Proposed Health Policy Commission Patient Centered Medical Home Certification Standards

The Massachusetts Medical Society (MMS) supports the provision of high-quality, high-value primary care through patient-centered medical homes (PCMH). The MMS has been committed to helping practices transform to more efficient, coordinated deliveries of care through our Physician Practice Resource Center, through continuing medical education courses and conferences, and through research published in the New England Journal of Medicine. However, given the existing, widely-recognized NCQA certification, MMS questions the necessity for the Health Policy Commission (HPC) to create a different PCMH certification program that substantially modifies the NCQA program.

Taking a step back, the MMS wishes to commend the HPC on its decision to create a certification based upon the existing, widely-recognized NCQA PCMH certification rather than creating a PCMH certification from scratch. As recommended in initial written comments last March, the MMS continues to supports a process whereby physician practices and other providers already certified by the NCQA—or those in the process of applying—would be deemed certified by HPC as a “Qualified PCMH.” The HPC could then use modifications to the current NCQA framework to establish the “Best Practice PMCH” certification.

If the HPC decides to continue with modification the NCQA certification for both levels of HPC certification, MMS urges the Commission to seek ways to financially incentivize its certification and to subsidize the investment needed by practices to obtain it. Absent such incentives, there is currently little reason for provider organizations to go beyond the National Committee for Quality Assurance (NCQA) certification and seek an HPC PCMH certification.

If the HPC chooses to modify the NCQA framework, it is imperative that the HPC strives to reduce the number of modifications to those that have a unique Massachusetts-based value that warrants the additional investment needed on top of the complex NCQA certification. We urge the HPC to simplify the necessary modifications including the streamlining of required documentation, and to limit the modifications solely to the “factor level” with minimal changes to existing NCQA scoring. We were pleased to see some simplification from HPC’s first iteration of the proposed modifications to this current version. We think additional simplification is necessary.   

The MMS encourages the HPC to limit any new factors to only the highest priority concerns, and to ensure than any modification is evidence-based and is crafted to be minimally burdensome. HPC must consider wide variations in patient populations and in the size and resources of those practices that serve them. The HPC does not need to be reminded of the many challenges already facing primary care practices—including declining reimbursements and added administrative burdens—that make additional infrastructure and practice change difficult. 

Existing Financial Incentives

The HPC asked commenters to describe the types of financial incentives received for PCMH transformations including incentives from payers. Our response, informed by discussions with MMS physician practice specialists and with physician members, is that practices receive no financial incentives from payers specifically for obtaining PCMH certification. Some modest benefits that may arise organizationally over the long-term from practice efficiencies, from improvements in quality measures and related incentives in certain contracts, and from total medical expenditure reductions (which may be mitigated by lack of or limit of upside risk), would be seen through a standard NCQA certification, and not necessarily by those practices seeking certification through the HPC’s process.

Threshold for HPC PCMH Certification

The MMS is concerned that the initial threshold for application to the Qualified HPC certification is too high. Specifically, limiting the provider groups that are seeking HPC certification through Pathways 1 & 2 to providers who have received 2014 NCQA Level 2 recognition is too high. Many providers whose NCQA scores fall into the upper end of Level 1 are high-functioning providers who have achieved substantial care transformation. Their practices largely reflect the vision of patient centered medical homes—they just may not have the infrastructure to complete a certain portion of the required components. Allowing practices that fall into the upper end of 2014 Level 1 to qualify to apply to be an HPC “Qualified PCMH” would encourage many smaller practices that cannot immediately achieve 2014 Level 2 status to still pursue practice transformation in substantial ways. Cutting off Level 1 NCQA practices from HPC certification could further dissuade such practices that may not reach Level 2 certification in their first attempt from seeking practice improvement and participating in the PCMH model. 

Comments on Specific Modifications

The MMS agrees with the spirit of HPC’s modification of Priority Factor 6.A.3, which would require that one of the three chronic or acute measures that a practice receives data on be related to behavioral health. However, the MMS has some concern that not every practice would have a sufficient patient population meeting the specified inclusion requirements. Perhaps adjusting the modification to be “subject to sufficient patient populations” would help allay this concern. 

The MMS has substantial concern about the two new priority factors added to the Behavioral Health Integration domain. The new HPC factors require practices to collect comprehensive health assessments that include anxiety screening and substance use disorder (SUD) screening, each using standardized tools. Primary care physicians are under increasing pressures that have constrained patient visits to 15-20 minutes. Most systems have scheduling with shorter times than this. While many administrative additions to mandated elements of clinical visits may seem reasonable in the abstract, they are not always clinically indicated for many patients and are inefficient when considered in analysis of how patient contact time is used. Physicians already have an innumerable and growing list of screenings to touch upon in a well visit, including other mental health conditions, safety and lifestyle. All physicians are trained to respond to clinical indicators and patient concerns in these areas. Adding two additional screenings is not an area in which the HPC should modify the current NCQA certification. Providing flexibility to physicians in this domain is paramount; no practice population is the same, and physicians should be able to cater their practices and allocate their precious patient time accordingly. Some practices may want to limit such screenings to new patients, or to incorporate them less formally into the general physical exam work-up rather than offering another standardized assessment. Lastly, screening tools for anxiety and substance use are currently less developed than those for depression, for example. There is little choice in tools validated for the primary care setting for anxiety, and for substance use- especially among adolescents. While the MMS appreciates the HPC’s offer to consider providing a consolidated diagnostic tool, it is important to remember the complexities of screening tool development, and the importance of ensuring that any tool is properly validated.

Additionally, the MMS has concern about the new factor in the behavioral health integration domain requiring practices that have care managers to have them be qualified to identify/coordinate behavioral health needs. As mentioned earlier, each provider organization has different patient populations. While many would practices would undoubtedly benefit from care managers qualified to identify/coordinate behavioral health needs, there are some whose patient population would be better served by care managers with alternative areas of specialization. Some primary care practices may specialize in patients with hepatitis C or with diabetes. Such practices would not be better served by hiring a care manager with behavioral health training over a care manager with experience managing complex infectious or chronic diseases. There is additional concern that such a factor could discourage practices from hiring additional care managers, if such hire comes with the added requirement that the care manger have this experience and/or training. 

Technical Assistance

The MMS appreciates the HPC’s commitment to offering technical assistance. The areas highlighted at present seem reasonable. However, technical assistance is really most needed not by practices who have achieved NCQA Level 2 and are seeking HPC certification, but those that are trying to work their way through Level 1. It would be incredibly beneficial to find ways to help practices to begin the process of practice transformation. 
    
Thank you for the opportunity to provide feedback for this important program.
 
The Massachusetts Medical Society, with more than 24,000 physicians and student members, is dedicated to educating and advocating for the patients and physicians of Massachusetts. The Society, under the auspices of NEJM Group, publishes the New England Journal of Medicine, a leading global medical journal and web site, and NEJM Journal Watch alerts and publications covering 13 specialties. The Society is also a leader in continuing medical education for health care professionals throughout Massachusetts, conducting a variety of medical education programs for physicians and health care professionals. Founded in 1781, MMS is the oldest continuously operating medical society in the country.

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