Though the amount and type of incentives vary, "Typically we are seeing things called care-coordination payments," says Madden, noting that these often come in the form of per member per month payments, in addition to traditional fee-for-service payments. Some payers are more actively embracing reimbursement changes, adds Matuszewski. For instance, they might provide a 10 percent to 20 percent uplift in E&M codes, or create new procedure codes for medical-home related activities, she says.

Seidel, the Maryland-based solo physician, is still primarily reimbursed fee-for-service, though she does receive a per member per month stipend for participating in a Maryland medical home demonstration project. Though reimbursement has not fully caught up to the medical home model, Seidel says for her - and her patients - it's worth it. "I think it does impact patient care in a positive way, I believe that in my heart - that's why I do it," she says. "I don't do it because it's easy. I don't do it because it's cheap."

PCMH recognition criteria

Practices can achieve one of three levels of Patient-Centered Medical Home recognition based on 2011 criteria set forth by The National Committee for Quality Assurance (NCQA). The level of recognition is based on the practice's ability to fulfill objectives in each of the following categories:

1. Enhance access and continuity. Medical homes must accommodate patients' needs for access and advice during and after hours, and provide patients with team-based care.

2. Identify and manage patient populations. Medical homes must collect and use data for population management.

3. Plan and manage care. Medical homes must follow evidence-based guidelines for preventive, acute, and chronic-care management.

4. Provide self-care support and community resources. Medical homes must assist patients in self-care management with information, tools, and resources.

5. Track and coordinate care. Medical homes must track and coordinate tests, referrals, and transitions of care.

6. Measure and improve performance. Medical homes must use performance and patient experience data for continuous quality improvement.

For more information on NCQA PCMH-Recognition, visit ncqa.org/pcmh.

Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the February 2013 issue of Physicians Practice.