Elements of the Patient-Centered Medical Home in Family Practices in Virginia

Goldberg and Kazel provide a sobering, but not unexpected, view of the current state of implementation of the Patient-Centered Medical Home model in Virginia family practices. Their survey of physician practices fills an important gap in our understanding of how family practices are currently implementing aspects of the PCMH. It is not surprising that smaller practices are less likely to have implemented some of the functions of the medical home, especially in a largely rural environment and in the absence of public or private reimbursement incentives or quality improvements collaboratives. However, that does not mean that small practices cannot implement the PCMH model. Over half of practices that have received recognition through NCQA’s Physician Practice Connections®--Patient-Centered Medical Home™ standards (PPC®-PCMH™) program have fewer than 5 physicians, and nearly 15% are solo practices. It is also the case that small practices are represented at all levels of recognition although a smaller proportion of small practices obtain level three recognition.

Our experience with small practices and other reports shows that financial incentives alone are insufficient to support the practice redesign called for in the PCMH model.(NCQA, 2009; Jaen 2009; Grumbach 2009). Practices need tools, training, shared resources, and opportunities for collaborative learning to adapt practice workflow and staffing, to undertake quality improvement activities and to implement and use health information technology to support better quality care. Policy efforts to encourage adoption of the PCMH should take into account the time and resources needed to implement the PCMH model and reward practices for moving along this continuum. This logic underpins the scoring of NCQA’s PPC-PCMH program, which allows initial recognition for practices that achieve 25 out of 100 points available and only requires a basic electronic database such as a practice management system.

As NCQA moves to update the PPC-PCMH program standards in the next year, we welcome research on demonstrations or pilot projects of this type that can help inform changes in the program. In particular, we are undertaking new efforts to consider how to incorporate a greater emphasis on patient experiences in the PPC recognition program.

Finally, while the lack of financial incentives in the study area gives greater credibility to the survey findings, we do caution that these findings may not be sufficient evidence of PCMH implementation. Research evidence from our work and others suggests that surveys do not agree well with on-site audits of practice capacities – both because some concepts such as population management are unfamiliar to practices and because tools or systems may exist but are not used consistently within a practice. (Scholle, 2008; Wise 2009).

Sarah Hudson Scholle, MPH, DrPH
Phyllis Torda
Greg Pawlson MD, MPH
National Committee for Quality Assurance

Competing interests:   We work for NCQA.