The Dissenter’s Viewpoint: There Has to Be a Better Way to Measure a Medical Home

I apologize to Drs. Antonucci and Ho for the inaccuracy in my response to their article. NCQA did not contact either of them at the time of my post. Our team reached out to them via email earlier this week.

Critiques such as this commentary from Drs. Antonucci and Ho are challenging us to think differently about the recognition process - and we are listening. Multi-stakeholder input from the field, commentaries such as those from Drs. Antonucci, Ho and Bujold, reports from industry, and robust evaluations of PCMH demonstration projects are driving many of the changes we are considering in the redesign effort. In addition, over the past few months NCQA has conducted 17 focus groups with a variety of stakeholders including small/large practices, professional societies, health plans, hospitals, accountable care organizations, community health centers, health IT companies, PCMH Certified Content Experts (CCEs), and representatives of State-based agencies to seek their opinions, hear their concerns, and solicit their recommendations.

Our team is pushing hard to deliver on your expectations for a more engaging and productive recognition program.

Competing interests: Full-time employee at NCQA.

We thank Dr. Barr for his response on behalf of NCQA, although we were disappointed that he failed to address the substance of our criticisms. We note for the record that, as of this writing, NCQA has yet to contact either of us. In addition, one of us (LH) served on a "Technical Expert Panel" for NCQA in 2010-2011. In that capacity, she raised a number of concerns about small practices' ability to complete NCQA certification. Thus far, those concerns have gone unaddressed. All of this reinforces our impression that NCQA is unreceptive to critical feedback from the field.

Furthermore, it seems to us that NCQA's description of procedural reforms misses two critical points.

First, the amount of money and time spent on measurement for accountability is staggering. Were most primary care offices in the US to undertake an NCQA-type certification process, the recurring costs would run into the millions of dollars. It appears highly unlikely that this program would save at least an equal amount of money in downstream quality improvement ( http://media.jamanetwork.com/news-item/patient-centered-medical-home-program-led-to-little-improvement-in-quality-and-no-reduction-in-use-of-services-total-costs/). Direct, indirect and opportunity costs to clinicians and patients for PCMH certification process should be part of any discussion of value.

Secondly, the NCQA program has never been formally vetted in any randomized, controlled trial against any other existing medical home program for cost, ease of use, and downstream results. Rather, it appears to be have been implemented using the "design, disseminate, and hope-for-good-results" model, far from the scientific rigorousness and evidenced-based practices that NCQA itself requires doctors using their program to adopt. If NCQA were a drug or treatment, not one of us would prescribe it for our patients. Oft-cited case-control studies, whether cross sectional or longitudinal, cannot adjust for the bias of a PCMH volunteer versus non-volunteer practice comparison. The NCQA PCMH certification hypothesis should be subject to randomized trials against much less costly alternatives to improve patient care (such as the point-of-service approach we and our colleagues have used for many years).

Payers and policy-makers seem to have been too eager to push PCMH certification without scientific scrutiny. We are now all paying the price and it is very high. We can do better and we should. Dr. Don Berwick of the Institute for Health Care Improvement recently called for physicians to take back their own quality leadership, steered by direction from patient voice. (Berwick DM, Feeley D, Loehrer S. Change from the inside out: Health care leaders taking the helm. Journal of the American Medical Association. 2015 May;313(17):1707-1708.) Recent events at the ABIM have shown how change can occur when we physicians decide to act. We are hoping that these letters will spur some long-overdue changes in how we engage in, demonstrate and improve quality in practice and practice measurement.

Competing interests: None declared

Dear Dr. Andrews, Thank you for underscoring that excessive and redundant documentation demands by quality initiatives create a poorly recompensed burden. As yet another example of how the economics do not compute, one author (LH) spent approximately 74K in opportunity costs on certification, and is now eligible to receive about 24K per year for 3 years (and this payment is dependent on extracting, fulfilling and submitting 12 additional quality metrics quarterly).

In reply to your concern about patients not being able to evaluate a practice because of "...being unaware or forgetting," we'd like to make two points:

First, we strongly believe that patients "know stuff." Basic "stuff" such as: Can they get an appointment when they need one? Is there one person in charge of their care? Do they see one provider that knows them well? OK, this appears to be basic "stuff", but it is the foundational "stuff" that holds up the pillars of primary care - access, continuity, coordination. Moreover, our practices have been easily extracting this information from patients using online non-proprietary patient-entered HowsYourHealth survey (www.howsyourhealth.com). When we talk about patient-entered surveys, we are not talking about your "Healthgrades-type" patient satisfaction surveys that ask if your staff was friendly, or your waiting room pleasing. We are not talking about patients being able to recall the date of their last pneumovax, or rattle off the side effects of their 6 medications. What should be queried, and what a good patient experience of care survey extracts, are the fundamentals of how the patient interacts with the office. Patients "get" this information on a very basic level and they can and should be the evaluators of the quality of care they receive, since they are the ones receiving the care. In the NCQA evaluation model, where practices are the responsible parties for submitting information about their quality of care, the "Lake Wobegon" effect is assured, i.e., all the practices will rank "above average."

