PCMH playbook

Transforming into a PCMH may become a financial safe harbor for many small practices as the government and private payers continue to emphasis value over volume. Starting in 2019, practices that certify as a PCMH will be able to reap the benefits of Medicare’s new alternative payment model program by receiving a 5% pay bonus while avoiding the down-side risk usually associated with value-based payment models such as accountable care organizations.

“If you are not in a patient-centered medical home (PCMH) now, you should be thinking about one,” Bob Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians, said at the organization’s annual conference in May. “If you’re a PCMH, you don’t have to deal with financial risk.”

Regardless of how PCMH certification affects the bottom line, practices that undertake the process have their work cut out. Small practices in particular often struggle to navigate the complex and time-consuming process with limited resources.

Related:Becoming a PCMH

It’s of little surprise then, that substantially fewer physicians in solo practices (6.7%) and small practices (18.9%) reported PCMH certification relative to those in large practices (35.1%) in 2013, according to a Robert Graham Center report. One-third of physicians in solo or smaller practices reported that their practices were considering applying for PCMH certification.

But even if you don’t have a hospital or large-group infrastructure to help you manage the process, you needn’t go through the journey alone.

Seek resources

One of the ways Salvatore S. Volpe’s, MD, New York-based solo primary care practice beat the odds and successfully became a level-3 PCMH was by sending his office manager to a one-day event run by his local regional extension center (REC).

“They went through all of the elements from NCQA and showed how to provide the evidence to prove the element,” says Volpe, who is a member of the Medical Economics editorial advisory board. “If you’re going to invest the money in a survey tool, software, and a practice transformation, it makes sense to go that one extra step and invest a day or two in hearing from experts what’s the best way to prove it.”

RECs were a key partner for Ed McBride, MD, vice president of clinical services for Summit Medical Group’s locations in eastern Tennessee. Summit recently applied for its corporate NCQA recertification under the 2014 criteria, with five sites up for renewal.

“The RECs across the nation are partnering with the Department of Health and Human Services to be the go-to person for their region for things such as meaningful use and PCMH,” McBride says. “If I were not at Summit with access to its resources, I would outreach to my community partners and state-level support.”

NEXT: Do your homework

Do your homework

Auburn, Massachusetts-based Grove Medical Associates, P.C. received its NCQA recognition via the NCQA as a level-3 PCMH, the highest certification, in 2013.

Gail Cetto, RN, the practice’s office manager, and Sharon Magner, data manager for the four-physician practice, scoured NCQA materials themselves, and admit to making some mistakes. Instead of reading through the entire manual before planning a strategy, they got to work tackling the easiest tasks first-and almost ran out of time for the most challenging pieces.

“Being an independent practice, we didn’t have a written procedure or policy for 90%, I would guess, of the stuff they were looking for,” Magner says. “Gail and I wrote the easy ones first but held off on figuring out how to implement them into practice. And at the very end we were both in the office working on this every morning and still pushing the deadline.”

Related:ACO or PCMH: Making a crucial decision for your practice

McBride serves on the NCQA’s review oversight committee, a group of physicians who analyze evaluation team’s findings and assign certification levels based on adherence to the group’s standards. He emphasizes the importance of doing one’s homework both before and throughout the process.

“The ones who fail to pass or don’t perform as well as their peers but achieve say a level-I recognition-it’s often because they never read what they were being asked to provide’” McBride notes. Sometimes it’s a policy and then a report showing how that policy was enacted and its impact … that they don’t have when it’s time to submit,” he says.

Buddy up

While some large organizations are able to dedicate personnel or hire a consultant to walk them through the PCMH transformation process, small practices often are left overburdening their existing managers and support staff with application legwork.

One alternative is to become involved with an ACO or integrated practice association that will allow a small practice to tap into a larger pool of resources, suggests Edward Bujold, MD, FAAFP, who leads North Carolina’s first practice to become a level-3 certified PCMH.

He also recommends that small practices partner with local colleges with health information or health IT programs. “Nobody pays you to do any of this [certification] stuff, and somebody’s asking you to put in 200 or more hours to go through the process and you don’t have the manpower or the money to support that,” he says. “If you can bring in people from your educational community, they may be more than willing to partner to you because their students need job experience.”

Practices that are seeking PCMH designation are particularly desirable for internships, he adds, because they’re on the cutting edge of HIT. Students come away from the experience not only with a good resume builder, but potential employment with the practice after graduation.

NEXT: Build a relationship wtih your accreditor

Leverage technology

Many practices find it ironic that PCMH principles push for more integrated technology in practice while becoming certified is a relatively manual process. Fortunately, many EHR systems offer a shortcut by way of a PCMH module.

