When Practice Transformation Impedes Practice Improvement

Sixty percent of office-based physicians practice in groups of seven physicians or less. It has recently been documented that physicians in one to two physician groups and physicians in three to nine physician groups had 33% and 27% fewer readmissions respectively than physicians in ten to 19 physician groups.[1] In addition, the Graham Center recently queried family physicians recertifying for their family medicine boards in regards whether their practices were certified as a PCMH at any level by NCQA. 6.7% of solo practices, 18.9% of small practices and 35.1% of large practices had attained certification.[2]

Clearly, based on these numbers, the PCMH/NCQA process is not serving the needs of solo and small group practices (and it could be argued larger practices), who provide care for a significant percentage of patients in the United States. No one argues with the need of all practices to transform to the new model of care and we applaud the example NCQA initially set to start this process but the NCQA process has lost its way. A paradigm shift needs to occur in their certification process.
1. A separate certification for solo and small physician practices should be designed taking into account the limited amount of resources these practices have financially and from a manpower perspective.
2. Credit should be given for large parts of the certification process if the practice attained other certifications (Meaningful Use, other NCQA modules, Maintenance of Board Certification, etc).
3. Each practice should be assigned a single NCQA representative who becomes a mentor for the process.
4. The process should be about continuous improvement each quarter and not every three years, which can only happen if each practice has an ongoing relationship with NCQA.
5. Each part of the process(and new additions to the process) should not be signed off by anyone at NCQA (and NCQA stakeholders) without first thinking very seriously how this will affect practices financially, from a manpower perspective and from a time perspective (as we say on the ground or in the trenches). The process should not interfere dramatically with our ability to take care of patients and impede a practice's ability to further improve patient care.

If NCQA doesn't get this right they are in danger of losing their space in this very important arena. Many states and insurance entities are looking elsewhere now or in the near future to establish another or a different process, finding the current NCQA process too burdensome or just not fitting the needs of their stakeholders. Hopefully, the CMS Comprehensive Primary Care Initiative may give us some answers.

Some of us through practice transformation have delivered on the Quadruple Aim; our patients have benefited as have Medicare, Medicaid and third party payers. We should all be sharing the same goal. We would all like to be certified but it certainly isn't going to happen under the current structure.

1. Casalino LP, et al. Small Primary Care Physician Practices Have Low Rates of Preventable Hospital Admissions. Health Affairs. 2014; 33(9):1680-88.
2. Raffoul M, et al. Smaller Practices Are Less Likely to Report PCMH Certification. American Family Physician. 2015 April 1; 91(7):440.

Competing interests: None declared