medical-home_5Transforming 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.

The five vital features of a PCMH are:

• Comprehensive care
The PCMH is designed to meet the majority of a patient’s physical and mental healthcare needs through a team-based approach to care.

• Patient-centered care
Delivering primary care that is oriented towards the whole person. This can be achieved by partnering with patients and families through an understanding of and respect for culture, unique needs, preferences, and values.

• Coordinated care
The PCMH coordinates patient care across all elements of the healthcare system, such as specialty care, hospitals, home healthcare, and community services, with an emphasis on efficient care transitions.

• Accessible services
The PCMH seeks to make primary care accessible through minimizing wait times, enhanced office hours, and after-hours access to providers through alternative methods such as telephone or email.

• Quality and safety
The PCMH model is committed to providing safe, high-quality care through clinical decision-support tools, evidence-based care, shared decision-making, performance measurement, and population health management. Sharing quality data and improvement activities also contribute to a systems-level commitment to quality.

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

• Health information technology
Health information technology (IT) can support the PCMH model by collecting, storing, and managing personal health information, as well as aggregate data that can be used to improve processes and outcomes. Health IT can also support communication, clinical decision making, and patient self-management.

• Workforce
A strong primary care workforce including physicians, physician assistants, nurses, medical assistants, nutritionists, social workers, and care managers is a critical element of the PCMH model. Amid a primary care workforce shortage, it is imperative to develop a workforce trained to provide care based on the elements of the PCMH.

• Finance
Current fee for service payment policies are inadequate to fully achieve PCMH goals. Providers are not routinely compensated for care coordination or enhanced access, contributions of the full team are often not reimbursed, and there is no incentive to reduce duplication of services across the care continuum. Payment reform is needed to achieve the potential.

PCMH transformation: Three key questions

1. Why become a certified Patient-Centered Medical Home (PCMH)?
Many healthcare experts 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.

2. 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. 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. If you’re really practicing patient-centered medical care, you’re running a continuous improvement, lifestyle-type visit, and that takes time.

3. Will you achieve a return on your investment?
In previous years, many practices worked to achieve PCMH recognition because many saw it as the “right way to practice.” Many organizations were already practicing medicine in this way, so once it was codified by NCQA, the practices wanted to get recognition to make it “official.”

Now 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.

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 PCMH, we realized if we went just one extra step we could bill for it.”

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.

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. Kentucky REC has been providing PCMH coaching and support to practices large and small at reasonable prices since 2013. The REC is a National Committee for Quality Assurance (NCQA) Partner in Quality (PIQ) with several NCQA-certified subject matter experts on staff. We have supported (or currently supporting) over 30 organizations throughout Kentucky. Contact us to learn more about how we can help you transform your practice! 

Source: Medical Economics: PCMH Playbook: 7 steps to plan today for a value-based payment future