Using a module, which essentially tells you where to plug in data so you can generate needed reports, may or may not have a cost attached. It’s a business decision as to the value of investing in the module, says Volpe, adding that putting data into unstructured fields can make it difficult to generate a report. “If you’ve taken a training class and your standard EHR still can’t provide the evidence the way NCQA needs to see it, bite the bullet and get the module if it’s affordable,” he advises.

Even at a fee of $25 per physician per month to use the reporting tool offered through their EHR, Cetto and Magner say that the module was a better solution for them than using a paper workbook and manually pulling charts.

Build a relationship with your accreditor

Just as there are people doing the bulk of the work on the practice side, your application will be processed at the accrediting body by human beings.

The NCQA, where McBride serves as a volunteer, is growing rapidly. “They exceeded 10,000 recognized PCMHs this year, and there’s an expectation that could double in the coming years,” he says. “As a result there’s been an influx of new faces to the NCQA, and growing educational opportunities, both live and virtual, are available for potential applicants and existing partners.”

Related:PCMH accredition: Is it worth it?

If you attend an educational event, use the opportunity to introduce yourself to the person reviewing your submission, who will often be present, McBride says. He adds that the association has adopted changes recently that are intended to make certification or recertification more applicant-friendly.

Specifically, applicants now have access to more feedback and coaching than they did in the past, he says. Even within the past year, practices’ experiences have improved. Now applicants have the opportunity to form more of a relationship with the reviewer and work closely with him or her throughout the process, according to McBride.

So be sure to respond to these people when they ask for clarification, he says. “They’re asking because they want you to get all the credit for the work you’re doing. It’s not their intent to fail; it’s their intent to partner with folks to help them transform their practice.”

NEXT: Focus on making a difference

Be persistent

Once you can put a face or name to your reviewer, if you do fall short of full recognition, don’t just hang your head. Instead, go to the source to find out why.

“When someone is close on a measure but not quite meeting it, there’s often a request for clarification or additional information, rather than in the past you would have just failed on that measure and found out about it when you received your notice of what you earned,” McBride says.

That’s what happened when Bujold submitted his application to recertify his practice as a level-3 PCMH. After months of preparation and then waiting for a response, he received a devastating email.

“It said we’re sorry to inform you that you haven’t certified at any level,” he recalls. While the email explained the steps Bujold could take to fix the problems and resubmit his application, he was livid that he’d received no communication about the problem up to that point.

Related:Becoming a PCMH: How one physician transformed his practice

As it turned out, a glitch prevented about half of the practice’s materials from being uploaded into the system, but Bujold had no idea that the NCQA hadn’t received all of his data. The NCQA ultimately did work with Bujold’s practice to resubmit the complete materials, which indeed earned the practice a level-3 recertification. “Initially, the way it was handled I almost blew a gasket,” he recalls.

“One of my suggestions to other practices is to not take no for an answer,” Bujold says. “If you get your application turned down, make a call and ask what you can do to fix it and whether they can help.”

Focus on making a difference

Even though all of the practices we spoke with described an arduous path to PCMH certification and recertification, and many had second thoughts about going through the trouble to recertify, they share a sense of pride in their achievement.

Bujold’s practice, for example, decreased hospital admissions by 80% over the past five years, as a result of forming a strong care team and improving its transitions of care, among other PCMH-related improvements.

It’s not just patients who benefit from a PCMH’s commitment to continuous improvement, McBride says. “Team satisfaction and morale goes up if the team takes on the attitude not that this is something we have to do, but this is something we get to do as far as transforming our practice and better meeting the needs of our patients.”

Volpe agrees: “When you are running a PCMH, staff satisfaction goes up a lot because they are making a bigger difference in the lives of these patients, and hopefully that means physician satisfaction goes up, too. And of course the appreciation you get from patients and their family is priceless.”

PCMH designation garners a deep respect within the healthcare industry. “When I hear that a practice is patient-centered, I think of that practice differently. You really have to have your act together,” Cetto says. “There’s a different way you look at people.”

“It’s the way we all want to be treated,” Volpe says. “We all want to have a physician who is thinking about us not just when we’re in the exam room.” Acute-care visits are like the fraction of an iceberg that can be seen above the water, he explains. The bulk of the care-chronic care management, patient-centeredness, continuous quality improvement-is the unseen yet critical foundation of the PCMH.

NEXT: Three key questions about PCMH transformation

PCMH transformation: Three key questions

Q1: Why certify?

All the experts we spoke with agree that patient-centeredness and a commitment to continuous improvement are worthy goals for all practices.