Second, it is important to know what your patients do not know. Using the HowsYourHealth survey, one author (LH) found that only 68% of her patients with hypertension knew what to do when they missed a dose of their medication. After the usual reactions (disbelief- that can't be true; annoyance- but I told them; then acceptance- OK, how can I fix this?), she was able to apply targeted education to her population of hypertensives, and in following year found that 75% of her hypertensive population stated they knew what to do when a dose of medication was missed.

Wasson JH, Anders SG, Moore LG, et al. Clinical microsystems, part 2. Learning from micro practices about providing patients the care they want and need. Jt Comm J Qual Patient Saf. 2008:34(8):445-452

Competing interests: None declared

NCQA appreciates detailed suggestions and constructive critiques from PCMH stakeholders, especially from NCQA-Recognized clinicians like Drs. Ho and Anonucci (vol. 13 no. 3 269-272) and Dr. Bujold (vol. 13 no. 3 273-275).

Diverse Research supports the effectiveness of NCQA PCMH Recognition. We are encouraged by Dr. Lewis Sandy's study in the same issue of Annals of Family Medicine (vol. 13 no. 3 264-268), reporting United Healthcare's quality gains, cost reductions and positive experience with NCQA PCMH.

Although NCQA PCMH Recognition is the most widely adopted medical home model, we agree that developing and demonstrating medical home capabilities is a major undertaking. We also believe that the model should evolve, and welcome the input of Annals of Family Medicine authors and readers in that effort.

NCQA is in contact with Drs. Ho, Anonucci and Bujold about their advice and would like to use Annals' forum to extend the invitation to all PCMH stakeholders that we extend to our customers: help NCQA improve the PCMH program by participating in our redesign project, already underway.

Goals of the NCQA PCMH redesign include:

1. Provide more guidance to practices through new channels, including live support, online resources and improved customer service.
2. Introduce a streamlined annual check-in for recognized practices, rather than a full documentation review every three years.
3. Use information generated in the course of daily clinical care to support the recognition process.
4. Redesign our online Survey Tool to be easier to use and more efficient.

NCQA asks that anyone interested in the future of PCMH send suggestions to Ideas4PCMH.

In the second half of 2015, NCQA will pilot new processes with practices going through recognition for the first time and with practices scheduled for recognition renewal.

We will use our experiences to refine the PCMH design and will solicit additional feedback. Lessons learned will influence the development of the fourth generation of NCQA PCMH standards and guidelines, which we will release in 2017.

A commitment to continuous improvement should compel all who believe in the medical home to collaborate to make it better. We welcome advice from Drs. Ho, Anonucci and Bujold, and others.

Competing interests: Employed by NCQA

Question: Why Did They Stop Building Pyramids?

Pyramids are visually, structurally, and metaphorically appealing. Even our dollar bill has a pyramid on its back. And front-line doctors have a pyramid on their backs... let's euphemistically call it a pyramid of accountability.

At the top of the accountability pyramid are, of course, business executives. Just five of whom representing just five healthcare corporations (United, Cigna, Davita, Anthem, Tenet) made off with 70 million this year. Near the top tier are the so-called certifying organizations. Two well-publicized examples just extracted about 100 million between them. The professional medical organizations and government-affiliated regulators, too numerous to count, also mine their share. (1) Next the measurement industry. According to a recent Institute of Medicine (IOM) report the estimated 850 integrated health systems in the US spend about 3.5-12 million EACH for measurement.(2) Finally, at the base, are physicians. Amongst them are the small-time doctors like Antonucci and Ho who ante up tens of thousands in time and money just to stay in the game though no one seems to care if they do. Little wonder that at a recent dinner party an executive admitted that she and some of her colleagues sometimes felt guilty about what was happening in health care... but how could they be expected to change when they were making so much money?

So what is to be done?

Why not make measures of accountability simpler. That is the strong message from the IOM. As an example, Ho and colleagues (3) have shown how the waste inherent in vendor administration of multi-item "patient- experience" measures could be eliminated by a single measure obtained at the point of service. That change might save 300 million dollars.

But just think of all the jobs lost!

Others suggest that physicians at the base of the pyramid should unionize. (4)

That's a possibility... but it didn't work for the ancient Egyptians or Mayans.

We see on the economic landscape pyramids and pyramid schemes everywhere. Pyramids must be good business...

Question: Why did they stop building pyramids?

Answer: Because the money ran out.

John H. Wasson, MD Dartmouth Medical School No conflict of interest.

