Student Forum Patient-Centered Medical Homes: Recognition and Reimbursement — Part 3
This is the final part of a three-part series on the concept of patient-centered medical homes. Part 1, an overview, discussed the key aspects and health care benefits of patient-centered medical homes. Part 2 outlined the approval process employed by the National Committee for Quality Assurance to evaluate, grade, and recognize medical homes. Part 3 describes the growing acceptance of, and reimbursement for, medical homes.
Last of a Series Eric Stack, Karen Kier As a result of current weaknesses and deficiencies in the United States health care system, the concept of patientcentered medical homes (PCMHs), a way of organizing primary care that emphasizes coordination and communication among patients and providers, has taken root. The formation of the National Committee for Quality Assurance—PatientCentered Medical Homes (NCQA-PCMH) Recognition Program and its associated standards has assisted many clinicians seeking to evolve with these changing models of medical practice. Not only have PCMHs been shown to improve patient health outcomes, but they also have been associated with decreasing overall health care costs. Additionally, there are many benefits of primary care practice sites to develop into a PCMH, including eligibility for both private party and government reimbursement. KEY WORDS: Institute for Healthcare Improvement, National Committee for Quality Assurance, Patient-centered medical home, Triple Aim. ABBREVIATIONS: ACIP = Advisory Committee on Immunization Practices, CCHAP = Colorado Children’s Healthcare Access Program, CMS = Centers for Medicare & Medicaid Services, FQHC = Federally Qualified Health Center, HRSA = Health Resources Services Administration, IHI = Institute for Healthcare Improvement, NCQA = National Committee for Quality Assurance, NCQA-PCMH Recognition Program = National Committee for Quality Assurance—Patient-Centered Medical Homes Recognition Program, PCMH = Patient-centered medical home, USPSTF = United States Preventive Services Task Force. Consult Pharm 2014;29:347-50.
THE CONSULTANT PHARMACIST
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Patient-centered medical homes (PCMHs) are a way of organizing primary care that emphasizes coordination and communication among patients and providers. The formation of the National Committee for Quality Assurance—Patient-Centered Medical Homes (NCQAPCMH) Recognition Program, and its associated standards, has assisted many practices that are looking to evolve with the changing models of medical practice. This model offers a venue that enables clinicians to be paid by both private and government health plans for the medical care conducted.1 PCMHs are gaining support from multiple payer models, and this recognition allows for primary care practice sites to get involved in the process.2 As the benefits of PCMHs are seen in the health system, both government and private health care payers are looking more and more for this type of primary care, and various payment incentives are arising.2 Furthermore, health care providers practicing within a model recognized by the National Committee for Quality Assurance (NCQA) have opportunities for financial return on services completed outside the patient visit. Overall, the health care system in the United States is more costly than those of many other nations, while producing inferior health outcomes. This has led the Institute for Healthcare Improvement (IHI), a nonprofit organization focused on partnering with patients and health care professionals to test new models of care, to develop a plan to better use the resources currently being devoted to health care. In 2007, IHI created three main objectives to meet this goal, known as “The Triple Aim”:
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Patient-Centered Medical Homes: Recognition and Reimbursement—Part 3
insurers that support the PCMH model include certain WellPoint, Aetna, Humana, United Healthcare, Blue Cross Blue Shield, and Kaiser Permanente plans. For example, in January 2012, WellPoint, which is a health care insurer for roughly 34 million Americans, announced that its whole network is devoted to the PCMH model.4 By improving the delivery of health care up front, insurance companies can decrease overall health care costs by reducing the money spent on complications, hospital admissions, and duplicative tests. For example, the Group Health, Seattle, Washington, reported a 25% reduction in hospital readmissions and inpatient stays as well as an estimated $15 million reduction in expenses from 2009 to 2010.9 This demonstrates the gaining momentum of reimbursement opportunities for PCMHs as the evidence builds for improved patient health outcomes. Despite the advantages of the PCMH model, there