“Given the state of the marketplace today and the rise of value-based care initiatives and accountable care-whether talking about accountable care organizations or contracts that simply hold us accountable for cost, quality, and patient experience of that care-the principles espoused and promoted by the National Committee for Quality Assurance (NCQA) in the PCMH are critical for the success of any organization that wishes to compete in this emerging marketplace, says Ed McBride, MD, vice President of clinical services for Summit Medical Group. The organization was in the process of applying for its NCQA recertification under the 2014 criteria, with five sites up for renewal.

The NCQA is not the only organization that offers PCMH recognition. Several national programs, including the Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission, and the Utilization Review Accreditation Commission (URAC) also offer a PCMH designation, as do some states and private insurers. Each program has specific requirements and benefits, giving practices the opportunity to find one that best suits their needs.

Obtaining formal PCMH recognition is not required, notes McBride. “If you have those principles and processes in place, you can succeed. To an extent, [certification] is a decision based upon your current relationships with payers, your contracts, and how you intend to pursue value-based care.”

A significant reason practices may choose to forego accreditation is a lack of direct financial incentives to offset the time and resources that go into not transforming a practice and proving it to the certifying body.

Q2: What is the cost?

“To do this costs money-in labor associated with staff, the cost of technology such as an electronic health record (EHR) and patient portal, and the opportunity cost,” says Volpe.

Many practices find they need additional support not just for the work of compiling application materials for PCMH recognition but also to implement new work flows that result from practice transformation. According to the most recent data available from the Medical Group Management Association (MGMA), that translates to a median of 4.81 support staff per full-time equivalent (FTE) physician, versus 4.51 per FTE physician for non-PCMH practices.

As for technology, primary care practices that are PCMHs can expect to spend $11,742 per FTE physician, compared to $12,251 per FTE physician in non-PCMH practices, according to the MGMA DataDive Cost and Revenue: 2014 Report Based on 2013 Data.

Practices should also consider the expense of potentially spending more time with patients, says Volpe. “If you’re really practicing patient-centered medical care, you’re running a continuous improvement, lifestyle-type visit, and that takes time.”

Q3: Will you achieve a return on your investment?

In 2008, when Volpe’s practice first attained PCMH certification from the NCQA, his payers did not offer additional reimbursement. The practice moved forward anyway, because leadership felt it was the “right way to practice,” he says. “We were doing those things anyway. So once it became codified by the NCQA, we figured we may as well get recognition so it becomes official.”

Even in 2015, direct payer incentives for becoming a PCMH range from none to as much as a 30% increase in reimbursement across the board, and the landscape is constantly shifting. Often, however, only practices that achieve level 3 NCQA certification are eligible for payer incentives- if incentives are even offered.

Three years ago, when it achieved its level 3 PCMH status, Grove Medical Associates, P.C., in Auburn, Massachusetts, for example, received just $400 in incentive for becoming a level 3 PCMH in 2013, but realized nearly $53,000 in extra revenue that year by improving and correctly billing for transitional care management, according to office manager Gail Cetto, RN. In 2014, when prompt calls to patients following hospitalizations or visits to the emergency department were part of the practice’s work flow for the entire year, that figure rose to about $135,000.

“We had never actually billed for this work before,” adds Sharon Magner, the group’s data manager. “But because we were so good at it from doing the PCMH, we realized if we went just one extra step we could bill for it.”

NEXT: The six baseline must-pass items

Making the grade

The National Committee for Quality Assurance uses a 100-point scoring system that consists of 27 individual elements of care, including six baseline must-pass items. Practices must achieve a passing grade on all 27 elements to become recognized as a level 3 patient centered medical home.

Elements are grouped into six broad categories:

Patient-centered access

• Patient-centered appointment access (must pass)

• 24/7 access to clinical advice

• Electronic access

Team-based care

• Continuity

• Medical home responsibilities

• Culturally and linguistically appropriate services

• The practice team (must pass)

Population health management

• Patient information

• Clinical data

• Comprehensive health assessment

• Use data for population management (must pass)

• Implement evidence-based decision support

Care management and support

• Identify patients for care management

• Care planning and self-care support (must pass)

• Medication management

• Use electronic prescribing

• Support self-care and shared decision making

Care coordination and care transitions

• Test tracking and follow-up

• Referral tracking and follow-up (must pass)

• Coordinate care transitions

Performance measurement and quality improvement

• Measure clinical quality performance

• Measure resource use and care coordination

• Measure patient/family experience

• Implement continuous quality improvement (must pass)

• Demonstrate continuous quality improvement

• Report performance

• Use certified EHR technology

Source: NCQA

NEXT: Five vital features of PCMH

The five vital features of a patient-centered medical home (PCMH) are:

Achieving the goals of the PCMH model requires aligning three vital components:

Source: Agency for Healthcare Research and Quality