ncqa’s patient-centered medical home 2011 recognition program · ncqa’s patient-centered...
TRANSCRIPT
NCQA’s Patient-Centered Medical Home 2011 Recognition Program
Tricia Marine Barrett, VP Product DevelopmentThird National Medical Home Summit: Mini Summit V
March15, 2011
2March 2011
Private, independent non-profit health care quality oversight organization founded in 1990
_________________________________________________MISSION
To improve the quality of health care.VISION
To transform health care through quality measurement, transparency, and accountability.
________________________________________________ILLUSTRATIVE PROGRAMS:
* HEDIS –
Healthcare Effectiveness Data and Information Set* Health Plan Accreditation
* Recognition Programs* Disease Management * Wellness & Health Promotion Accreditation
* Consumer Union’s Health Plans Rankings * Quality Dividend Calculator
National Committee for Quality Assurance NCQA
3March 2011
Evaluation of PCMH Demonstrations: Driving Quality and Cost Savings
• Outcomes for seven medical home demonstrations – Reduce hospitalization rates (6-19%)– Reduce ER visits (0-29%)– Increase savings per patient ($71-$640)
• Four common features in demonstrations– Dedicated care managers – Expanded access to clinicians– Data-driven
analytic tools
– Use of incentives
Elements or uses of NCQA’s PCMH
evaluation
Source: Fields, et al. 2010
4March 2011
Published and Ongoing Research on PCMH1.
Patient access to care through visits outside of regular practice hours and same day access has been shown to reduce emergency department use
(Bodenheimer and Pham, 2010)
2.
A PCMH demonstration project in an integrated group practice showed significant improvements in patients’
and providers’
experiences
and in the
quality of clinical care (Reid 2009)
3.
Clinical practice systems are associated with decreased use of inpatient and emergency care
but
do not appear to affect ambulatory care utilization in diabetes (Flottemesch, under review)
5March 2011
The Case for Patient-Centered Medical Home Recognition
• Gives practices a roadmap to improve quality with systematic approach to preventive and chronic care delivery
• Focuses on evidence-based requirements to improve quality and reduced costs
• Considers capabilities of small and large practices, without sacrificing quality
• Balances desirable requirements with feasibility and burden of review
6March 2011
The Case for Patient-Centered Medical Home Recognition
• Requires electronic information when necessary– Electronic systems alone are not sufficient
• Incentivizes investment in quality infrastructure and processes
• Complements evaluation of clinical effectiveness, patient experiences and efficiency
7March 2011
Strengths of NCQA’s PCMH Program
• Standardization• Reach• Flexibility• Feasibility• Aligns with meaningful use• Continuous improvement
8March 2011
PCMH Strength: Standardization• Consistent, understandable method of
rating and scoring• Aligned with the Joint Principles• Endorsed by NQF (Sept 2008) as “Medical
Home System Survey”• Enables apples-to-apples comparisons of
demonstrations and pilot projects– Saves developers the trouble of creating
standards & scores from scratch • Reassures sponsors that a “medical home”
really is one
9March 2011
PCMH Strength: Reach
• NCQA has the most widely-adopted model
• Milestone: 1,500th Recognition, Dec. 2010