are a number of barriers to successful implementation. Technology, such as electronic health records, must be in place for efficient communication among various health care professionals. This is a common issue when trying to incorporate an entire team of health care workers involved in the care of a patient, including pharmacists practicing in various settings.6,10 For example, community pharmacists often lack sufficient access to patients’ health care records, which often delays appropriate care because of the need to call or fax the physician office regarding medication therapy questions and recommendations. For PCMHs to become fully functional, all health care providers must buy into the idea of teamwork to provide coordinated care in an efficient and effective manner.10 By recognizing and addressing barriers to successful implementation and operation of a PCMH, health care provided in these practice settings can continue to evolve and advance. Because of the current weaknesses and deficiencies in the health care system, there is increasing support for the establishment and expansion of PCMHs. Not only have they been proven to improve patient health outcomes, but they also have been associated with decreasing overall
THE CONSULTANT PHARMACIST
MAY 2014
health care costs. There are many benefits of primary care practice sites to become an accredited PCMH, including being eligible for both private-party and governmentsponsored reimbursement. PCMHs involve a variety of health care professionals, which allows for the establishment of a solid interdisciplinary team to provide efficient continuous patient care. NCQA provides a set of welldefined standards for practice sites assessing the feasibility of becoming a recognized PCMH. In conclusion, PCMHs can have an increasingly positive impact on the health care system if embraced by health care professionals.
Eric Stack is a 2014 PharmD candidate, Ohio Northern University, College of Pharmacy, Ada, Ohio. Karen Kier, BSPh, PhD, RPh, BCPS, BCACP, is professor of clinical pharmacy, Ohio Northern University, College of Pharmacy. For correspondence: Karen Kier, PhD, College of Pharmacy Practice Department, Ohio Northern University, College of Pharmacy, Robertson-Evans 236, 525 S. Main St., Ada, OH 45810; Phone: 419-772-2285; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.347.
Previous Articles in This Series • Stack E, Kier K. Key aspects and health care benefits of patient-centered medical homes. Part 1 of 3. Consult Pharm 2014;29:196-9. • Stack E, Kier K. Patient-centered medical homes: standards for approval. Part 2 of 3. Consult Pharm 2014;29:275-8.
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Student Forum • Improve the health of the defined population • Enhance the patient care experience (including quality, access, and reliability) • Reduce, or at least control, the per capita cost of care3 This means that there should be a concentration on patient-centered care (which includes families), and a coordination of care—the backbones of PCMHs.3 Medical homes can provide an avenue for decreasing overall health care costs, especially since estimates are that 30% of the United States’ health care costs are unnecessary (duplication of services, etc.). There is vast room for improvement in health care, and the PCMH model is a foundation that can be effectively built upon to meet this pressing need.4 In concert with objectives of The Triple Aim program, there are numerous examples of PCMHs that have demonstrated impressive results. For example, HealthPartners, located in Bloomington, Minnesota, saw a 39% decrease in emergency department visits and a 40% reduction in hospital readmissions.4 The federal government is also supporting PCMHs. The Affordable Care Act (ACA) recognizes their use for patients on Medicaid with chronic disease states to help increase the coordination of care.5 Thirty-one states are either in the process of setting up or running a PCMH pilot project based on Medicaid or the children’s health insurance models. Similarly, there are state Medicaid programs that are using the PCMH model, such as the Colorado Children’s Healthcare Access Program (CCHAP). This pilot project, created in 2006, involves almost 7,000 children in the Denver metropolitan area being cared for at seven private, primary care practice sites. To promote private practices to get involved with such a project, CCHAP increased payments for Medicaid patients if they offered preventive health services. As a result, there was an increase in immunization rates, a decrease in number of emergency department visits, a greater number of preventive health appointments, and lower overall Medicaid costs. By January 2010, an estimated 93% of privately operated pediatric practices in Colorado were involved with the project, which represents 116 primary care practices and 405 providers. This is a prime example of how a pilot project quickly expanded to meet the
