In last month’s blog post I shared information about the number of recognized patient-centered medical homes in Texas. I also mentioned that in Texas, the overwhelming majority of the medical homes are sponsored/owned by health systems.
Since then, I have learned that the percentage of physicians practicing in medical homes in Texas is not dissimilar to the national rate of about 20%. What is perhaps more interesting than that is the according to the Patient-Centered Primary Care Collaborative, roughly 43% of family physicians in the US are practicing in medical homes. I do not have statistics for internists and pediatricians but one can infer that their percentages are significantly smaller.
One of the original Joint Principles of the Patient-Centered Medical Home is that “practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.”
At least 4 organizations have programs that certify or recognize practices as patient-centered medical homes. The National Center for Quality Assurance (NCQA) was the first of these organizations to offer a recognition program in 2008. They have now revised and updated their standards 3 times. They have the largest share of the market with 59,278 clinicians working in 12,724 practices nationwide. There are now over 800 NCQA recognized PCMH practices in Texas.
The Joint Commission’s program, Ambulatory Care Accreditation, has accredited 1,418 sites nationally with 66 accredited sites in Texas. Of these, the overwhelming majority of practices are either Federally Qualified Health Centers or community health clinics. Only one private practice – Southeast Texas Medical Associates in the Beaumont area – is accredited by JCAHO.
Data for URAC and AAAHC, the other certifying organizations are not available on their public websites.
As promised, I am sharing information about the location and ownership of NCQA recognized practices in Texas (map courtesy of the NCQA):
The distribution of medical homes in Texas is fairly consistent with what is known about physician supply and distribution:
With regard to ownership of practices, in 2015 between 45 and 49% of all Texas physicians were individual practice owners compared to 30% nationwide. The number of private practices has continued to decrease in the last several years while there has been massive consolidation of markets in many Texas cities.
This graph shows the distribution of NCQA recognized medical homes by ownership in Texas:
Further analysis of the NCQA data shows that 11 Texas health systems own/sponsor 10 or more medical home practices.
Questions to consider:
1. Why are health systems disproportionately represented among NCQA recognized practices?
In part, it’s because becoming a recognized PCMH is costly in terms of personnel and resources so larger entities have an advantage. Also, larger systems are more likely to be in a position to leverage their PCMH status to gain more favorable insurance contracts that pay them for services like care coordination. Unfortunately, smaller practices rarely have the same leverage.
2. Why would a private practice embark on the journey of becoming a PCMH complete with recognition?
Funny you should ask.I am about to send a questionnaire to private practices that are recognized by NCQA to find out the answer to that question. Stay tuned! And if you get a request to complete the survey, please do! It will add greatly to our understanding.
3. The Joint Principles notwithstanding, can a practice become a medical home without being officially “deemed” as such by an outside organization?
I have no doubt that the answer to this is yes. However, I also believe that a PCMH needs to have a range of capabilities and processes that help it to deliver accessible patient-centered care. Proving this is accomplished through data. Bigger systems typically have more robust data gathering and reporting abilities.
4. And finally, and perhaps most importantly, how can practice culture be measured in a standardized format?
Practice culture that embraces teamwork; acknowledges the contributions of all team members; has strong clinical and administrative leadership ; a unified vision of what is means to be a PCMH and works tirelessly to continuously improve the delivery of care can’t be measured on a form. And only through true cultural change can the promise of the PCMH be fulfilled.
I invite your comments and thoughts.
Till next time.
This is the second in a series of blog posts about the state of primary care and the medical home with an emphasis on Texas.
2017 marks the 10th anniversary of the adoption of the Joint Principles of the Patient- Centered Medical Home which serve as the blueprint for transforming practices to this model of care. In my first blog post I shared an overview of the most recent review of research on the PCMH published by the Patient Centered Primary Care Collaborative. The authors conclude that the overall impact of the PCMH has been positive, but not uniformly so. An updated version of the Joint Principles, the 2017 Shared Principles of Primary Care will be released by the PCPCC in October.
People frequently ask me about the state of the Patient-Centered Medical Home in Texas. I can cite statistics on the number of clinicians and practices recognized as medical homes by the NCQA and the Joint Commission and refer people to the interactive location map on the NCQA website. Beyond that, until now, I haven’t been able to shed much light on the medical home in Texas.
In order to learn more, I have embarked on a deep dive into the data on the NCQA website. I will be sharing what I’ve learned in the next couple of blog posts. For now, though, here are some statistics that can help us understand the state of the PCMH in Texas and set the stage for further discussion:
We know that in states such as Rhode Island, Pennsylvania and Colorado multi-payer initiatives have overall been successful and have accelerated transformation efforts on a larger scale. While there are anti-trust concerns when convening meetings of payers, these can be addressed and dealt with when payers are convened by a governmental entity. My biggest disappointment in the 8 years of working on adoption of the PCMH in Texas is that we haven’t been able to engage the people that pay for healthcare in a meaningful way on a large scale.
I am, however, an eternal optimist. And I want to share 2 stories about practices that have embarked on the journey of transformation. They are inspiring and encouraging.