• States/practices can get on board with a system that’s working across the country
10March 2011
NUMBER OF PPC-PCMH SITES BY STATE
ME
VT
RINJ
MD
MA
DE
NY
WA
OR
AZ
NV
WI
NM
NE
MN
KS
FL
CO
IA
NC
MI
PAOH
VAMO
HI
OK
GA
SCTN
MT
KY
WV
AR
LA
AL
INIL
SD
ND
TX
IDWY
UT
AK
CA
CT
NH
61-200 Sites
*As of 01/31/11
MS
21-60 Sites
0 Sites
1-20 Sites
201+ Sites1635 PPC-PCMH SITES
11March 2011
NUMBER OF PPC-PCMH CLINICIAN RECOGNITIONS BY STATE
ME
VT
RINJ
MD
MA
DE
NY
WA
OR
AZ
NV
WI
NM
NE
MN
KS
FL
CO
IA
NC
MI
PAOH
VAMO
HI
OK
GA
SCTN
MT
KY
WV
AR
LA
AL
INIL
SD
ND
TX
IDWY
UT
AK
CA
CT
NH
61-200 Recognitions
*As of 01/31/11
MS
21-60 Recognitions
0 Recognitions
1-20 Recognitions
201+ Recognitions8308 PPC-PCMH CLINICIAN RECOGNITIONS
12March 2011
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Jan-08Feb-08M
ar-08Apr-08M
ay-08Jun-08Jul-08Aug-08Sep-08O
ct-08N
ov-08D
ec-08Jan-09Feb-09M
ar-09Apr-09M
ay-09Jun-09Jul-09Aug-09Sep-09O
ct-09N
ov-09D
ec-09Jan-10Feb-10M
ar-10Apr-10M
ay-10Jun-10Jul-10Aug-10Sep-10O
ct-10N
ov-10D
ec-10Jan-11
PPC
-PC
MH
Dat
a To
ols
Month
Recognitions/DenialsSubmissionsApplications Survey Tools
Survey Tools Sold
Applications Submitted
Surveys Submitte
Decisions Completed
4294 Survey Tools Sold
2595 Surveys Submitted
2409 Applications Submitted
1659 Decisions Completed
*As of 01/31/11
Demand for Recognition is Surging
13March 2011
Organizations Using NCQA’s Medical Home Recognition Include…
• EmblemHealth/ UCONN -
NY• NYC DOH• Independence Health –
Buffalo• NYS Medicaid• Taconic IPA –
NY• LA Public Health Initiative• LA Primary Care Assoc• WV Primary Care Assoc• Rhode Island CWF Pilot• Colorado CWF Pilot• Ohio CWF Pilot• NJAFP/ Horizon• PA Chronic Care Initiative –
SE, SC, SW, NE
• Independence Blue Cross -PA
• HealthPartners• Dartmouth Hitchcock• Geisinger• Kaiser CA and CO• Vermont Blueprint for Health• New Hampshire PCMH Pilot• Maine PCMH Pilot• BCBS AL and NC• Key IPA –
NC• CareFirst BCBS• Maryland State • Qualis Health CHC Project• Priority Health -
MI• UHC –
AZ and NM• Navy BuMed• Federal Initiatives: CMS, HRSA
14March 2011
PCMH Strength: Flexibility
• Standardization is not a straightjacket– Many ways to score points toward Recognition– Three levels of Recognition
• NCQA provides goals and guidelines for practice transformation based on evidence – Practices decide how best to reach goals
based on their size, location, area conditions
15March 2011
PCMH Strength: Feasibility
• Program is built on what is shown to improve care and can be copied or replicated
• Multi-stakeholder development process and public comment ensure thorough vetting, practical design that practices can follow
16March 2011
PCMH Strength: Aligns with Meaningful Use• Practices that demonstrate meaningful use of
health IT are well positioned for PCMH Recognition, and vice versa
• Specific Meaningful Use language is embedded in Factors
• Distinct scoring/separate report for MU
• NCQA is on the right track…
17March 2011
PCMH Strength: Aligns with Meaningful Use“Organizations such as the National Committee for Quality Assurance (NCQA)…could affect health IT adoption if they incorporated meaningful-use criteria into the various accreditation systems. The NCQA has already done so, in part, by incorporating electronic communication, electronic prescribing, and registry functions into the qualifying criteria for the patient-centered medical home.”
