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Over the past four years, New York State has made considerable progress in the expansion of the Patient Centered Medical Home (PCMH). Between 2011 and 2012, there was a 42% increase in recognized practices throughout the state. New York has more providers and practices with PCMH recognition by the National Committee for Quality Assurance (NCQA) than any other state in the nation, and there have been a number of PCMH pilots and initiatives designed to test and expand the PCMH Model.
To assess the current PCMH environment in New York and better understand the challenges to expanding and sustaining patient-centered models of care delivery and payment, the Primary Care Development Corporation (PCDC), a nonprofit that provides primary care transformation technical assistance services, conducted interviews with the leadership of eight New York State organizations leading PCMH initiatives:
• Adirondack Medical Home Demonstration (AMHD)
• Capital District Physicians Health Plan Medical Home Pilot (CDPHP)
• Crystal Run Healthcare
• Empire Blue Cross/Blue Shield (Empire)
• Excellus and MVP Rochester Medical Home Initiative (interviewed Excellus)
• New York State Department of Health PCMH Medicaid Incentive Program (NYSDOH)
• Patient Centered Information Project (PCIP)
• P2 Collaborative of Western New York.
Although the findings from these interviews were not intended to be a comprehensive or scientific analysis, the responses of those implementing PCMH efforts brought to light the following themes and issues that could help inform PCMH adoption and expansion in New York State and across the country. The full report includes profiles of each initiative.
Evidence of Improved Clinical Quality and Access are Emerging. All initiatives experienced improvements in clinical quality including increases in preventive screenings, better access to care, and control of chronic conditions. Improved clinical processes intended to ensure patients were receiving appropriate, evidence-based care at the right time were often cited as reasons for the improvement in clinical quality scores.
For example, Crystal Run Healthcare was able to bring the percentage of their patients with a hemoglobin A1C greater than 9 from 10 percent down to 8 percent by encouraging collaboration between the primary care providers, endocrinologists, and care managers. This team would review lists of these patients and identify actionable items to address with each patient regarding his or her diabetic condition. This also decreased charges for diabetic care by 9 percent.
In general, the improvements in clinical quality metrics experienced by the pilots interviewed were similar to those cited in recent analyses of other PCMH pilots. Improvements in patients’ access to care and adherence to treatment and costs savings from reductions in hospital use have been documented in some PCMH evaluations. However, many pilots are still in the process of measuring the long-term sustainability of these improvements.
Cost savings: Still Uncertain. In general, the initiatives interviewed made the investment either on their own with some additional PCMH monthly payments from payers; by payers contributing for their own members; or by payers covering PCMH practice costs even though the benefit extended beyond the payer’s own members.
The payer-led PCMH initiatives interviewed used a variety of payment methodologies, including additional per-member per-month (PMPM) incentive payments, risk-adjusted capitated rates, or enhanced FFS rates. Most of the initiatives saw their current payment methodology as evolving toward a more precise pay-for-performance methodology.
It often took some trial and error to determine the magnitude of additional funds or enhanced payment rates needed to cover the costs of PCMH transformation and of providing incentives to improve clinical quality. Many pilots cited a lack of confidence and clarity in the data available to them as a main reason for the time and effort it took them to develop an adequate payment methodology.
Widespread adoption of PCMH will depend largely on the ability to show cost savings or at least cost neutrality. While initial results were encouraging, there was still uncertainty among most of the initiatives that measured cost savings about whether or not the savings were associated with PCMH, particularly over the long term. Some initiatives said more time was needed to demonstrate clear evidence of cost savings.
Data Challenges Complicate Progress. Despite the large amount of data the healthcare system generates, interviewees all expressed concern with availability, accuracy, validity, and completeness of data. Major challenges and barriers included pulling and ensuring accurate data from multiple sources; getting timely access to patient data from other stakeholders such as hospitals and health plans; attributing activities and outcomes to providers and practices appropriately; and connecting various data points to get an accurate picture of access, quality of care, patient outcomes, and costs.
Data barriers can stall transformation and quality improvement efforts. For example, the lag time in receiving claims data makes it difficult for physicians to understand the connection between what they did months ago and the associated cost and quality outcomes they are currently experiencing.
As mentioned earlier, these barriers can make it difficult to move towards pay-for-performance models in the PCMH setting. Excellus found significant variations in physician documentation within the same EMR system that led to dramatic differences in reporting. Without uniformity, Excellus may reward some doctors and “punish” others because of data idiosyncrasies rather than actual quality variances.
In the short term, having actionable data to demonstrate quantitative and qualitative impact on costs and patient health is critical to the sustained engagement of providers and payers in the PCMH enterprise. In the long term, it is essential to building a reliable performance-based payment system and risk-sharing Accountable Care Organization (ACO) models.
NCQA Recognition: One Element of Transformation. NCQA PCMH recognition was generally seen by interviewees as providing an important framework for becoming a PCMH. Official recognition was generally not viewed as the end goal but rather an important element of the transformation process.
In comparison to the 2008 standards, the 2011 standards were viewed as much more rigorous, and as a result, the problem of practices becoming recognized without transforming has lessened. This is important, since most enhanced payments are still based primarily on PCMH recognition level.
Recognition-based incentive payments have been seen as an imperfect but necessary method to incentivize quality outcomes until more precise data-driven performance-based methodologies are developed. This was the case for the NYSDOH project, which started by providing incentives to eligible providers who reached any level of PCMH, but is now stopping incentives for PCMH Level 1. NYSDOH will likely take other steps to incentivize more rigorous recognition and may require data reporting and meeting performance standards.
Leadership and Collaboration are Critical. Engagement and enthusiasm from practice-level leadership was seen as essential to success. The P2 Collaborative of Western New York found that “pockets of resistance” could slow down PCMH transformation. They had several cases where the physician leading the practice was the biggest barrier to change, even if the staff was eager to move forward. This can be a challenge for technical assistance providers as well. Faced with similar resistance, PCIP had to stratify the practices it served, engaging those who were most committed to succeed, while postponing others who were not yet willing or able to commit the necessary resources.
For those operating PCMH initiatives across practices (and/or payers), collaboration was key. There had to be recognition that while the stakeholders may be competitors on some level, PCMH was in their collective best interest of all involved. For example, to preempt resistance from its stakeholders, particularly payers, AMHD created a governance structure that made all decisions by consensus. Collaboration was also viewed as a primary factor for AMHD, CDPHP, Excellus and P2 being selected to participate in large multi-stakeholder initiatives.
PCMH Training Needed at All Levels. Practically all of the initiatives cited the need for more personnel at all levels to be trained and attuned to the tenets of PCMH -- from the front desk staff to care managers to the clinicians. Training, recruiting, and retaining individuals with critical thinking, collaboration, and team skills were seen as necessary for sustaining the PCMH model. The need for more care management training was specifically identified by several initiatives as they went about expanding their PCMH efforts.
For example, Crystal Run expressed difficulty recruiting nurses with a care management background and suggested a care manager training role for clinical institutions.
Building on the PCMH Foundation. Regardless of the challenges, the process of transforming, collaborating, and risk-taking prepared all of the initiatives for the next stage in a fast-evolving healthcare environment. Whether going from demonstration to widespread adoption, or participating in a broader multi-stakeholder effort, each initiative made enough progress to take the next step on the healthcare transformation journey. These eight initiatives are pushing ahead with a more advanced model of care delivery. Their successes and struggles will be important to understand as the healthcare market shifts to emphasize quality of care over quantity, and as the country moves forward with initiatives that put our healthcare system on a more sustainable path.