Patient-Centered Medical Homes—Are You Eligible?

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You may be familiar with the Patient-Centered Medical Home (PCMH) practice model. If you practice primary care, you may even be part of a PCMH or in the process of establishing one. Primary care practices are consolidating with each other, affiliating with hospital organizations and establishing contractual relationships with specialty practices, all in a move toward creating PCMHs and providing accountable care. A PCMH has the interdependent goals of improving the quality of primary care for better patient outcomes and a healthier patient population with the anticipated results of reduced patient utilization of certain services and controlling healthcare costs. These goals are achieved through patient-centered whole-person coordinated care across care settings.

PCMHs embody the core primary care components of an Accountable Care Organization or “ACO” as described in the Affordable Care Act. Both PCMHs and ACOs models are based on delivering quality coordinated whole-person primary care. An ACO, however, will necessarily have multiple PCMHs working together and relationships with specialty practices, hospitals, and other health care providers to offer fully-integrated care to a large patient population. Healthcare systems are moving towards forming private ACOs and preparing to qualify for participation in the Medicare Shared Savings Program.1

The American Academy of Pediatrics (AAP) first used the term “medical home” in 1967 to describe a practice model for pediatricians to coordinate all aspects of care for special needs children in a family centered and culturally sensitive way.2 The practice model was later revised by the American Academy of Family Practitioners (AAFP) and envisioned as a means for healthcare reform by the American College of Physicians (ACP) in a 2006 position paper.3 In 2007, these organizations together with the American Osteopathic Association (“AOS”) published the “Joint Principles of the Patient-Centered Medical Home” with a new emphasis on quality delivery of “patient-centered” primary care.4 The National Committee on Quality Assurance (“NCQA”) working with these same professional organizations published an initial set of standards for NCQA recognition of PCMHs in 2008 and revised PCMH Standards in 2011 that incorporate Medicare/Medicaid EHR Incentive Program Meaningful Use of EHR Stages I and II core requirements.5 Each of the five PCMH Standards has multiple Elements. Achieving a designated number of points for specific Elements within each the Standards is required for NCQA recognition.6

With many primary care practices seeking recognition as PCMHs, physicians in other specialties have questioned whether NCQA recognition as a PCMH is restricted to primary care? The answer is a qualified “yes.” NCQA clarified in the 2011 PCMH Standards that eligibility for recognition is limited to “primary care practices” which are described as one or more clinicians practicing primary care together in one geographic location. NCQA defines “primary care” as the practice of internal medicine, family medicine or pediatrics with the intention of serving as the personal and primary clinician(s) for their patients.7 Clinicians include physicians/osteopaths, nurse practitioners and physician assistants, as long as they are providing primary care and a patient can select them to be the patient’s primary care provider.8 This limitation to primary care is understandable considering the conceptual basis of the model which is to provide “whole-person care” across care-settings.

However, NCQA has indicated that it will consider recognizing a non-primary care specialty practice as a PCMH if the practice can demonstrate that it provides whole-person care and satisfies the other elements of the Joint Principles for at least 75 percent of its patients. Using an example from the NCQA webpage, an HIV clinic may be considered a PCMH even though the patient population is limited to patients with HIV or AIDs. HIV treatment and AIDs impact multiple organs and systems within the body and require whole-person care. By contrast, an oncology practice would not be able to demonstrate that it is the primary source of ongoing comprehensive health care for 75 percent or more of its patients.9 The oncology practice may provide a degree of whole-person care for the period of time the patient is undergoing treatment. But, if that treatment is successful, the patient will not continue seeing their oncologist for their primary healthcare needs.

The parameters of what constitutes whole-person care become less clear with some specialties that have many but not all of the core elements of a primary care medical home as, for example, a women’s clinic. The American College of Obstetricians and Gynecologists even issued its own medical home policy statement in 2009 supporting the application of the PCMH Joint Principles by its members to develop women’s medical homes. But, whether NCQA would find an OB-GYN or other specialty practice eligible for PCMH recognition is still questionable. To address the desire of specialty/subspecialties for recognition and because better coordination of care is a fundamental component of the PCMH, NCQA is scheduled to release recognition standards for a new “Patient-Centered Specialty Practice Recognition Program” this March. NCQA describes the new Program as one that reinforces the need for strong connections between primary and specialty care. The program encourages support of care coordination by recognizing specialty practices that successfully coordinate patient-care with the patient’s primary care provider and with other specialists for timely access to care, continuous quality improvement and a reduction in duplication of services.10

(Endnotes)

1 An ACO must be able to accept a minimum of 5,000 Medicare beneficiaries as patients to participate in the MSSP. See 42 U.S.C. 1395jjj.

2 See e.g., L.G. Pawlson, MD (NCQA); B. Bagley, MD, (AAFP); M. BARR, MD, (ACP); X. Sevilla, MD, (AAP); P. Torda, (NCQA); S. Scholle, Dr. PH, (NCQA); The Patient-Centered Medical Home From Vision to Reality, (NCQA 2011) p. 3.

3 Id. at p. 4.

4 AAFP, AAP, ACP, AOA (March 2007). The Joint Principles are: personal physician, physician directed medical practice, whole-person orientation, care coordination and/or integration, quality and safety, enhanced access to care, value based payment including for primary care coordination.

5 See generally, Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2011 (11/21/2011) and “NCQA’s Patient-Centered Medical Home (PCMH) 2011- Changes and Clarifications” (11/16/2012). www.ncqa.org/Programs/Recognition/atientCenteredMedicalhomePCMH.aspx.

6 Id.

7 Id. pp. 11–12.

8 Id.

9 http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH/BeforeImConsideringPCMH/ PCMHEligibility.aspx.

10 http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPracticeRecognition.aspx and http://www.ncqa.org/Portals/0/PublicPolicy/Improving_Specialty-Care.aspx.

This article is intended as a summary of newly enacted state law and does not constitute legal advice.

WITH MANY PRIMARY CARE PRACTICES SEEKING RECOGNITION AS PCMHS, PHYSICIANS IN OTHER SPECIALTIES HAVE QUESTIONED WHETHER NCQA RECOGNITION AS A PCMH IS RESTRICTED TO PRIMARY CARE?THE ANSWER IS A QUALIFIED “YES.”

Sarah Charles Wright is a partner with Sturgill, Turner, Barker & Moloney, PLLC. Ms. Wright advises health care entities and providers on corporate compliance with state and federal laws and regulations. She can be reached at swright@sturgillturner.com or (859) 255–8581.