348
demand set forth from the government, while receiving adequate reimbursement in return.6 In addition, ACA supports the use of preventive care, especially for patients on Medicare and Medicaid. Currently, any preventive health measure ranked as Grade A or Grade B by the United States Preventive Services Task Force, an independent panel that evaluates the latest scientific evidence on clinical preventive services, or any adult immunization recommended by the Advisory Committee on Immunization Practices, a group of medical and public health experts that advises the Centers for Disease Control and Prevention, is a reimbursable expense for PCMHs. This reimbursement model appropriately corresponds to the increasing emphasis on preventive health, encouraging overall patient well-being.7 Likewise, the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice is a federally funded demonstration project developed to help manage the health care of Medicare beneficiaries. In 2011, Donald Berwick, former administrator of the Centers for Medicare & Medicaid Services, said, “This project will go a long way toward creating comprehensive and coordinated health care opportunities for the many people on Medicare who rely on FQHCs as their primary medical providers.” This demonstration program, begun in September 2011 and set to continue through August 2014, is designed to help Medicare patients use PCMHs, especially to help control chronic disease and to help coordinate an integrated health care network. Each of the 469 FQHCs gets paid on a monthly basis for the primary health care of Medicare patients. The six standards set forth by the NCQA-PCMH recognition program are strongly incorporated into the success of these programs on the quality of health care services provided.8 Currently, there are numerous insurance companies pushing for the use of services based on patient-centered care and an increased accessibility to primary health care, core aspects of the PCMH.4 Widespread support exists for PCMHs from payers, including more than 90 private commercial insurance plans, Medicaid programs in 42 states, and federal agencies such as the Veterans Administration and the Department of Defense. Some commercial
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Student Forum References 1. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home PPC-PCMH. National Committee for Quality Assurance. Available at http://www.ncqa.org/Portals/0/PCMH%20 brochure-web.pdf. Accessed January 26, 2013. 2. National Committee for Quality Assurance. NCQA’s Patient-Centered Medical Home (PCMH). National Committee for Quality Assurance 2011. Available at http://www.ipfcc.org/advance/topics/PCMH_2011_ Overview_White_Paper.pdf. Accessed January 26, 2013. 3. Institute for Healthcare Improvement. The Triple Aim: Optimizing Health, Care and Cost. Healthcare Executive 2009. Available at http://www.ihi.org/offerings/Initiatives/TripleAim/Documents/ BeasleyTripleAim_ACHEJan09.pdf. Accessed January 26, 2013. 4. Nielsen M, Langner B, Zema C et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative 2012. Available at www.pcpcc.net/guide/benefits-implementing-pcmh. Accessed January 26, 2013. 5. Patient-Centered Primary Care Collaborative. Health Care Reform. Patient-Centered Primary Care Collaborative. Available at http://moo. pcpcc.net/content/health-care-reform-and-patient-centered-medicalhome. Accessed January 26, 2013.
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6. American Hospital Association Committee on Research. AHA Research Synthesis Report: Patient-Centered Medical Home (PCMH). American Hospital Association 2010. Available at www.aha.org/research/ cor/content/patient-centered-medical-home.pdf. Accessed January 26, 2013. 7. Long A, Bailit M. Health Reform and the Patient-Centered Medical Home: Policy Provisions and Expectations of the Patient Protection and Affordable Care Act. Safety Net Medical Home Initiative 2010. Available at www.co.fresno.ca.us/viewdocument.aspx?id=47522. Accessed January 26, 2013. 8. U.S. Department of Health and Human Services. New Affordable Care Act Support to Improve Care Coordination for Nearly 200,000 People with Medicare. U.S. Department of Health and Human Services 2011. Available at http://www.hhs.gov/news/press/2011pres/06/20110606a. html. Accessed January 26, 2013. 9. Patient-Centered Primary Care Collaborative. Achieving the Triple Aim: Quality, Outcomes and Cost. Patient-Centered Primary Care Collaborative 2013. Available at http://www.pcpcc.net/content/achievingtriple-aim. Accessed February 27, 2013. 10. Abrons JE, Smith MA. Patient-centered medical homes: primer for pharmacists. J Am Pharm Assoc 2011;51:e38-e50.
