A guest column by the American College of Physicians, exclusive to KevinMD.com.
When the American College of Physicians (ACP) and the other primary care societies introduced the Patient-Centered Medical Home (PCMH) over 10 years ago, the model was untested. Here’s a look at how the PCMH recognition process has evolved and how my experience seeking recognition helped me in my role on the PCMH 2017 Advisory Committee that was established to guide the National Committee for Quality Assurance (NCQA) on the next update of the recognition program.
The Joint Principles of the Patient-Centered Medical Home adopted in 2007 served as an early blueprint, with one of the hallmarks of a PCMH being that “Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.”
This recognition process was important for a couple of reasons. In addition to guiding practices in the transformation process, recognition also served as assurance to health plans and others that were interested in testing the model that a practice was “ready and able” to provide this enhanced type of care.
NCQA was the first organization to develop a recognition program with the primary care specialty societies. Since then, other organizations have introduced additional recognition or accreditation programs for the PCMH.
Ten years ago, as a member of ACP’s Medical Service Committee, I had an opportunity to provide feedback on the recognition program’s proposed list of elements to ACP’s representatives who were working with NCQA. As we reviewed the draft, we tried to balance the need for practices to be able to demonstrate that they could deliver care consistent with the Joint Principles and the desire to avoid creating additional burdens for the physicians that we were trying to help.
My second encounter with NCQA PCMH was when my practice sought recognition in 2010. I’m convinced that going through the process made us a better practice. However, from my being on the “receiving end” of the program, I developed an appreciation for the amount of work involved in achieving recognition. I also started to question the relevance of some of the program’s elements, especially as my practice gained more experience with the PCMH model.
My group was fortunate enough to have staff members that could do most of the work involved in submitting data to NCQA. In contrast, smaller practices, such as my personal physician’s, were challenged by the sheer number of checklists, screenshots, and questions.
A little over a year ago, I was invited to chair the PCMH 2017 Advisory Committee. This revamping of PCMH recognition coincided with NCQA’s redesigning the way that it interacts with its “customers,” moving away from an every three-year process to a more continuous one, and tailoring the interaction to the needs and experience of the practice.
At our first Advisory Committee webinar, I commented that the existing recognition process, like many other activities that practicing physicians deal with, was analogous to holding track team tryouts and instead of qualifying runners based on their times, also requiring them to prove that they could walk and knew how to tie their shoes.
It’s the many “shoe tying” exercises that frustrate physicians and their staffs. For example, if a practice is successfully tracking chronic conditions, why does it need to document that it maintains problem lists in its records? Instead of requesting screenshots of schedules to document timely access, why not ask patients if they are satisfied with their access to appointments?
Our Advisory Committee included physicians from a variety of settings, including solo and rural practices, as well as non-physician clinicians, patients, and representatives of health plans and government agencies. In addition to the input of the Advisory Committee, NCQA solicited public comment on the proposed changes. ACP submitted suggestions for improvement during the comment period.
As a result of our efforts, the PCMH 2017 program that will be released in March has fewer elements than the current version and increases the ability to customize the process compared to previous versions. It also cuts down on paperwork and offers more options to submit information electronically.
Instead of the current program’s elements, some of them “must pass,” PCMH 2017 has “core” and “elective” criteria. Core criteria are those that all PCMHs should be able to meet. While successful completion of a minimum number of elective criteria is required for recognition, the choice of electives can be adapted to the abilities and resources of the practice. For example, while providing basic behavioral health services is included in the core criteria, more advanced activities such as onsite or virtual integration with behavioral health providers are electives, since not all practices and their communities have the resources for this.
The elective criteria can also serve as ideas for more experienced practices to develop further as PCMHs. Also, to further simplify the program, the three levels of recognition were eliminated. Even with the streamlining and enhanced “live” support, the PCMH recognition process won’t be easy, but the work involved should be more relevant and less burdensome.
As a proponent of the PCMH model, it was not only educational to participate on the Advisory Committee, but also empowering because it enabled me to tell NCQA what my colleagues and I liked about the program and what could be improved. We often decline such opportunities to weigh in because it involves time away from our families and practices, but by participating, we can reclaim some of the control that we have lost over our day-to-day lives as physicians.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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