18 Summer 2012 • The NC Family Physician www.ncafp.com/ncfp

For primary care, the PCMH is the cornerstone of Health Reform, and we are inundated in publications that mark the potential for better patient health outcomes and increased cost efficiency [1, 2, 3]. Its traction is great enough that a “how to” guide for transformation has been published [4].

Although the merit of transformation is well documented, missing from much of the literature is a sense of the upfront cost of transformation. Semi-structured interviews with three triangle-area practices revealed that transformation is possible without much upfront financial investment [Table 1].

As previously mentioned in the NC Family Physician, it pays to be recognized as a PCMH – literally [5]. Demonstration projects across the state and Blue Cross and Blue Shield of North Carolina’s unique Blue Quality Physician Program (BQPP)

have enhanced payments for PCMH-accredited physicians. Please contact your BCBS of NC representative for details about BQPP; Community Care of North Carolina (CCNC) has information on participating in the demonstration projects.

Regarding upfront cost, addition of an EMR or new staff would be the most costly financial investments, followed by consultant services [Table 2]. However, there are resources to help reduce the upfront cost of the transformation.

1. Practice Fusion is a free EMR that is also highly functional for clinical use, and has an electronic billing feature (although that is $150 fee per provider per month). There are other high-quality EMRs that are free or low-cost. NCAFP Past President Chip Watkins, MD, MPH has made a tool for identifying EMRs that are high-quality but low cost.

2. In working through the accreditation, some practices may identify areas that need additional patient services. As you think about practice redesign, it may be possible to redistribute existing team members rather than hire additional staff.

3. Consulting services can be helpful, but also quite expensive. Instead of contracting with TransforMED or another private consulting group, try to arrange for a college or graduate student in public health or health management programs to help coach your practice through the process in exchange for hands-on experience. The Multi-Payer Advanced Primary Care Practice Demonstration in Western NC has already implemented student internships at local clinics with positive feedback

Now you can provide a complete allergy testing and immunotherapy service line.

Your patients no longer have to suffer from seasonal allergies and you don’t have to risk losing them by referring out to specialists. By offering this service line, physicians are able to provide a higher level of care to a large portion of their patient base, while generating a new revenue stream.

• WehireandtrainaCertifiedClinicalAllergySpecialisttotest, educate and custom build immunotherapy under the supervision of the on-site physician.

• Provideallsuppliesandmaterials related to the service line.

• Focuseffortsonpatientsafety,patient compliance and patient outcomes.

• Allowyoutotreatallergypatients rather than cover their symptoms with medications.

About United Allergy Services:

Interested in becoming a UAS Allergy Center? Visitwww.UnitedAllergyServices.comorcall 888.50.ALLERGY. Formerly United Allergy Labs

A Cost Analysis of Becoming A NCQA-Recognized Patient-Centered Medical Home By Ashley Wofford Leong

The following article was researched and drafted by Ashley Wofford Leong as part of her participation in the Academy’s 2012 Student Leadership Elective. The Leadership Elective works to increase a medical student’s knowledge of organized medicine and its role in medical education. Participating students spend four weeks working collaboratively with the NCAFP headquarters in Raleigh and complete a special project of their own design.

Summer 2012 • The NC Family Physician 19

Table1.UpfrontexpendituresforPCMHaccreditationthroughNCQAfromthreetriangle‐areapractices.

Small Practice (2 MD, 1 NP) 

Medium Practice (5 MD, 3 NP) 

Large Practice  (64 MD) 

Application fees   NCQA Survey Tool  $80  $80  $80 

Fee (based on # of Providers)  1,000  2,500  4,140 Subtotal  $1,080  $2,580  $4,220 

Consulting/Time Lost 

Money Invested  *  *  $16,000  

Time Invested  *  six months 80 hours over 4 

months  

Who's Involved  MD  practice manager; MD 

Interns§; MDs; practice manager 

Operating Costs (change) EMR**  $0  $0  $0 

Electronic Billing  0  0  0 Utilities  0  0  0 

Medical Supplies  0  0  0 Staffing 

  New Personnel  *  *  Interns§ 

*Notapplicabletothepractice.**EachpracticealreadyhadafunctionalEMR.

§Thelargepracticesolicitedhealthpolicy&managementgraduatestudentstohelpthepracticegatherinformationandsubmittheNCQAapplicationasaninternshipexperience.Collectively,the

internsspentapproximately80hourstopulltogetherallnecessarydocumentationfortheapplication.Additionally,therewerecliniciansandmanagementstafffromthepracticewhometonaregularbasiswiththeinterns.Throughoutthefourmonths,theamountoftimetheclinicianswere

scheduledtoseepatientswasnotreduced,sotherewasnolostpotentialrevenue. 

