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Margaret O'Kane, NCQA
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Reform Update: NCQA previews new medical home standards


By Andis Robeznieks
Posted: March 10, 2014 - 2:00 pm ET
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The National Committee for Quality Assurance, under increasing pressure to demonstrate the value of its recognition programs, previewed new patient-centered medical home standards (PDF) intended to put more emphasis on team-based care, integrating behavioral health and sustaining practice transformation.

The NCQA has now recognized more than 7,000 practices in which about 36,000 clinicians practice as medical homes. But a recent Journal of the American Medicine Association study, conducted by RAND Corp. researchers between 2008 and 2011, found little quality improvement in 32 Southeast Pennsylvania practices that had NCQA recognition compared with 29 that were not recognized.

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NCQA President Margaret O'Kane noted Monday during an online question-and-answer period that the JAMA study reflected a snapshot in time capturing the early days of the medical home movement with practices using the 2008 standards, which were revised in 2011 and now again in 2014.

“We have a lot of respect for the researchers,” O'Kane said. But she added that the medical home is a “moving target” that continues to evolve. A new NCQA white paper (PDF), she said, describes other studies that have found the medical home can improve quality, patient experience, continuity of care and disease management while lowering hospital admissions and emergency department visits.

NCQA medical home recognition is being used in primary-care improvement initiatives in 37 states and the District of Columbia. In 14 of those states, the initiatives are private-payer efforts and in seven they operate under public programs. Seventeen states have both private and public health plans involved.

The NCQA recognition program has been criticized, however, for relying too much on process or structural measures and not enough on outcomes.

The NCQA recognition program has been criticized for relying too much on process or structural measures and not enough on outcomes.

“The NCQA PCMH survey should never be used by itself to assess a true patient-centered medical home, and should never be the basis for rewarding practices,” Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, wrote in a blog post responding to the recent JAMA study. “In fact, its usefulness has run its course. In an age of wide adoption of (electronic medical records) and registries, the focus of incentives has to shift entirely to the results of the care provided. We've already lost enough time on this. No need to lose any more.”

The NCQA acknowledges this argument in its new white paper and notes that “working toward measuring outcomes in PCMHs is a top NCQA priority,” but that practices often lack the data needed to track hospital admissions and emergency room visits. They may also lack the volume of certain patient types to “support robust case sampling.”

“Structural measures are the best option until we have consensus and good data sources on the best outcome measures for PCMH evaluation,” according to the white paper. “Further, structural measures are useful as a roadmap that tells practices what they need to do to become PCMHs.”

The NCQA medical home recognition program also came under fire at the March 6 meeting of the Medicare Payment Advisory Commission, also known as MedPAC.

While acknowledging he was “hardly an expert on this,” MedPAC Chairman Glenn Hackbarth said he was worried that the NCQA model had become “gold plated” with “a lot of bells and whistles added.

“My impression is that not all of them have really been validated as adding value, but they add cost,” Hackbarth said.

The criticism came up during a discussion on possible replacements for the Patient Protection and Affordable Care Act's Medicaid parity provision, which reimburses Medicaid primary-care services at Medicare rates for 2013 and 2014. One option discussed was per-beneficiary per-month payments (PDF)—a popular payment method for medical home services.

Hackbarth said he was looking for other ways to address concerns about access to primary care without “putting all of our eggs into the medical home basket.”

O'Kane, though, stressed that the NCQA's standards for medical homes are a project of great ambition. “We are trying to change a delivery system,” and doing so requires constant learning, measuring and improving, she said. “This is a formula that is incredibly powerful.”

Physician groups respond to proposals to add amendments to SGR repeal

Physician groups did not respond favorably to a proposal by House Republicans to pay for the repeal of the Medicare sustainable growth-rate formula by delaying implementation of the Patient Protection and Affordable Care Act's individual insurance mandate.

The idea, they said, wound inject the poisonous politics of healthcare reform into a genuine effort to fix the longstanding problem.

American College of Physicians President Dr. Molly Cooke noted the months of hard work and bipartisan cooperation it took to get this close to an SGR repeal.

“Yet this historic bipartisan opportunity to eliminate the SGR, once and for all, is at risk of being upended because of partisan disagreements on how to address the budget impact of SGR repeal and on other policies unrelated to the SGR itself,” Cooke said in a statement. “If either political party or chamber decides on its own to attach provisions to the bill that are unacceptable to the other, it would kill any chance for SGR repeal.”

It will cost about $138 billion to scrap the SGR. A report by the nonpartisan Congressional Budget Office estimated that a one-year delay of the individual mandate would save about $9 billion over 10 years because the government would pay less for insurance subsidies and states' expenses for new Medicaid enrollees because fewer people would get coverage.

American Osteopathic Association President Norman Vinn said his organization would not support “any approach to advance this important legislation that potentially interferes with patient access” to care.

Sixteen legislative “patches” (PDF) postponing SGR-driven cuts have been enacted in the past 11 years at a cost of $153.7 billion.

Dr. Joshua Jacobs, president of the American Academy of Orthopaedic Surgeons, also noted his concern that financial “offsets are being considered that were not agreed to in a bipartisan, bicameral fashion.” He called on Congress to find a way to pay for SGR repeal that “would provide a real opportunity to see this legislation enacted.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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