I recently visited the campus of El Buen Samaritano in Austin
. I was directed to “El Buen” by 2 of my colleagues – Tom Manley, CEO of the Texas Medical Foundation and Dr. Dan Crowe, Senior Medical Director for Superior Health Plan. I met Iliana Gilman, the dynamic CEO of that organization. El Buen is a healthcare organization that improves the health and quality of life for Latino families. They were recently recognized as a Level 3 PCMH by NCQA. El Buen is more than a health clinic. Indeed, they sponsor a food pantry, adult education (in English and Spanish), behavioral health services and more. The overwhelming majority of their clients are at less than 100% of the poverty level. When I asked Ms. Gilman why El Buen undertook this challenge, she stated simply that the PCMH offers a structure and framework to put progress in place and to integrate the various services offered there. I left El Buen with a big smile on my face and a renewed sense of hope in my heart. Felicitaciones!
The second story comes from our devoted friend and colleague Jettie Eddleman. Jettie shared the exciting news that the Texas A&M Family Medicine Residency/TAMU Physicians recently achieved recognition as a medical home by the NCQA. One of the members of this practice is Nancy Dickey, MD, the former President of the AMA and champion for primary care. According to Jettie, the desire to become recognized as a PCMH in a rural Texas practice is secondary to the true desire to do more and do it more effectively in delivering patient and family-centered care. The clinic is in Bryan, Texas, an underserved area. Jettie notes that the transformation was facilitated through the A&M Regional Extension Center and was made possible, in part, through funding from the 2011 Texas Medicaid 1115 waiver. In Texas, we say “Whoop”! Well done, Aggies.
People ask why a practice decides to become a medical home. These 2 stories underline the fact that many practices undertake this journey because it is the right thing to do for their patients, clinicians and community.
My next blog post will present data on ownership, specialty (IM, FM, peds or multi) and geographic distribution of PCMHs in Texas. In the meantime, I’d love to hear your thoughts on my posts.
The mission of the Texas Medical Home Initiative is to ensure that every Texan has a medical home. In a state as vast and varied as Texas, we feel that the most effective way to accomplish this goal is through ongoing education and advocacy. We have held 5 successful Primary Care and Health Home Summits and through those, have reached many hundreds of health care professionals, policy makers and consumers.
However, we recognize that a once a year Summit is not sufficient to keep informed of the developments in healthcare that affect primary care. So starting now, we will be sharing useful information about practice transformation through our website.
The plan is to let you know about important developments in the literature and in the business of practice transformation by sharing links to the studies and also by offering concise summaries of the key points from the studies and reports.
More to come...
News you can use:
1. One of the major reports released recently is the Patient-Centered Primary Care Collaborative’s Annual Report . The report can be found here:
Dr. Russell Kohl, TMF Medical Director and member of our planning committee was one of the reviewers for the report.
This year’s report, the sixth, reviewed results from 45 peer-reviewed reports and additional government and state evaluations published in 2016. The authors state “the PCMH has demonstrated improved outcomes in terns of quality, cost and utilization, but not uniformly.” Other important findings are that the longer a practice has been transformed, and the higher the risk of the patient pool in terms of co-morbid conditions, the more significant the positive effect of practice transformation, especially in terms of cost savings.
This year’s report featured an in-depth look at the Michigan BCBS PCMH program. In its 8th year, this is one of the oldest and largest PCMH projects with 4,531 primary care physicians at 1,638 practices.
Statewide in Michigan, transformation of care has resulted in:
2. One of the great challenges to practice transformation in the US is chronic underinvestment in primary care. It is estimated that only 5-7% of our healthcare spending goes to primary care, while European countries invest 12-14% of their spending in primary care.
What can be done about this inequity? The Rhode Island Insurance Commissioner used his authority to boost primary care health plan spending as a percentage of medical spending from approximately 5% in 2008 to between 8-11% in 2014. What was the result? During that time, overall health spending in Rhode Island grew more slowly than in any other northeastern state. Of note is the fact that the RI Insurance Commissioner is the one who essentially forced all the RI health plans to sit at the same table and come up with a plan for a PCMH demonstration project a number of years ago.
More recently, Oregon passed Senate Bill 934 which requires the Public Employee Benefit Board and Oregon Educators Benefit Board to spend at least 12% of total medical expenditures on primary care by 2023.
I know what you’re thinking. We live in Texas – not Michigan, Rhode Island or Oregon. But that doesn’t mean that we shouldn’t stop making the case to our policy makers and legislators that investing in primary care is the right thing to do for our great state.
Till next time.
Sue Bornstein, MD, FACP
Executive Director, Texas Medical Home Initiative (TMHI) Regent, American College Physicians (ACP) Member, Texas Medical Association (TMA) Board of Trustees
Sue Bornstein, MD, FACP is a Board-certified internist. She practiced in a small group setting in Dallas for 12 years. Sue is a graduate of the University of Texas at Austin and Texas Tech School of Medicine. She did her internal medicine residency at Baylor University Medical Center in Dallas.