Managed Care Innovator: Michael S Barr, MD

The National Committee for Quality Assurance (NCQA) is unveiling a redesign of its Patient-Centered Medical Home (PCMH)  Recognition program in April. We recently sat down with Michael S Barr, MD, MBA, MACP, NCQA’s executive vice president, quality measurement and research group, to discuss the new process. In addition to reviewing the program’s roots, Dr Barr explains the reasons for the redesign, how it reduces documentation burden, and how it dovetails into what practices might already be working on to address quality care. 

Dr Barr describes a new practical check-in process that provides real-time feedback, reveals the “must-dos” to get ready for the new process, and explains why even practices who are not on an advanced IT platform are probably further along than realized.  

Dr Barr will be leading the steering committee and speaking at the 2017 PCMH Congress, November 3-5, 2017.

Implementing Quality Care Integration

You have been with NCQA since 2014. Can you start by telling us about what you were involved in prior to that, and how it feeds into today’s PCMH concept? 

I was at the American College of Physicians (ACP) for 9-plus years before joining NCQA. I became involved early on in the ACP policy paper on the advanced medical home. We released the paper in 2006 as a response to perceived challenges in primary care and the need to present it as the foundation of the US health care system.  Other organizations were forming their own policy positions in this area, all centered on primary care. 

At that time, IBM became interested in supporting primary care transformation. Paul Grundy, [MD, currently IBM’s chief medical officer] and Martin Sepulveda, [MD, formerly the VP of health systems and policy research at Watson Research Laboratory] encouraged the societies to work together. From that was born the Joint Principles of the Patient-Centered Medical Home, which was released in 2007. 

IBM pulled together the largest employers in the country, and we presented the concept to them, and then to payers. They all supported it, and asked about a mechanism by which they could identify practices that were adhering to the model.  Over the course of several months, we worked with NCQA and in 2008 released the very first version of the NCQA recognition program. 

So, the 2017 redesign has its roots in your work at the ACP with NCQA, as well work done by others?

Yes, and the evolvement continued through the 2008, 2011, and 2014 versions, arriving to where we are today. 

Can you tell us what the redesign is based on? 

It’s based on extensive published research, input from advisory committees and the public, and our internal data about how practices were doing [under the old system] on specific criteria. It also takes into account major changes in the health care system—the American Recovery and Reinvestment Act, Health Information Technology for Economic and Clinical Health, the Affordable Care Act, and other efforts. 

Can you describe some of the issues you uncovered with prior iterations of the process? 

Of course. First, for practices going through recognition for the first time, we learned that the process was akin to tackling a huge to-do list.  There were many months of work and heavy documentation burden.  You could get guidance in the form of an email. But other than that, there wasn’t really any interaction with NCQA. The value added from such a process was questionable. Then everything was submitted all at once and there was a waiting period when applicants knew nothing about how they did. 

Secondly, we realized we were asking practices to do things just for NCQA. It didn’t necessarily align with other work that they might be doing with PQRS, HEDIS, CMS, and others. There was a lot of duplicative effort. 

How did NCQA address these issues? 

We became much more transparent, and reduced the documentation burden. Our pilot program—which included 130 practice sites—showed that work involved went down by 30%.  We reduced the number of reporting elements to 100 from 167. There is also an option to submit electronic clinical quality measures to satisfy several PCMH 2017 criteria; the measures align with existing CMS specifications and programs, as well as other private initiatives. Plus, it is designed to adapt to future changes.  

We have identified 35 electronic clinical quality measures that cover the primary care specialties and align with other reporting requirements already in place such as MACRA, CPC+ and the CMS/AHIP Core Measures Collaborative list, rather than changing the specifications. 

So, if a practice is reporting to CMS electronically, it can submit the same measures to us and get credit toward its recognition requirements for several criteria. Several measures in the eCQM list for PCMH have corollaries in HEDIS and many align with the CMS/AHIP Core Measure Set for primary care and accountable care organizations. Therefore, if a practice is working on one of these measures, for example on diabetes mellitus, is it also helping plan and network measure performance. Everyone is pulling in the same direction.

What are you doing to minimize the wait period, and make the recognition effort more continuous?  

The old submission process did not provide any interval feedback. Now, for initial recognition there will be a check-in process that the practice schedules with us. Three will occur at mutually-agreeable times over a roughly 12-month period. Practices will receive direct feedback from NCQA reviewers during the check-ins, and know exactly where they stand relative to achieving recognition.

Do providers have a choice of what to address during a check-in?  

Yes, there will be flexibility. For example, if a practice is not ready to focus on team-based care and would rather address access, it can choose to work on that first.  The practice will either upload documents ahead of time, or share their computer screen with the NCQA reviewer during the call to demonstrate how it meets the PCMH criteria. If what is presented meets the criteria, the reviewer will check it off. 

