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Francois de Brantes
De Brantes

Revised NCQA standards still focused on process, critic says

By Andis Robeznieks
Posted: March 11, 2014 - 1:45 pm ET

The National Committee for Quality Assurance's revised standards for patient-centered medical homes received a generally positive reception, but one critic says the changes don't address the program's biggest problem: a focus on process over outcomes.

The revisions, which build on previous standards released in 2008 and 2011, include an emphasis on team-based care and high-need patients, an integration of behavioral health into primary care, and a performance measure gauging resource stewardship.

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Criticism of the organization erupted after a recent study in the Journal of the American Medical Association by RAND Corp. researchers found that after three years, there was scant difference in the care delivered in 32 NCQA-recognized medical home practices and 29 practices without NCQA recognition.

Dr. Michael Barr, senior vice president of the American College of Physicians division of medical practice, served on committees that helped develop the 2011 and 2014 revisions. Barr said he was impressed with the thoroughness of the NCQA revision process, especially with how it identifies gaps in the standards and assesses a standard's value.

“They do a robust analysis,” he said. “What is being asked for is directly related to quality healthcare.”

Barr noted that care was taken to align the revised standards with HHS' National Strategy for Quality Improvement, the CMS' requirements for the meaningful use of health information technology, and other aspects of the drive to increase quality, lower costs and improve the patient experience, known as the triple aim.

The revised standards also put greater emphasis on integrating behavioral health into primary care, which drew praise from Dr. Sue Bornstein, executive director of the Texas Medical Home Initiative and chairwoman of the Texas Medical Association's committee on primary care and medical homes.

But Bornstein also criticized some aspects of the recognition program.

Many practices, she said, could struggle to collect data to satisfy new resource stewardship measures. “Without better data, most practices don't know exactly what healthcare costs are—there is very little transparency and very little consistency,” Bornstein said.

The NCQA has recognized more than 7,000 practices as medical homes, but Bornstein noted that these practices have achieved that designation without any onsite interaction with the NCQA—the process is all done by telephone or correspondence. Without meeting in person, Bornstein questioned the ability of the NCQA team to get a sense of what practices are doing, what their goals are and what's the direction of their leadership.

The NCQA's medical homes program has drawn criticism from Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, and Glenn Hackbarth, chairman of the Medicare Payment Advisory Committee, who said at a recent meeting that he feared “a lot of bells and whistles” are adding costs without proof of their value.

But Susan Stuard, executive director of the Taconic Health Information Network and Community in Fishkill, N.Y., worked on the NCQA standards committee and made a plea for Hackbarth and de Brantes to show some patience. She compared the NCQA medical home recognition program to a marathon runner's training regimen. Once completed, it attests to a runner's ability to compete in a marathon—but with no sense of how long it will take them to complete the race.

“I completely understand why those two gentlemen are impatient with the rate of change, but it's unrealistic to think it can happen that fast,” Stuard said. “This is building capabilities and muscles that the fee-for-service environment and previous primary-care financial arrangements didn't cultivate.”

Neither this explanation nor the new standards satisfied de Brantes who said the time NCQA took on revisions could have been better spent.

“I personally don't think the new standards change much of anything because there still aren't any measures reporting outcomes of care,” de Brantes said.

Outcomes could be measured by using electronic health records and all-payer databases to generate data on ambulatory-care sensitive emergency department visits, hospital admissions and hospital readmissions, he said.

“Instead, all you're looking at is whether you have System X or System Y in place,” de Brantes said. “But are you delivering better care? Are you getting better outcomes? No, but you've defined a 'Care Delivery Team.' Whoop dee doo.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks

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