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 2018 Care Transformation Plan is 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:

  • Practiceis participating for the first time in a formal transformation initiative (e.g., CTC-RI, PCMH-Kids, RIQI’S TCPI Program, or an approved payer- or ACO-sponsored program) and/or practice has obtained NCQA recognition. Practices meeting this requirement through achievement of NCQA recognition may do so independent of participating in a formal transformation initiative.
  • Practice has implemented at least 80% of the cost-management strategies according to the implementation timeline, which are described in more detail below. Please note that OHIC is currently evaluating and streamlining these cost management strategy requirements with a work group of practice and plan representatives. Work will be completed by Spring 2018, at which point the new requirements will be posted here. The strategies relate to a practice employing the following types of processes:
    • 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 2017, OHIC revised the performance measures and 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 aligned measure set adopted pursuant to CMS State Innovation Model (SIM) grant activity.

Measure Included in the 2018 PCMH Measure Set

  • In 2018, practices will need to report on the following measures for the 10/1/17 – 9/30/18 measurement period.  Measures new for 2018 have an asterisk following them.  New measures are “reporting only”, i.e., they will be used to establish baseline performance and to help practices develop reporting capacity.
    • Adult Practices -
      • Adult BMI Assessment (HEDIS) (Process)
      • Colorectal Cancer Screening (HEDIS) (Process)*
      • Comprehensive Diabetes Care: HbA1c Control (<8) (HEDIS) (Outcome)
      • Comprehensive Diabetes Care: Retinal Eye Exam (HEDIS) (Process)*
      • Controlling High Blood Pressure (HEDIS) (Outcome)
      • Screening for Clinical Depression and Follow-up Plan (CMS) (Process)
      • Tobacco Use: Screening and Cessation Intervention (CMS) (Process)
    • Pediatric Practices -
      • Adolescent Well-Care Visits (HEDIS) (Process)*
      • Developmental Screening in the First Three Years of Life (OHSU) (Process)
      • Weight Assessment and Counseling for Nutrition and Physical Activity (OHIC-adapted version of the HEDIS measure – all-or-nothing measure including three sub-measures) (Process)
      Detailed specifications for these measures can be found here.

For 2018, "meaningful performance improvement" is defined as follows:

A practice meets OHIC’s definition of demonstrating “meaningful performance improvement” if performance is at or above a pre-defined defined benchmark or if performance improves by at least 3 percentage points over one or two years.  The benchmarks are as follows:

NCQA HEDIS Measures
Practices will be scored against the HEDIS national 66th percentile. For process measures, all practices will be scored against the Commercial insurance 66th percentile.  For outcome measures, practices with more than 50% of their patients covered by Medicaid or uninsured will be scored against the Medicaid 66th percentile, while the rest of practices will be scored against the Commercial 66th percentile. 
All HEDIS rates will be from NCQA’s national benchmark database (“Quality Compass”) for two years prior to the measurement period (i.e., OHIC will use CY 2016 data for the 10/1/17 – 9/30/18 measurement period).  In the past, OHIC used more recent benchmarks, but has elected to use previous data in order to inform practices of the benchmarks at the start of the reporting year.

Includes: Adolescent Well-Care Visits, Adult BMI Assessment, Colorectal Cancer Screening, Comprehensive Diabetes Care: HbA1c Control (<8), Comprehensive Diabetes Care: Retinal Eye Exam, and Controlling High Blood Pressure

Non-HEDIS Measures
In response to practice feedback from OHIC’s advisory committee, OHIC will evaluate practice performance against the state 25th percentile for measures without a HEDIS national benchmark.  OHIC will use the data from the prior performance period to obtain the state 25th percentile (i.e., for the 10/1/17 – 9/30/18 performance period, all practices will be scored against the 25th percentile for the state from the 10/1/16 – 9/30/17 performance period). 

Includes: Developmental Screening in the First Three Years of Life, Screening for Clinical Depression and Follow-up Plan, Tobacco Use: Screening and Cessation Intervention, and Weight Assessment and Counseling for Nutrition and Physical Activity.  OHIC considers “Weight Assessment and Counseling for Nutrition and Physical Activity” to be a non-HEDIS measure because it utilizes an all-or-nothing version of the measure with the three HEDIS sub-components.

Benchmarks for 2018 Reporting

Measure Name

Benchmark

Measures for Adult Practices

 

Adult BMI Assessment

77.01%

Colorectal Cancer Screening

61.35%

Comprehensive Diabetes Care: HbA1c Control (<8)

Commercial: 56.04%
Medicaid: 50.24%

Comprehensive Diabetes Care: Retinal Eye Exam

51.16%

Controlling High Blood Pressure

Commercial: 56.69%
Medicaid: 60.00%

Screening for Clinical Depression and Follow-up Plan

70.50%

Tobacco Use: Screening and Cessation Intervention

94.01%

Measures for Pediatric Practices

 

Adolescent Well-Care Visits

47.01%

Developmental Screening in the First Three Years of Life

69.98%

Weight Assessment and Counseling for Nutrition and Physical Activity (all-or-nothing measure including three sub-measures)

75.05%

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

PDF Version of the Survey

As part of OHIC’s PCMH definition, a practice needs to implement specific cost management strategies.  In response to 2017 practice feedback, OHIC is currently evaluating and streamlining these cost management strategy requirements with a work group of practice and plan representatives.  Work will be completed by Spring 2018. 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 (which will be posted in the summer) by October 15, 2018.

Performance Improvement Survey

PDF of Detailed Measure Specifications for 2018

OHIC continuously works with its stakeholders, including both providers and insurers, to develop and update 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. Performance improvement measures and benchmarks for 2018 are described in detail above. 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 (which will be posted in the summer) by October 15, 2018.

2017 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