Medical home recognition revised to address physician feedback

Many doctors in accredited medical homes complain about the difficulty in obtaining recognition from the National Committee on Quality Assurance (NCQA), the largest accreditation body for medical homes.

They raise several issues, including the challenge of understanding what NCQA wants, the relevance of some requirements and the voluminous documentation required. Other organizations, including the Joint Commission, URAC and the Accreditation Association for Ambulatory Health Care, also accredit medical homes, but NCQA recognizes the vast majority of them.

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NCQA says it has heard these complaints and taken steps to address them. Aided by a physician advisory committee, NCQA redesigned both its process and its criteria in the 2017 medical home recognition program it announced in early April. While doctors are just starting to read the fine print, some of them say they are encouraged by what they’ve seen so far.

Here’s what primary care physicians need to know about the new NCQA approach and how it differs from the previous one.

Challenges of the former process  

The NCQA has been recognizing medical homes since 2008. Under its 2014 criteria, which were in effect until April 3, a practice could aspire to one of three levels of recognition, depending on how many points it received. There were six “standards,” including access, team-based care, population health management, care planning, care coordination and performance measurement. Practices had a choice of 27 elements across these six domains, but they had to meet the criteria for a particular element in each domain. Under “enhance access,” for example, “patient-centered appointment access” was a must-pass element.

In applying for NCQA recognition, a practice had to provide written documentation showing that its staff and providers were conducting the requisite activities. All of that documentation had to be gathered and presented to NCQA at one time. If the application was incomplete or the evidence was unsatisfactory, the site was not recognized as a medical home. If the practice was recognized, it had to repeat this process every three years to renew its accreditation.

Internist Yul Ejnes, MD, of Cranston, Rhode Island, the chairman of NCQA’s physician advisory committee, says that some of the NCQA’s earlier documentation requirements didn’t show anything about the quality of care in his practice. For example, he says, his staff had to record what percentage of his patients used the practice’s patient portal and what percentage of scripts he was sending electronically.

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“If your patients are happy that they can reach you, by whatever means is convenient for them, what does it matter what percentage of patients are using the portal?” he says. “Those are the kinds of things that seemed like busy work that had no impact on how well we did as a medical home.”

While Ejnes is in a large group that can handle the application paperwork, he notes it is much more difficult for a small practice. His own primary care doctor, he says, had to hire a part-time person to help his staff complete the NCQA application.

So did Carolina Internal Medicine, a nine-doctor practice in Asheville, North Carolina, says Kenneth Kubitschek, MD, a partner in the group.

Susan Kressly, MD, who has a primary care practice in Warrington, Pennsylvania, says her group didn’t hire anybody from outside. But she had to work nights and weekends to fill out and provide documentation for the NCQA application. Altogether, this work took her and her staff about 100 hours each time they applied for or renewed their recognition, she estimates.

New Process

NCQA’s 2017 recognition program includes updated standards and a substantially revised process for recognition, says Michael Barr, MD, executive vice president of the organization’s quality measurement and research group.

Next: Major changes

One major change is that the three former levels of medical home recognition have been replaced by a single level similar to the previous level 3. Barr says this was done because it’s hard to differentiate practices at various levels. (Three-quarters of recognized practices are at the highest level, level 3.)

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The number of criteria for recognition has been reduced to 100 from 167, including 40 core criteria and 60 elective criteria, which are grouped into six domains. Applicants must meet all core requirements, which are roughly similar in number to the requirements within the six “must-pass” elements of the 2014 program. Practices must select enough electives to get 25 points. Electives must be chosen from five of the six domains.

Ejnes says the new approach is more flexible than the former one and that it focuses on the elements that are really important in medical homes. “There are core elements that any medical home should be able to do,” he says. “But then there are areas that some practices can do but other practices can’t.”

Interaction with practices

In the new NCQA scheme, applicants are assigned a staff representative who can help them schedule reviewer appointments, known as “check-ins,” and navigate NCQA’s new online platform.

Over the course of 12 to 15 months, a practice will have up to three check-ins, during which the reviewer will evaluate how the practice is performing on the core and elective elements. If the reviewer feels the practice needs to do something more or differently on some criteria, the office can resubmit its documentation on those requirements later.