1. Howard Bauchner, MD; Phil B. Fontanarosa, MD, MBA; Amy E. Thompson, MD. Professionalism, Governance, and Self-regulation of Medicine. JAMA. 2015;313(18):1831-1836. doi:10.1001/jama.2015.4569

2. Vital Signs: Metrics for Health and Health Care Progress. David Blumenthal, Elizabeth Malphrus, and J. Michael McGinnis, Editors; Committee on Core Metrics for Better Health at Lower Cost; Institute of Medicine 2015

3. Lynn Ho, MD; Adam Swartz, MD; John H. Wasson, MD. The Right Tool for the Right Job: The Value of Alternative Patient Experience Measures. 2013. J Ambulatory Care Management. Vol. 36, No. 3, pp. 241-244

4. http://onhealthtech.blogspot.com/2015/01/why-physicians-must- unionize.html?m=1

Competing interests: None declared

One could be unkind and point out that the NCQA has presided over the rapid decline in standing of US health services and outcomes, and one could add the JCAHO. But the common kernel is the administrative approach to patient-centered care, which over and over is institutional system based care. If it worked, ok, let's figure out solid tech networks with community sources of care to work with us independent docs. Heck-let's do that anyway! We lower the admission rate for ambulatory care sensitive diagnosis by 20-25% already, give us a medal for meeting the triple aim now. But it is the current trend of [real] transformation of health systems into financial ventures that acquire what they can, and make their money not through profit, but through financial transactions, that is scary. It looks like 2007 with real estate and collateralized debt obligations, especially because the not-for-profit sector escapes oversight by the Securities and Exchange Commission as to appropriate reserves on loans for transactions. NCQA's PCMH requirements are part of an unsustainable financial bubble. The NCQA atomizes and monetizes all the elements of the 'business' of health systems, as do big EHRs. So-it looks like it is not working in the interests of patients. It is not. The NCQA documents the bases of transactions. We thank the ABFM for moving in a much better direction for measurement based on real practice. I have enough 3-ring binders.

Competing interests: None declared

As a member of a small practice that has certified as a PCMH through NCQA twice, I can certainly backup that the time Dr. Antonucci's practice spent on documentation is accurate. While our practice has benefited monetarily by being a certified PCMH, the benefits barely covered our expenses. There has to be a better way. I am convinced that a well-run Patient-Centered Medical Home does improve the health and well-being of our patients, but taking time away from our patients for documenting how we document, then documenting over and over for each patient what we are doing for them is not helpful. However, I don't know that querying our patients would be a substitute. My experience is that patients are often unaware of or forget what has been discussed and done. Also, patient satisfaction has been found to be inversely related to quality in at least one study, perhaps because working on quality increases the time a patient spends in the doctor's office. Either NCQA needs to drastically streamline the process or another group needs to come up with a method to help practices become certified as PCMHs. Since Medicare will pay more if you are certified, the designation will not go away. Our doctors have been paid much better for quality over the past few years, but that was a result of strong efforts at quality, not our PCMH certification.

Competing interests: None declared

We thank Dr Brady as well as the many many other primary care doctors we have been hearing from in the last few days. Their stories about dealing with NCQA, and their dedication to providing service to patients in the face of endless barriers, is inspiring. The frustration in primary care is enormous. We thank Dr Moore for his usual simple elegance in seeing to the heart of the matter, and wish the political forces would have the courage to do the right thing. To Dr Ornstein I also say, nice to see you/been a long time since my brief tar heel days, and I thank you for your work. To Kurt Stange and the wonderful folks at Annals, we thank you for daring to do a themed issue on one of the biggest good ideas to crush primary care -PCMH- a good idea swooped up and vendorized by NCQA. We call out for action on the part of the country's movers and shakers.

Jean Antonucci and Lynn Ho

Competing interests: None declared

For several years, a running joke among some members of the "value-based payment" movement was that the only ones that received payments for PCMH was the NCQA. This has changed, perhaps not for the best based on Drs. Ho's and Antonucci's careful case studies.

Fortunately, the Center for Medicare and Medicaid Services are supporting different approaches to value-based payment, as recently reviewed by U.S. DHHS Secretary Burwell in a recent New England Journal of Medicine perspective ( http://www.nejm.org/doi/full/10.1056/NEJMp1500445 ).

Hopefully all of these approaches, including PCMH, will be studied in carefully designed, multi-method studies, so that evidence, not opinion or fiat, can guide value-based payment.

Competing interests: None declared

Drs. Antonucci and Ho remind us that process measures and box-checking can add cost and complexity while having little impact on important outcomes.

High performing health systems are founded on high performing primary care (Starfield 2005), yet we confound the work of primary care with measurement approaches tangential to or completely divorced from the attributes of high performing primary care.

Their suggestion to use the patient voice + cost and outcome data from other sources (e.g. claims) deserves serious consideration.

L Gordon Moore MD

Starfield, Barbara, Leiyu Shi, and James Macinko. "Contribution of Primary Care to Health Systems and Health." The Milbank Quarterly 83, no. 3 (September 2005): 457-502. doi:10.1111/j.1468-0009.2005.00409.x.

Competing interests: None declared