Patient-Centered Medical Home Definition and Requirements

OHIC’s affordability initiatives have emphasized the need for a strong primary care infrastructure and since 2011, OHIC has been promoting PCMH transformation to help strengthen Rhode Island’s primary care network. In 2015, OHIC worked with its Care Transformation Advisory Committee to define patient-centered medical homes and to set a year over year insurer target for PCMH adoption. Insurers subject to OHIC’s Affordability Standards are required to have 80% of their contracted clinicians operating in a PCMH by the end of 2019. There are also supplemental payments to designated primary care practices to help finance PCMH transformation and operations.

The three part definition of a PCMH requires demonstration of practice transformation, implementation of cost management initiatives, and clinical improvement. This three part definition of PCMH also includes a provider reporting component. The full text of the 2017-2018 Care Transformation Plan and Committee notes and materials are available here.

Definition of Patient-Centered Medical Home:
The Care Transformation Committee developed the following three-part definition of PCMH against which RI primary care practices will be evaluated:

  • Practice is participating in or has completed a formal transformation initiative (e.g., CTC-RI, PCMH-Kids, RIQI’S TCPI Program, or a payer- or ACO-sponsored program) and/or practice has obtained NCQA Level 3 recognition. Practices meeting this requirement through achievement of NCQA Level 3 recognition may do so independent of participating in a formal transformation initiative.
  • Practice has implemented the following specific cost-management strategies according to the implementation timeline, included in the Plan as Attachment A (strategy development and implementation at the practice level rather than the practice site level is permissible):
    • develops and maintains a high-risk patient registry that tracks patients identified as being at risk of avoidable intensive service use in the near future;
    • practice uses data to implement care management3, focusing on high-risk patients and interventions that will impact ED and inpatient utilization;
    • implements strategies to improve access to and coordination with behavioral health services;
    • expands access to services both during and after office hours;
    • develops service referral protocols informed by cost and quality data provided by payers; and
    • develops/maintains an avoidable ED use reduction strategy.
  • Practice has demonstrated meaningful performance improvement. During 2016 OHIC shall define the measures for assessing performance and the precise definition of “meaningful performance improvement” in consultation with the Advisory Committee. To promote measure alignment across statewide initiatives, measures selected to measure performance improvement will be selected from the multi-payer measure set adopted pursuant to CMS State Innovation Model (SIM) grant activity.
  • Practice has demonstrated meaningful performance improvement. For 2017, the measures for assessing performance are as follows:
    • Adult Practices -
      • Adult BMI Assessment
      • Screening for Clinical Depression and Follow-up Plan
      • HbA1c Control (<8)
      • Controlling High Blood Pressure
      • Tobacco Cessation Intervention
    • Pediatric Practices -
      • Weight Assessment and Counseling for Nutrition and Physical Activity (including 3 sub measures)
      • Developmental Screening
For 2017 and 2018, "meaningful performance improvement" is defined as follows:

a. 3 percentage point improvement over one or two years or performance at or above the national 66th percentile* or performance at or above the state median in absence of an NCQA HEDIS rate, or

b. Performance at or above the national 66th percentile* alone if the practice does not report a prior year rate in addition to the performance measurement period rate.

*For outcome measures with an NCQA HEDIS rate, practices with more than 50% of patients in Medicaid or uninsured will be scored against the Medicaid 66th percentile, while the rest of practices will be scored against the Commercial 66th percentile.

Benchmarks for 2017 reporting are as follows:

Measure Category

Measure

HEDIS 66th Percentile

Medicaid

Comm.

Adult Measures

Adult BMI Assessment

N/A

77%

Comprehensive Diabetes Care: HbA1c Control (<8.0)

50%

56%

Controlling High Blood Pressure

60%

57%

Pediatric Measures

Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity

N/A

60%

For more information or if you have any questions, please contact Libby Bunzli (libby.bunzli@ohic.ri.gov).

Letter to Primary Care Practices, including a FAQ on the PCMH Definition

*updated as of 8/1/2017

On July 17, 2017, Commissioner Ganim released a letter to primary care practices that explains the rationale for the Office’s emphasis on PCMH adoption, the insurer requirements, the provider reporting component, and the timeline for implementation.

Once the survey information has been collected and analyzed, OHIC will post on its website a list of practices and which elements of the PCMH definition they have met.

Cost Management Strategies Survey (Due October 16, 2017)

PDF Version of the Survey

OHIC collected feedback from its stakeholders to develop a set of cost management strategies as part of the OHIC PCMH definition. Providers wishing to meet the three-part definition of a PCMH and qualify for supplemental PCMH payments are asked to submit the Cost Management Strategies Survey (link to survey above) by October 16, 2017.

OHIC worked with its stakeholders, including both providers and insurers, to develop these performance improvement measures as part of the OHIC PCMH definition. The performance improvement measures all come from a new aligned measure set that commercial insurers will be utilizing for contracting. Providers wishing to meet the three-part definition of a PCMH and qualify for supplemental PCMH payments are asked to submit the Performance Improvement Survey (link to survey above) by October 16, 2017.

The measures for internal medicine and family practices are:

  • Comprehensive Diabetes Care:  Hemoglobin A1c (HbA1c) Control (<8.0%)
  • Controlling High Blood Pressure
  • Tobacco Use:  Screening and Cessation Intervention              
  • Adult Body Mass Index Assessment
  • Screening for Clinical Depression and Follow-Up Plan

The measures for pediatric practices are:

  • Body Mass Index Assessment for Children/Adolescents
  • Counseling for Nutrition for Children/Adolescents
  • Counseling for Physical Activity for Children/Adolescents
  • Developmental Screening

2016 PCMH Recognition Results

OHIC Recognized PCMH's Public Release PDF / Excel Spreadsheet

Please direct any questions to Libby Bunzli, Principal Policy Associate - Libby.Bunzli@ohic.ri.gov