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Does Patient-Centered Medical Home Transformation Take Too Long?

- The patient-centered medical home (PCMH) is often lauded as one of the most effective frameworks for practice transformation.  Integrating health IT and data analytics with population health management and care coordination strategies, the PCMH offers a structured, step-by-step guide for healthcare providers that want to provide high quality, highly personal care. 

Patient-centered medical home recognition

Many of the organizations that fully embrace this mission see measurable improvements in their chronic disease management programs, their patient satisfaction scores, and even their accounting books.  But praise for the model isn’t universal, and a new report from the RAND Corporation about a long-term PCMH pilot program for federally-qualified health centers (FQHCs) adds to doubts about the patient-centered medical home’s practicality and financial feasibility for certain types of organizations.

Can healthcare providers afford to invest the time and effort it takes to slowly transform into an effective patient-centered medical home?  Are current financial incentives adequate to offset the burdens of such a complicated improvement project?  Is there enough technical assistance available to the provider community to make large-scale patient-centered medical home adoption a reality?

The three-year FQHC Advanced Primary Care Practice Demonstration was formed as part of the CMS Innovation Center, and included 434 healthcare organizations spread across the country.  The project, which concluded in October of 2014, hoped to add to the growing body of evidence that showed the effectiveness of the patient-centered medical home for care coordination, quality, and population health management.

Participating organizations were expected to achieve Level 3 NCQA PCMH recognition by the end of the three-year term.  To aid them in their quest, each provider was given technical assistance by CMS and the Health Resources and Services Administration (HRSA).  They were also paid an $18 quarterly patient management fee for each eligible Medicare beneficiary receiving primary care services under a fee-for-service model.

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Most organizations seeking NCQA recognition do not receive this additional financial assistance, and so it was expected that the participating FQHCs would demonstrate rapid progress towards their PCMH goals. 

The reality of this “enormous undertaking” was not quite as rosy as innovators hoped.  In this second annual report, RAND reveals that providers found that it took significantly longer than anticipated to reach the high levels of PCMH adoption outlined in the pilot, and the report found “no evidence” that the per-patient care management payment translated into quicker or more effective advanced practice care.

At the beginning of the project, just one of the 493 FQHCs had achieved Level 3 PCMH recognition, and the number only slowly increased over the first half of the pilot.  By the sixth demonstration quarter, 44 organizations had reached Level 3, increasing to 131 a year later and 208 by the end of the study period. 

Fifty-five percent of participating FQHCs had achieved Level 3 patient-centered medical home recognition by August of 2014, compared to just 11 percent of comparison federally-qualified health centers not partaking of CMS assistance.  While this represents a significant leap from baseline, it falls far short of the initial expectations for the program.  CMS hoped that 90 percent of participating health centers would become Level 3 PCMHs by the three-year mark.

So why has the demonstration project “failed” to meet its goals?  The main issue seems to be time.   Patient-centered medical home transformation is a complex and deeply involved process that includes technical upgrades, cultural changes, workflow renovations, and community outreach.  FQHCs often have few resources to treat safety net patient populations with high levels of need, and may have trouble meeting their basic goals, let alone committing effort to PCMH tasks.

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Additionally, the RAND report acknowledges that the technical assistance promised to the program participants was slow to gear up.  “Despite substantial planning and implementation, the approach toward technical assistance began slowly, in a series of fits and starts that spanned almost two years of the three-year demonstration,” the report admits. 

“Multiple course corrections” for the technical assistance resulted in providers feeling as if they were being “pulled in several different directions while they tried to simultaneously submit a successful application for achievement of NCQA Level 3 recognition and transform their practices with new methods of delivering care for patients.”

The report points out that healthcare organizations that had previous experience with shared savings models were more likely to achieve PCMH recognition with less need for technical assistance.  “Sites that participate in shared-savings demonstrations may benefit from additional resources gained from participating in these demonstrations, which facilitate achievement of Level 3 recognition,” the report states. “In addition, the potential for shared savings may serve as a potent driving force behind these sites’ pursuit of Level 3 recognition.”

Financial motivation is a prerequisite for success with many health IT and quality improvement programs, but it does not always make the process any speedier.  Many successful patient-centered medical homes have specifically taken a slow-and-steady approach to achieving higher levels of recognition, and credit their ability to maintain high levels of care quality to their incremental efforts.

“We’ve been working with Valley Health Partners in Western Massachusetts for the past four years,” said Pam Minichiello, Project Director at the Massachusetts eHealth Collaborative (MAeHC), to HealthITAnalytics.com in a March interview.  “They were involved in a payer incentive program where they were required to do things that were what we like to call ‘medical hominess,’ where they would adopt certain workflows and certain standards of the NCQA patient-centered medical home requirements, but not the whole package.”

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“So for the first three years that we worked with them, they would pick a couple of the standards and they would develop and implement those workflows and those processes,” she continued.  “Then the next year, they would pick two more, and so on.  But in 2014 they decided to go for full recognition, and it was easier for them because they had already adopted a lot of the ‘must-pass’ elements.  So they weren’t starting from square one.”

Taking time to assess organizational strengths, generate enthusiasm from staff, and slowly approach the necessary investments before charging forward into full-blown adoption were critical steps for Valley Health Partners, agreed Dr. Robert M. Fishman, DO, FACP, who helped to coordinate VHP’s patient-centered medical home achievements.  “We got our staff onboard with all these changes by doing the pilot project with Health New England,” he explained.  “So by the time we said that we're going to do this full tilt, it wasn't really a major shift.  It was just an expansion of what we were doing already.”

“We started out with a few slow baby steps.  Those baby steps became larger steps for about two to three years.  And then the state assessment that was done showed that hey, we're not that far from the finish line.  So it wasn't an overnight deluge of issues.”

The CMS demonstration project may simply have failed to provide enough time for its participating providers to meet the demands of patient-centered medical home transformation.  Providers involved in the program noted that they felt overwhelmed by competing initiatives and untenable demands on their working hours, which are familiar complaints to those who take a dim view of the laundry list of expensive mandates and improvement programs required for the healthcare industry. 

“I think sometimes we’re so caught up in all of these different requirements to be in our phone calls or webinars or whatever, and nobody has any time left to do the work that needs to be done,” one organization said of the assistance structure.  

“One of the biggest challenges: We’re probably going to have to hire more nonclinical staff, more in the way of medical assistants, case manager–type of roles, possibly another referrals specialist or two,” added another. “And there’s really not that much extra money coming in through the demonstration project to support those salaries, so we’re going to have to fight a little bit to get some of that money.”

Despite its pitfalls, the PCMH demonstration project did prove that large-scale patient-centered medical home adoption is possible with the right motivation and the right assistance.  The process may just be too lengthy – and too individualized – for such a structured and limited effort.  Should future pilots run for a longer period, they may have a better chance of meeting ambitious thresholds for adoption, and may be able to generate measurable cost savings and quality care improvements. 

The RAND report notes that data on these issues is pending analysis, and a final report will be necessary to draw conclusions about the effectiveness of the program on these fronts.

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