THE CONSULTANT PHARMACIST
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This is the final part of a three-part series on the concept of patient-centered medical homes. Part 1, an overview, discussed the key aspects and health care benefits of patient-centered medical homes. Part 2 outlined the approval process employed by the National Committee for Quality Assurance to evaluate, grade, and recognize medical homes. Part 3 describes the growing acceptance of, and reimbursement for, medical homes.
Last of a Series Eric Stack, Karen Kier As a result of current weaknesses and deficiencies in the United States health care system, the concept of patientcentered medical homes (PCMHs), a way of organizing primary care that emphasizes coordination and communication among patients and providers, has taken root. The formation of the National Committee for Quality Assurance—PatientCentered Medical Homes (NCQA-PCMH) Recognition Program and its associated standards has assisted many clinicians seeking to evolve with these changing models of medical practice. Not only have PCMHs been shown to improve patient health outcomes, but they also have been associated with decreasing overall health care costs. Additionally, there are many benefits of primary care practice sites to develop into a PCMH, including eligibility for both private party and government reimbursement. KEY WORDS: Institute for Healthcare Improvement, National Committee for Quality Assurance, Patient-centered medical home, Triple Aim. ABBREVIATIONS: ACIP = Advisory Committee on Immunization Practices, CCHAP = Colorado Children’s Healthcare Access Program, CMS = Centers for Medicare & Medicaid Services, FQHC = Federally Qualified Health Center, HRSA = Health Resources Services Administration, IHI = Institute for Healthcare Improvement, NCQA = National Committee for Quality Assurance, NCQA-PCMH Recognition Program = National Committee for Quality Assurance—Patient-Centered Medical Homes Recognition Program, PCMH = Patient-centered medical home, USPSTF = United States Preventive Services Task Force. Consult Pharm 2014;29:347-50.
THE CONSULTANT PHARMACIST
MAY 2014
Patient-centered medical homes (PCMHs) are a way of organizing primary care that emphasizes coordination and communication among patients and providers. The formation of the National Committee for Quality Assurance—Patient-Centered Medical Homes (NCQAPCMH) Recognition Program, and its associated standards, has assisted many practices that are looking to evolve with the changing models of medical practice. This model offers a venue that enables clinicians to be paid by both private and government health plans for the medical care conducted.1 PCMHs are gaining support from multiple payer models, and this recognition allows for primary care practice sites to get involved in the process.2 As the benefits of PCMHs are seen in the health system, both government and private health care payers are looking more and more for this type of primary care, and various payment incentives are arising.2 Furthermore, health care providers practicing within a model recognized by the National Committee for Quality Assurance (NCQA) have opportunities for financial return on services completed outside the patient visit. Overall, the health care system in the United States is more costly than those of many other nations, while producing inferior health outcomes. This has led the Institute for Healthcare Improvement (IHI), a nonprofit organization focused on partnering with patients and health care professionals to test new models of care, to develop a plan to better use the resources currently being devoted to health care. In 2007, IHI created three main objectives to meet this goal, known as “The Triple Aim”:
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Patient-Centered Medical Homes: Recognition and Reimbursement—Part 3
insurers that support the PCMH model include certain WellPoint, Aetna, Humana, United Healthcare, Blue Cross Blue Shield, and Kaiser Permanente plans. For example, in January 2012, WellPoint, which is a health care insurer for roughly 34 million Americans, announced that its whole network is devoted to the PCMH model.4 By improving the delivery of health care up front, insurance companies can decrease overall health care costs by reducing the money spent on complications, hospital admissions, and duplicative tests. For example, the Group Health, Seattle, Washington, reported a 25% reduction in hospital readmissions and inpatient stays as well as an estimated $15 million reduction in expenses from 2009 to 2010.9 This demonstrates the gaining momentum of reimbursement opportunities for PCMHs as the evidence builds for improved patient health outcomes. Despite the advantages of the PCMH model, there are a number of barriers to successful