Written documentation or screen shots are no longer required in some areas. Instead, the practice staff can use a screen-sharing session with the reviewer to explain what they’re doing. Although this option isn’t available for all criteria, it “will significantly reduce the amount of documentation required for this process,” Barr says. Moreover, he points out, fewer requirements mean less documentation. NCQA will also make it easier for multiple sites within a physician group to share their documents in the application process.

Once the practice has been recognized as a medical home, it will never have to renew its application from start to finish, Barr says. Instead of re-applying every three years, it only has to check-in online once a year. This annual reporting, he says, is a very slimmed down version of the original process. The practice just has to pass a test showing it’s still meeting the core requirements and provide some data on the elective functions.

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NCQA will also add a new “distinction” to medical homes that submit quality data electronically in lieu of some other criteria. The organization has compiled a list of 35 electronic clinical quality measures (eCQMs) that meet the specifications of the Centers for Medicare & Medicaid Services (CMS). Practices that are already reporting on these measures for CMS quality programs can re-use those eCQMs and get credit for reporting them.

After NCQA certifies some EHR vendors, it will begin to add credit for quality performance, Barr says. But electronic quality reporting will be voluntary, at least for now, he adds.

Next: Is the effort worthwhile?

Physician reaction

Suzanne Berman, MD, a partner in a small primary care practice in Crossville, Tennessee, and a member of the NCQA physician advisory committee, mostly likes the changes in the NCQA recognition program. For instance, she appreciates the ability to submit an application “in pieces so you can see how you’re doing as you go along. It’s a more interactive process. That part will be a lot better.”

But having dealt with earlier NCQA criteria that were not focused on pediatric practice, she still wonders whether she’ll get a reviewer versed in her specialty.

Amy Mullins, another primary care physician on the advisory committee, says she is hopeful that the new renewal process will be less burdensome for physicians than the old one. She also thinks the availability of NCQA reviewers to answer practices’ questions-as well as screen sharing-will be an improvement.

Kubitschek likes details of the new program, especially screen sharing and immediate feedback from reviewers.

“They can say yes or no before you put a lot of effort into something and find out it was the wrong effort,” he notes. “That would be very helpful.”

Is the effort worthwhile?

The patient-centered medical home was originally designed as a way to revitalize primary care. Internist Yul Ejnes, MD, of Cranston, Rhode Island, feels his practice has achieved that goal in becoming a medical home. Michael Barr, MD, executive vice president of NCQA’s quality measurement and research group, believes that many practices have sought recognition because they “find it rewarding and helpful to improve patient care.”

Many physicians have also obtained NCQA recognition in order to get financial incentives from payers. However, not all plans provide such incentives. Primary care physician Suzanne Berman, MD, whose practice has had NCQA recognition as a patient-centered medical home since 2010, said her group didn’t receive its first health plan bonus for being a medical home until last year.

In the Philadelphia area, says primary care physician Susan Kressly, MD, one large payer recently stopped incentivizing medical home bonuses after a majority of the primary care practices in the area obtained recognition of their medical homes.  

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The insurer still pays efficiency and quality bonuses to all primary care practices, she adds.

Some practices, however, have done very well with incentives for their medical homes. Internist Kenneth Kubitschek, MD, says that Blue Cross and Blue Shield of North Carolina is paying him and his colleagues a 25% bonus on all of their E&M charges due to the certification.

There are other sources of revenue for recognized medical homes. CMS automatically gives full credit to these practices in the improvement section of the Merit-based Incentive Payment System (MIPS), helping them qualify for an upward adjustment in Medicare payments. CMS and some commercial payers will pay care management fees and performance-based bonuses to up to 5,500 medical home practices participating in CMS’ Comprehensive Primary Care Plus (CPC+) demonstration project. These practices will not be subject to MIPS because they qualify to be paid differently as an Advanced Alternative Payment Model (APM.)

Some accountable care organizations (ACOs) also qualify as APMs. These ACOs welcome medical homes because of their expertise in population health management. So whichever track of the new Medicare payment program a physician is in, notes Barr, NCQA medical home recognition can financially benefit him or her.