National Committee for Quality Assurance and the Value of the Patient-Centered Medical Home
An interview with Margaret E O’Kane, President, and Manasi A Tirodkar, PhD, MS, Research Scientist, National Committee for Quality Assurance
Years of rising health care costs and variability in the quality of care provided have caused the Centers for Medicare and Medicaid Services (CMS) and other private organizations to demand more accountability from health care providers. That demand has led to a number of different initiatives, such as shared savings programs, accountable care organizations, and more reimbursement incentives for practitioners. However, there is perhaps no more recognizable seal indicating quality health care performance than that of the National Committee for Quality Assurance (NCQA), which gathers the best research in the industry to develop the best health care solutions.
The NCQA is a private, not-for-profit organization dedicated to improving health care quality. Founded in 1990, it has helped to drive a number of advancements in medical practices by encouraging greater accountability for care by elevating the issue of health care quality and bringing it to the forefront of national dialogue. To do so, the NCQA has formed a consensus on some of the key issues in health care by working with premiere industry professionals, including policymakers, doctors, and patients. That consensus manifests itself in the NCQA’s central formula for health care improvement: measure, analyze, improve, repeat. This method has helped the organization to develop new standards, tools, and measures for how the providers can evaluate the effectiveness of their care processes and improve them in the future.
At the center of these tools is the NCQA’s patient-centered medical home (PCMH), a model of care for primary physicians to improve comprehensive care through enhanced coordination and communication among practitioners. Medical homes are often instrumental in helping to manage costs for both patients and hospitals, but perhaps more importantly, they are often also associated with improved patient and provider experiences. Today, there are a number of nationwide PCMH recognition accreditation programs, but none are as widely used as that of the NCQA due to the organization’s commitment to inspiring not only a better quality of care, but also better patient relationships and improved access to care.
Margaret E. O’Kane was president of the NCQA when it was first founded in 1990 and still holds that position today. With her leadership, the NCQA has become one of the most influential health care organizations in the country. Ms. O’Kane has been honored numerous times for her achievements and work with the NCQA and was named one of the “100 Most Influential People in Health Care” in 2015 by Modern Healthcare magazine. In addition, Manasi Tirodkar, PhD, is one of the lead researchers on a new project experimenting with how PCMH models can be applied to an oncology care setting. Journal of Clinical Pathways spoke with Ms. O’Kane and Dr. Tirodkar about the development of the PCMH program, its past successes, and plans to expand beyond primary care in the future.
What is the value of obtaining PCMH recognition by the NCQA, from the perspectives of practitioners, payers, and patients?
MO: The medical home is a completely different way of viewing primary care. So, instead of a system that is reactive and deals with the patient when the patient comes in, PCMH integrates care management and population management down at the practitioner level. So, it is actually asking practices to take on a whole lot more responsibility for the right things getting done and for the patients doing well. NCQA has had a lot of experience with disease management programs that operate outside of the practice; and, while some of those have been effective, there’s something about your doctor or your nurse or your team that seems to be more compelling to patients, and we see much higher rates of participation. So, it builds on the strengths of the doctor-patient relationship in a really positive way. It is also a way of working with primary care societies to operationalize what primary care is really meant to be, and that is at the hub of integrating care. It seems to be most important for the most complicated patients—the patients who are seeing multiple doctors who may all be on a different page—and for people with chronic conditions who may have a hard time keeping up with their meds and so forth. So, the benefits are usually easier to see in patients with particular challenges.
There are also requirements for enhanced access, because a lot of people’s illnesses don’t occur between 9 am and 5 pm. So, having a way to get access to care has been shown to keep people out of the emergency room. And being on top of their care keeps them out of the hospital, in the best-designed program.
Would you say this ultimately helps all three stakeholders: practitioners, payers, and patients?
MO: If it is designed correctly, yes. If the practitioner is just expected to take on all of this new responsibility without any new budget or without care management hiring the team they need to make this feasible, then it isn’t going to work. The American College of Physicians (ACP) published a paper about an ideal payment model where there would be a per-member-per-month care management fee, and you’ll see that in CMS’s comprehensive primary care initiative as well as in other demonstration programs. And that is really critical to success.