* Not applicable to the practice.** Each practice already had a functional EMR.§ The large practice solicited health policy & management graduate students to help the practice gather information and submit the NCQA application as an internship experience. Collectively, the interns spent approximately 80hours to pull together all necessary documentation for the application. Additionally, there were clinicians and management staff from the practice who met on a regular basis with the interns. Throughout the four months, the amount of time the clinicians were scheduled to see patients was not reduced, so there was no lost potential revenue.

Table 2. Minimum and maximum estimated upfront costs associated with NQCA accreditation for PCMH.

* Not applicable.** $10,000 for TransforMED and $30,000 for an EMR are high-end estimates, but not necessarily the upper threshold.§ CCNC is a sponsor if participating in a demonstration project.¶ Staffing costs represent median salary and benefits for various healthcare workers in NC [7].

Table2.MinimumandmaximumestimatedupfrontcostsassociatedwithNQCAaccreditationforPCMH.

Minimum  Maximum 

Application fees  (with sponsor) § NCQA Survey Tool  $80  $80 

Fee per Provider 

400/provider first 8    0 for next 42   

8/provider > 50 

500/provider first 8 0 for next 42    

10/provider > 50 

Subtotal $80 + $400 x          # providers 

$80 + $500 x             # providers 

Consulting/Time Lost Money Invested  *  ≥ $10,000** 

Time Invested 6 months             

(80‐100h to gather documentation) 

1 ‐ 2 years 

Who's Involved  MD, practice mgmt, +/‐ student intern 

TransforMED (or other), clinician, practice mgmt 

Operating Costs (change) 

EMR  $0  ≥ $30,000** 

Electronic Billing  

150/mo/provider  0 Utilities  0  0 

Medical Supplies  0  0 Staffing 

New Personnel¶ no new paid staff;    +/‐ student intern 

Medical Asst      $45,446 Practice Mgr    $143,606 PA or NP           $124,057 MD or DO         $231,365 

Practice Size  Minimum Est.  Maximum Est. N = 1  $480 + $150/mo  ≥ $40,580 + new staff N = 2  $880 + $300/mo  ≥ $41,080 + new staff N = 5  $2,080 + $750/mo  ≥ $42,580 + new staff N = 10  $3,280 + $1,500/mo  ≥ $44,080 + new staff N = 60  $3,360 + $9,000/mo  ≥ $44,180 + new staff 

*Notapplicable.**$10,000forTransforMEDand$30,000foranEMRarehigh‐endestimates,butnotnecessarilythe

upperthreshold.§ CCNCisasponsorifparticipatinginademonstrationproject.

¶ StaffingcostsrepresentmediansalaryandbenefitsforvarioushealthcareworkersinNC[7].

References:

Grumbach K, Grundy P. Outcomes of implementing patient centered medical home interventions: a review of the evidence from prospective evaluation studies in the United States. Patient-Centered Primary Care Collaborative. November 16, 2010. Available at: www.pcpcc.net. Accessed June 30, 2012.

Gilfillan R.J., Tomcavage J., Rosenthal M.B., et al. (2010). Value and the medical home: effects of transformed primary care. Am J Manag Care 16. (8): 607-614. Accessed June 30, 2012 via PubMed.

Reid R.J., Coleman K., Johnson E.A., et al. (2010). The Group Health medical home at year 2: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood) 29. (5): 835-843. Accessed June 30 2012 via PubMed.

Valko G, Wender RC, Zawora MQ. (2012) A “how to” guide to creating a patient-centered medical home. Prim Care. 2012 Jun;39(2):261-80. Accessed June 30, 2012 via PubMed.

The Road to PCMH Recognition & Why It Pays for Family Physicians. (2011, Summer). The North Carolina Family Physician. 7(3), 18, 20.

2011 PCMH Resources. http://www.communitycarenc.org/emerging-initiatives/pcmh-central1/2011-pcmh-resources/ Accessed Jan 31 2012.Salary data for Medical Assistants, Practice Managers, Physician Assistants and Nurse Practitioners, and Physicians in Raleigh, NC. http://www.salary.com/category/salary/ Accessed Feb 20 2012.

from the practices as well as the students. Additionally, webinars on PCMH transformation are available through CCNC’s website [6].

Ultimately, the time and effort dedicated by core team members driving the application process are the most important investments. This team should include clinicians and a practice manager, at the very least. There is no good way to qualify the cost of the time invested by members of the core team. It does require sacrifice of time beyond clinic duties, but the benefits of an appropriately functioning medical home are worth it – to the practice and to the patients alike. The PCMH is here to stay, and payment models will likely continue to grow around the medical home concept. It’s time to get on board. There are ways to successfully – and inexpensively – become

a PCMH.

Table 1. Upfront expenditures for PCMH accreditation through NCQA from three triangle-area practices.