implementation. Technology, such as electronic health records, must be in place for efficient communication among various health care professionals. This is a common issue when trying to incorporate an entire team of health care workers involved in the care of a patient, including pharmacists practicing in various settings.6,10 For example, community pharmacists often lack sufficient access to patients’ health care records, which often delays appropriate care because of the need to call or fax the physician office regarding medication therapy questions and recommendations. For PCMHs to become fully functional, all health care providers must buy into the idea of teamwork to provide coordinated care in an efficient and effective manner.10 By recognizing and addressing barriers to successful implementation and operation of a PCMH, health care provided in these practice settings can continue to evolve and advance. Because of the current weaknesses and deficiencies in the health care system, there is increasing support for the establishment and expansion of PCMHs. Not only have they been proven to improve patient health outcomes, but they also have been associated with decreasing overall
THE CONSULTANT PHARMACIST
MAY 2014
health care costs. There are many benefits of primary care practice sites to become an accredited PCMH, including being eligible for both private-party and governmentsponsored reimbursement. PCMHs involve a variety of health care professionals, which allows for the establishment of a solid interdisciplinary team to provide efficient continuous patient care. NCQA provides a set of welldefined standards for practice sites assessing the feasibility of becoming a recognized PCMH. In conclusion, PCMHs can have an increasingly positive impact on the health care system if embraced by health care professionals.
Eric Stack is a 2014 PharmD candidate, Ohio Northern University, College of Pharmacy, Ada, Ohio. Karen Kier, BSPh, PhD, RPh, BCPS, BCACP, is professor of clinical pharmacy, Ohio Northern University, College of Pharmacy. For correspondence: Karen Kier, PhD, College of Pharmacy Practice Department, Ohio Northern University, College of Pharmacy, Robertson-Evans 236, 525 S. Main St., Ada, OH 45810; Phone: 419-772-2285; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.347.
Previous Articles in This Series • Stack E, Kier K. Key aspects and health care benefits of patient-centered medical homes. Part 1 of 3. Consult Pharm 2014;29:196-9. • Stack E, Kier K. Patient-centered medical homes: standards for approval. Part 2 of 3. Consult Pharm 2014;29:275-8.
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Student Forum • Improve the health of the defined population • Enhance the patient care experience (including quality, access, and reliability) • Reduce, or at least control, the per capita cost of care3 This means that there should be a concentration on patient-centered care (which includes families), and a coordination of care—the backbones of PCMHs.3 Medical homes can provide an avenue for decreasing overall health care costs, especially since estimates are that 30% of the United States’ health care costs are unnecessary (duplication of services, etc.). There is vast room for improvement in health care, and the PCMH model is a foundation that can be effectively built upon to meet this pressing need.4 In concert with objectives of The Triple Aim program, there are numerous examples of PCMHs that have demonstrated impressive results. For example, HealthPartners, located in Bloomington, Minnesota, saw a 39% decrease in emergency department visits and a 40% reduction in hospital readmissions.4 The federal government is also supporting PCMHs. The Affordable Care Act (ACA) recognizes their use for patients on Medicaid with chronic disease states to help increase the coordination of care.5 Thirty-one states are either in the process of setting up or running a PCMH pilot project based on Medicaid or the children’s health insurance models. Similarly, there are state Medicaid programs that are using the PCMH model, such as the Colorado Children’s Healthcare Access Program (CCHAP). This pilot project, created in 2006, involves almost 7,000 children in the Denver metropolitan area being cared for at seven private, primary care practice sites. To promote private practices to get involved with such a project, CCHAP increased payments for Medicaid patients if they offered preventive health services. As a result, there was an increase in immunization rates, a decrease in number of emergency department visits, a greater number of preventive health appointments, and lower overall Medicaid costs. By January 2010, an estimated 93% of privately operated pediatric practices in Colorado were involved with the project, which represents 116 primary care practices and 405 providers. This is a prime example of how a pilot project quickly expanded to meet the