--David Blumenthal, national coordinator for health ITHealth Affairs, September 2010, p.1669
18March 2011
PCMH Strength: Continuous Improvement
• Program is built for “controlled evolution”– e.g., transition planned for early adopters
• NCQA commitment to keep improving the PCMH model
• New standards are based on advances in evidence, changes in practice capability
19March 2011
PCMH 2011 Advisory CommitteeSusan Edgman-Levitan - CHAIRMassachusetts General HospitalMelinda Abrams, MSCommonwealth FundBruce Bagley, MDAmerican Academy of Family PhysiciansMichael Barr, MD, MBA, FACPAmerican College of PhysiciansDuane E. Davis, MDGeisinger Health PlanTom Foels, MD, MMMIndependent HealthAlan Glaseroff, MDHumboldt-Del Norte Foundation for Medical Care/IPAFoster Gesten, MD New York State Department of HealthVeronica GoffNational Business Group on HealthPaul Grundy, MD, MPHIBMMarjie Grazi Harbrecht, MDHealthTeam Works
Edward G. Murphy, MDCarilion ClinicMary Naylor, PhD, RNUniversity of PennsylvaniaAnn O’Malley, MD, MPHCenter for Studying Health System ChangeAmanda H Parsons, MD, MBANYC Department of Health and Mental HygieneLee PartridgeNational Partnership for Women and Families Carol Reynolds-Freeman, MDPotomac PhysiciansMarc Rivo, MD, MPHPrestige Health ChoiceHealth Choice Network Xavier Sevilla, MD, FAAPWhole Child PediatricsJeff SchiffMinnesota Department of Human ServicesAnn TorregrossaGovernor's Office, PennsylvaniaEd Wagner, MD, MPHGroup Health Cooperative
20March 2011
PCMH 2011 Vision• Multiple performance levels• Streamline requirements/documentation;
establish process for renewals• Raise bar on scoring• Focus on aspects of medical home with
strongest link to desired outcomes (better quality, patient experience, cost)
• Move toward/facilitate performance benchmarking
• Embed Meaningful Use
21March 2011
Stakeholder Suggestions for PCMH 2011
• Underscore the importance of system cost-savings to employers
• Enhance patient-centeredness• Emphasize language, culturally
sensitive aspects
• Integrate behavioral health/risk factor assessment & management
• Include comprehensive care• Consider relationship with/expectations of
subspecialists• Evaluate patient experience
22March 2011
Comparison of PPC-PCMH and PCMH 2011 PPC-PCMH (9 standards/30
elements)1.
Access and Communication– Processes – Results
2.
Patient Tracking and Registry Function
3.
Care Management– Continuity Between Settings
4.
Self-Management Support5.
Electronic Prescribing6.
Test Tracking7.
Referral Tracking8.
Performance Reporting and Improvement
– Measure Performance– Measure Patient/Family Experience
9.
Advanced Electronic Communication
PCMH 2011 (6 standards/27 elements)1.
Access/Continuity – Access/Continuity – Medical Home Responsibilities– CLAS– Practice Team
2.
Identify/Manage Patient Populations3.
Plan/Manage Care– Care Management (Incl. Behavioral Health – Identify High Risk Patients– Medication Management/E-Prescribing
4.
Self-Care and Community Referrals 5.
Track/Coordinate Care– Test/Referral Tracking and Follow-Up– Coordinate with Facilities
6.
Performance Measurement/Quality Improvement– Measure Performance/Patient Experience– Continuous Quality Improvement – Report Performance and Data
23March 2011
PCMH 2011 Key Components • Access
– Evening/weekend hours, agreement with facility for after-hours care• Coordination of care
– Information to/from specialists/facilities/patient, update care plan • Team-based care
– Defined roles and responsibilities, training, communication• Role of medical home
– Discuss roles/expectations for medical home and for patients• Care management
– Pre-visit planning, care planning during visit, patient self-care, point of care reminders
– Medication management– Include mental health/substance abuse/behaviors affecting health
• Self-care management with community resources/referrals• Identify/address population needs/risks• Quality improvement
– Performance measurement– Patient experience
24March 2011
Scoring Total 100 Points
Level Points Required Must Pass1 ≥
35 6 Must Pass
2 ≥
60 6 Must Pass
3 ≥
85 6 Must Pass
Must Pass Elements (≥50% score)1A: Access During Office Hours2D: Use Data for Population Management3C: Manage Care4A: Self-Care Process5B: Referral Tracking and Follow-Up6C: Implement Continuous Quality Improvement
Rationale•Identifies critical concepts of PCMH•Helps focus Level 1 practices on most important aspects of PCMH•Guides practices in PCMH evolution and continuous quality improvement•Standardizes “Recognition”
25March 2011
Testimonial“First, there is the recognition both internally and externally that you provide state-of-the-art primary healthcare. Second is the way the criteria force your delivery system to think about routes of communication between the various parts of the healthcare system. We know that those points of transition of patients and their information are dangerous opportunities for medical errors to occur. Third, we anticipate that the recognition will bring increased reimbursement at some time down the line and improving reimbursement is always a major goal.”
