NCQA Offers Evaluation of Patient-Centered Medical Homes
In the Winter 2008 CAFP News I wrote about how “The Value of Providing a Medical Home May Help Family Physicians.” That article listed the Joint Principles of the Patient Centered Medical Home, which include: 1) care is provided by a personal physician to provide first contact, 2) a physician directs medical practice, 3) care is oriented toward the whole person – caring for all of the patient’s health care needs or arranging care with other qualified professionals, 4) care is coordinated and/or integrated, 5) quality and safety are important features, 6) enhanced access to care is available, and 7) payment should recognize the added value the patient-centered medical home provides. These are all elements that are typically provided through a Family Medicine practice. Although most Family Physicians provide these elements, national parameters and standards have been developed by NCQA (National Committee for Quality Assurance) which can lead to your practice being certified as a Physician Practice Connections – Patient Centered Medical Home (PPC-PCMH) practice. Once insurance companies validate the value of providing a medical home, they may require that your practice be certified to qualify for additional payment for providing this added service.
I mentioned in my last report that there is a pilot project being led by United Healthcare to study the benefits of care provided through a medical home. This pilot project will be conducted over 24 months and be done collaboratively with other insurance companies in both Colorado and Florida. If the results of this pilot project indeed show what is expected – that care provided through a medical home is of higher quality and saves costs – then it is expected that the insurance companies would roll this out and compensate practices an additional payment above fee for service to practices that provide a medical home. I will attempt to describe this evaluation process as developed by NCQA.
NCQA, an organization that helps to establish standards by which insurance companies monitor quality care, has established physician recognition certification for a number of specific areas including: back pain, diabetes, cardiovascular disease and stroke, and physician practice connections (use of information technology). This enhanced recognition can lead to enhanced payment or referrals from insurance companies. A Physician Practice Connections – Patient Centered Medical Home (PPC-PCMH) is a new certification that has just come out this year, which includes a scoring method to rate what level of a medical home your practice provides with different levels of qualification. This scoring method may be used by insurance companies in the future to determine if you qualify for additional payment. By understanding the score of your practice you can also understand what it would take to improve your scoring. It is important to point out that although you can obtain NCQA certification now, it is still being worked out by insurance companies how they intend to handle this, and may take time before a decision is made to compensate practices additionally for providing this and what scoring level is required. Although it is a work in progress, it is important to understand what is being discussed nationally that may impact your reimbursement and practice in the future. You can read more about NCQA certification by going to the website www.ncqa.org and clicking on “Patient Centered Medical Home.”
The PPC-PCMH includes nine standards for medical practices to meet. Under each standard there are a number of elements with different scoring weights that add up to a total potential score of 100. Of the various elements, there are 10 elements listed as “Must Pass Elements,” and practices must specifically pass at least five of these elements. The levels of qualifying are: Not Recognized, Level 1, Level 2, and Level 3, with Level 3 being the highest. To achieve Level 1 a minimum score of 25 out of 100 must be achieved. It is not clear what level will be required to qualify for additional reimbursement from insurance companies. There is a charge for being certified by NCQA, which is based on the number of physicians in a practice, which can be found on their website. The following is the table of the NCQA Scoring method and explanation of levels.
Although this overview is brief and not intended to be a comprehensive description, it is intended to provide information on some of the new developments taking place nationally that will likely eventually have an influence over how you will be paid in the future and potentially how you practice. Formalizing certification of a medical home is intended to improve the quality of patient care, and certification can serve to demonstrate to the public that your practice indeed provides this higher level of quality. It is anticipated that in the future that insurance companies will provide additional compensation for this, but this is still in the evaluation phase.
The above charts were produced by the National Committee for Quality Assurance and can be viewed, along with additional information, at www.ncqa.org. To see the charts, click on “Patient Centered Medical Home” and then “PPC-PCMH Summary.”
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