So, at the end of that check-in the practice knows where it stands relative to the total number of credits it needs for recognition and members of the practice can decide the area of focus for the next check-in.  

What if a practice falls short during a check-in and does not receive credit?  

It flows over to the next check-in so they get another chance relatively soon. It becomes a more responsive and interactive process.

What happens after the final check-in?  

The practice should know that it is ready for the final review. If the review oversight committee agrees, the practice is recognized and flows into annual reporting.  It never has to do the full three check-in process again unless it lets recognition lapse.  

What else is important to know about the check-in process? 

NCQA representatives will assist practices with logistics, answer procedural questions, and help work through the web-based application. Their job is to make the process of getting recognized as easy as possible.  However, they are not going to serve as consultants. 

You eliminated the 3-year cycle in favor of annual reporting. I imagine that makes the process feel less like scaling a huge mountain and more of an even-keeled journey?  

Yes, that is what we heard during pilot testing— 83% preferred annual reporting versus the 3-year cycle. And what they liked most was the menu of reporting options. 

For the initial recognition, there are 40 core criteria that every practice needs to meet to be recognized. Beyond that, there is a set of 60 elective criteria from which practices need 25 credits. This allows practices flexibility and the opportunity
to highlight innovation, high performance, and to identify opportunities for their future development. The annual reporting requirements include attestation for certain core features of the PCMH and options to satisfy a subset of criteria in each of the six PCMH concepts. We also eliminated PCMH levels.

Lower levels of recognition within earlier versions was not consistently associated with higher performance, so we did away with it.  A practice is either recognized or not.

What are the other advantages of annual reporting? 

We understand that practices have many other challenges, interruptions, and factors that impact whether they can continue to perform at a high level. It’s fine when this is temporary. But sometimes practices just no longer perform well, yet [under the old system] they continue to be recognized. 

Annual reporting helps ensure the process yields more than just a PCMH in name, but also a PCMH in practice. 

What are the most important aspects new applicants should pay attention to as they enter the process—the must-dos?

Our research shows that practices that try to go through the recognition without appropriate preparation are among the most frustrated with the process.  So, if you’re going through this for the first time, it’s important to get ready. Do an honest assessment of your practice status by taking these steps:

• Conduct a pre-assessment, engaging an expert to help. [Certified experts are listed on the NCQA website.] 

• Review the initial recognition requirements and identify the core criteria that you think will be your biggest challenges; initiate a plan to address those items.

• Enroll in the program and get familiar with the new platform, which is called QPASS. Ask questions. Attend training webinars, including previously recorded sessions. View educational materials. 

• Engage with the NCQA representative to plan the check-ins according to your preferred schedule and priorities.

What about for those who are renewing?

If you achieved Level 3 status in 2014, you can transition directly into the annual reporting process. Get familiar with those requirements. If you achieved lower level recognition in 2014, you have the option of continuing under the old system or transitioning. 

No matter if you’re a first-timer or renewing, there are tools to help practices help themselves. There will be challenges, which of course is by design. It’s a recognition process to differentiate practices who are performing at a higher level than other practices.  It’s going to be hard, but it shouldn’t be because you’re ill-prepared.

Can you address the technological requirements needed to become certified? What is needed at minimum?

Most practices have already implemented EHRs (electronic health records) and other health information technology. Optimizing this technology to facilitate better care is the key.

Do practices that might be somewhat intimidated—or feel as if they are behind the tech curve—have anything to worry about?

I don’t’ think so. Many criteria can be satisfied without advanced health IT.  You need to show that the practice can triage and stratify the patient population and see who needs follow-up, who needs preventive care, etc. The routine things that people used to do with registries or spreadsheets. 

Most requirements can be fulfilled without a fully certified EHR.  Don’t get me wrong, it’s a lot easier if you have one.  But we don’t want small practices who’ve done a nice job to not be recognized because they don’t have certified technology yet. We heard very clearly from practices that they didn’t think this needed to be a requirement, so we followed their recommendation. 

At the same time, we want to acknowledge those who are more advanced technologically. For that reason, having health IT that is ONC certified is an elective criterion worth 2 credits.

What technological shortfalls are you addressing?

It is widely acknowledged that data that comes out of EHRs may not always be accurate. We have to get to a point where we are confident that the data we receive are trustworthy.  We’re going to be encouraging health IT vendors and data intermediaries to become NCQA certified on the set of measures that they are reporting for the practices. This way, practices have a vehicle through which they can submit metrics to us from a certified health IT vendor. 

From there, we can start doing benchmarks and comparisons, and set thresholds the same way we do at the plan level. The goal is to align those measures across the health ecosystem so that we can continue to move patient care in the right direction.