The patient needs to be with a practice they feel a connection with, and I think one of the stories that doesn’t get written very often is about how, if you look at Medicare data, patients are actually seeing more than one primary care doctor each year. And so, who is the Medicare home? There needs to be a contract between the patient and the payer and the doctor. And I think that is still an incomplete journey.
There are different levels to PCMH certification, with Level 1 indicating basic satisfaction of PCMH guidelines, Level 2 indicating a novice level of adherence, and Level 3 indicating mastery of all elements associated with PCMH recognition. What do each of these levels mean in the context of improving care?
MO: We developed the program with three levels to help practices ramp up to a full set of capabilities. Level 1 is being ready to start the process. In the early years of the program, there were a lot of practices that received Level 1 recognition, because this is really not what people learned in medical school; this is really a lot of system management that works to surround the patient and the practitioner in a very different way. It took a long time. So, since the PCMH program started, we had a distribution that started out with mostly Level 1’s. As a result, as research studies began to come out assessing how the adoption of the PCMH model and NCQA recognition specifically impacted outcomes, practices of all levels were pooled, which masked improvements more likely to be achieved in the Level 3 practices. In initiatives in which a larger number of practices achieved Level 3 or they used later versions of our standards (2011 vs 2008), the studies showed more consistent, positive impact.
Now, we hardly have any Level 2s. What’s happening is that there’s a maturing of the program in the markets where groups have really come together as a community or where the state has really deliberately worked with practitioners to make this model work. So we’re beginning to ask ourselves whether we want to continue having Levels 1, 2, and 3. We believe the model and the market have matured enough to warrant a change in approach again. Rather than issuing a Level 1 recognition, we think we can identify a specific cut point within the requirements that would distinguish a fully functioning medical home and one that is not yet there. Those in progress can demonstrate that commitment by their engagement in our recognition process. Once they have put enough features in place, they would become fully recognized. We anticipate having a means of also acknowledging those practices that have exemplary capabilities or outcomes on specific topics of interest, such as behavioral health integration or patient engagement.
The PCMH model isn’t specialty-specific, but many oncology programs have implemented the PCMH model in their oncology practices, with similar success. Why do you think this model applies well to oncology practices?
MO: We have a Patient-Centered Specialty Practice Recognition program, but that is less of a medical home model and more of a model for coordinating with primary care. I think that oncologists have made the argument that, during the treatment phase, the oncology practice really is the patient’s medical home. Dr. [John D.] Sprandio’s practice in Pennsylvania, [Consultants in Medical Oncology and Hematology], which came through with an oncology PCMH program before we had a specialty practice program, shows a lot of the benefits of that holistic model.1 Now, we’re actually in the process of trying to figure out what is the right paradigm for oncology, because not every specialty is the same. When we think of behavioral health, oncology, maternity care—I think those are situations in which the demands are more hands-on than just what is good coordination with primary care. So, we’re in the process of examining our own premises this year, and you’ll have to stand by for that. That’s the work Manasi is doing in a [Patient-Centered Outcomes Research Institute] PCORI-funded project with a patient-centered care oncology practice.
MT: We’ve taken the patient-centered specialty practice model and enhanced it for oncology to try and answer the question of how well the model applies to oncology care. We’re currently in the third year. We’re studying the impact on patient experiences, quality of care, outcomes, and cost and utilization of services. We’re still in the middle of implementation, but what we have found is that the standards or the functions that oncology practices can at least start to measure are tracking and coordinating tests and medication, as well as quality improvement. And the functions that they can most commonly demonstrate are referral coordination and care management. So those are some of our early results after implementation, and we now have a published paper about that.2
MO: I think what Manasi’s early data tells us is that this is a place that people want to go with the program and one we want to take it to—both on the specialty side and on the primary care side. We would just need to have more measures of actual performance. I think people are feeling impatient with structure and process measures, such as how well you are organized and whether you have off-hours care. What people really want to see is whether your systems and processes are working to deliver higher quality care. And that is one of the nice things about the PCORI project—it has both. Manasi is also working on some other measures on oncology.