--Institute for Family Health (IFH), The Bronx, Manhattan and inthe Mid-Hudson Valley
26March 2011
Testimonial“Going through the process of becoming recognized as aPCMH also assisted Lamprey Health Care in streamliningprocesses for patients to access healthcare. In addition,the process enables staff to become part of the solution,improving morale.”
--Community Health Access Network, NH
27March 2011
COMING SOON…
28March 2011
What is an ACO?• Provider based organizations that take
accountability for both the quality
and costs
of health care for a defined population
• At minimum include primary care and may include sub-specialists and hospitals – No consensus on specific structure or capabilities
• Align incentives and reward providers based on the performance (both quality and financial)
29March 2011
ACOs: Getting to Know the Neighbors• Accountable Care Organizations are envisioned to
provide incentives for increasing clinical integration and care coordination throughout the continuum of care
• Builds on a strong base of primary care (PCMH) capability
• Takes accountability for performance to a new level– Greater opportunity to coordinate across settings– Direct responsibility for the triple aim with payment incentives
• Relationships with specialists, hospitals and other care settings are key
30March 2011
Relationship of ACO criteria to PCMH 2011
• Patient-Centered Medical Homes form the foundation of ACOs
• Concepts and standards from PCMH 2011are integrated into ACO Criteria– ACO Level Patient-Centered Capabilities
• Support the delivery of patient-centered care within medical homes
• Make resources to support patient-centered care available to other providers in the system
– Primary Care Capabilities• Medical home functions
31March 2011
ACO Evaluation Principles• Qualifying criteria should be flexible but protect
against failures of the past – Demonstrate core capabilities such as sufficient
access/capacity, patient protections, information systems and ability to manage financial risk
– Strong governance to guard against ‘referalist’
problem• Monitoring criteria to demonstrate achievement of
outcomes over time– Cost– Quality– Patient experience
• Significant policy issues remain– Concentration of market power– Patient attribution (who is accountable and for what)
32March 2011
NCQA ACO Task Force: An All-Star Team• Chair: Robert J. Margolis,MD
HealthCare Partners Medical Group • Lawrence P. Casalino, MD, PhD
Weill Cornell Medical College• Sabrina Corlette
National Partnership for Women & Families• Jay Crosson, MD
The Permanente Federation• Nicole G. DeVita, RPh, MHP
Blue Cross Blue Shield of MA• Duane E. Davis, MD, FACP, FACR
Geisinger Health Plan• Joseph Francis MD, MPH
Veterans Affairs• George Isham, MD, MS
HealthPartners • Julie Lewis
Dartmouth Institute
• Phil Madvig, MDPermanente Medical Group
• Dolores MitchellGroup Insurance Commission
• Edward Murphy, MDCarilion Clinic
• Gordon Norman, MDAlere Medical Inc.
• Cathy Schoen, MSCommonwealth Fund
• Jeff Stensland, PhDMedPAC
• Susan S. Stuard, MBATHINC, Inc.
• John Toussaint, MDThedaCare
• Woody Warburton, MDDuke University Medical Center
• Nicholas Wolter, MDBillings Clinic
33March 2011
Questions?
Thank You!
Tricia Marine Barrett
NCQA VP, Product Development