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.”