348
demand set forth from the government, while receiving adequate reimbursement in return.6 In addition, ACA supports the use of preventive care, especially for patients on Medicare and Medicaid. Currently, any preventive health measure ranked as Grade A or Grade B by the United States Preventive Services Task Force, an independent panel that evaluates the latest scientific evidence on clinical preventive services, or any adult immunization recommended by the Advisory Committee on Immunization Practices, a group of medical and public health experts that advises the Centers for Disease Control and Prevention, is a reimbursable expense for PCMHs. This reimbursement model appropriately corresponds to the increasing emphasis on preventive health, encouraging overall patient well-being.7 Likewise, the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice is a federally funded demonstration project developed to help manage the health care of Medicare beneficiaries. In 2011, Donald Berwick, former administrator of the Centers for Medicare & Medicaid Services, said, “This project will go a long way toward creating comprehensive and coordinated health care opportunities for the many people on Medicare who rely on FQHCs as their primary medical providers.” This demonstration program, begun in September 2011 and set to continue through August 2014, is designed to help Medicare patients use PCMHs, especially to help control chronic disease and to help coordinate an integrated health care network. Each of the 469 FQHCs gets paid on a monthly basis for the primary health care of Medicare patients. The six standards set forth by the NCQA-PCMH recognition program are strongly incorporated into the success of these programs on the quality of health care services provided.8 Currently, there are numerous insurance companies pushing for the use of services based on patient-centered care and an increased accessibility to primary health care, core aspects of the PCMH.4 Widespread support exists for PCMHs from payers, including more than 90 private commercial insurance plans, Medicaid programs in 42 states, and federal agencies such as the Veterans Administration and the Department of Defense. Some commercial
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Student Forum References 1. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home PPC-PCMH. National Committee for Quality Assurance. Available at http://www.ncqa.org/Portals/0/PCMH%20 brochure-web.pdf. Accessed January 26, 2013. 2. National Committee for Quality Assurance. NCQA’s Patient-Centered Medical Home (PCMH). National Committee for Quality Assurance 2011. Available at http://www.ipfcc.org/advance/topics/PCMH_2011_ Overview_White_Paper.pdf. Accessed January 26, 2013. 3. Institute for Healthcare Improvement. The Triple Aim: Optimizing Health, Care and Cost. Healthcare Executive 2009. Available at http://www.ihi.org/offerings/Initiatives/TripleAim/Documents/ BeasleyTripleAim_ACHEJan09.pdf. Accessed January 26, 2013. 4. Nielsen M, Langner B, Zema C et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative 2012. Available at www.pcpcc.net/guide/benefits-implementing-pcmh. Accessed January 26, 2013. 5. Patient-Centered Primary Care Collaborative. Health Care Reform. Patient-Centered Primary Care Collaborative. Available at http://moo. pcpcc.net/content/health-care-reform-and-patient-centered-medicalhome. Accessed January 26, 2013.
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6. American Hospital Association Committee on Research. AHA Research Synthesis Report: Patient-Centered Medical Home (PCMH). American Hospital Association 2010. Available at www.aha.org/research/ cor/content/patient-centered-medical-home.pdf. Accessed January 26, 2013. 7. Long A, Bailit M. Health Reform and the Patient-Centered Medical Home: Policy Provisions and Expectations of the Patient Protection and Affordable Care Act. Safety Net Medical Home Initiative 2010. Available at www.co.fresno.ca.us/viewdocument.aspx?id=47522. Accessed January 26, 2013. 8. U.S. Department of Health and Human Services. New Affordable Care Act Support to Improve Care Coordination for Nearly 200,000 People with Medicare. U.S. Department of Health and Human Services 2011. Available at http://www.hhs.gov/news/press/2011pres/06/20110606a. html. Accessed January 26, 2013. 9. Patient-Centered Primary Care Collaborative. Achieving the Triple Aim: Quality, Outcomes and Cost. Patient-Centered Primary Care Collaborative 2013. Available at http://www.pcpcc.net/content/achievingtriple-aim. Accessed February 27, 2013. 10. Abrons JE, Smith MA. Patient-centered medical homes: primer for pharmacists. J Am Pharm Assoc 2011;51:e38-e50.
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