MT: We are developing new measures for cancer quality, and we’re doing it in response to CMS’s release of the Oncology Care Model description, which will be launched this year. Two categories of measures are both in development right now. The first is guidelines concordance—
MO: Which is a big deal and something important in clinical pathways.
MT: Right. The guidelines concordance measure is specifically for NCCN-preferred regimens. It asks if practices are prescribing treatments in accordance with those guidelines. There are two of those types of measures that we’re developing: one is for metastatic lung cancer, and the other is for stage 3 colon cancer.
The second category of measures is patient-reported outcomes, where we’re looking at systematic assessments of patient symptoms at each chemotherapy visit using a patient-reported, or validated patient report tool for a battery of symptoms. These are used by the care team to ask the patient about their symptoms. So the first step of measurement—the first question we ask providers—is, “are you asking patients about their symptoms?” The second question is whether or not the care team is managing the symptoms that patients report they have problems with. So, if they report that they have pain the first day of the month, the next time they’re there for chemotherapy, has that pain been managed? This patient-reported symptom tool should be asked of the patient every time they come in for their chemotherapy. And it’s actionable for the provider, because they should be using it to manage symptoms.
MO: We think this is the paradigm for a lot of kinds of care. And it is kind of surprising how little of that has actually been going on. I think it’s where CMS needs to be congratulated for demanding a lot more from the system in terms of how your patients are experiencing your care—what kind of side-effects are they having, and are you trying to manage them? And cancer is probably the best example of that. Personally, I think there has just been too little effort on that front; certainly that doesn’t mean everyone, but in general, as a category, oncology care hasn’t been as patient-centered as I believe it should be.
Value is one of the core principles of NCQA. How does PCMH change the way value is delivered to their patients?
MO: The key to this program is getting alignment of those different parties: the payer, the patient, and the provider. For the patient, a care experience is very important. I think, for many people, not having to walk in and say your name again, but knowing that the practice has all your information and is prepared for you—that is a great value to you as a patient, to have a practice that really values you.
For the provider, I think primary care, in particular, has been kind of a hamster wheel—to use a tired metaphor—of troubles. The physicians tend to be underpaid, they’re working in isolation from the specialties, and so many different things are being ordered without other people knowing. So, there are a number of patient values that just come from that. We have done focus groups with patients who have chronic conditions, and we have heard them say things like, “My doctor has my back,” which is great to hear, because a lack of organization is really obvious to a patient who is very sick. So, it’s noticeably satisfying if a facility is staffed right and paid right.
And then, for the payer, the dysfunction that comes from a lack of coordination can create a lot of health care costs. Redundant tests, drugs not working in tandem, patients going to ED because they couldn’t get in to see their doctor—these types of things drive up costs. If you can get the right alignment though, you can get a win across the board, which is really a marvelous thing.
And all of that is the same in cancer. I knew of a patient who had lung cancer and the lack of coordination is really, at times, shocking to me. And the fact that this patient went to see a surgeon first and was told he couldn’t speak to a medical oncologist or radiation oncologist until he was discharged from surgery was, to me, unreasonable. There were weeks of agonized waiting with very little information on his prognosis and what he could be expecting in terms of treatment, which is unnecessary. This patient would have certainly had a different experience were he in an oncology medical home.
We’re very proud of this work. Health care has never suffered from a shortage of good people and smart people who want to do the right thing, but it has suffered from the ability of people to organize their work in a way that maximizes the benefit to the patient while minimizing cost. And that is what we’re all about.
MT: I agree 100%. It will be interesting to see how this develops in the future.
2. Tirodkar MA, Acciavatti N, Roth LM et al. Lessons from early implementation of a patient-centered care model in oncology [published online ahead of print September 29, 2015]. J Oncol Pract. doi:10.1200/JOP.2015.006072.