Provider Experiences with a Payer-Based PCMH Program

Abstract

BACKGROUND: The patient-centered medical home (PCMH) is an enhanced primary care model that aims to improve quality of care. Over the past several years, the PCMH model has been adopted by Medicare and private payers, which offer financial resources and technical assistance to participating practices. However, few studies have examined provider experiences and perspectives on the adoption of payer-based PCMH models in different practice settings. OBJECTIVE: The goal of this qualitative study was to analyze how providers experienced specific elements of a payer-based PCMH model and identify cross-cutting themes that can be applied to other payer-based PCMH initiatives. DESIGN: Observational qualitative study. PARTICIPANTS: A total of 65 individuals (which includes 57 primary care physicians) participated in focus group sessions. Telephone interviews were conducted with an additional 14 physicians and 2 practice administrators. APPROACH: Interviews and focus groups were recorded after obtaining the informed consent of participants. Written transcripts from the recordings were then imported into NVivo 11 for subsequent coding and qualitative analysis of themes. KEY RESULTS: We found that nurse care coordinators (NCCs) were the single most valuable and visible program element. Individual care plans served as effective tools of communication between the NCC and physician on patient care management goals and issues. The online data portal was viewed as the least valuable element. With regard to cross-cutting themes, some providers expressed a strained relationship with CareFirst due to communication challenges, a lack of trust, and differing priorities in selecting patients for care plans. CONCLUSION: Nurse care coordinators and the targeted use of individualized care plans are essential components in a payer-based PCMH program. Improving communication and trust in data reports are critical for effective implementation. Future research should examine provider experiences in other payer-based PCMH programs to see how interactions with payers affect program implementation.

To What Extent Are ACO and PCMH Models Advancing the Triple Aim Objective? Implications and Considerations for Primary Care Medical Practices

“…According to the National Committee for Quality Assurance (NCQA), which issues PCMH recognition, the cost of pursuing PCMH recognition is based on a practice's eligibility for single-site pricing or multi-site pricing and on the number of clinicians in the practice (NCQA, 2020). In addition to recognition process costs, 2 of the highest costs in becoming a PCMH are hardware and software purchases, specifically electronic health records (EHRs), and employee time spent on achievements recognizing NCQA recognition (Fisher et al, 2007).…”

Medicare Access and CHIP Reauthorization Act in Small to Medium-Sized Primary Care Practices

“…We implemented a purposeful sampling, a maximum variation strategy, among practices participating in the HVH. We recruited practices for focus-groups [19][20][21][22][23] by stratifying the sample to obtain a maximum variation on practice ownership (independent practice, hospital-owned practice or federally qualified health center); 11,14,24,25 practice size (2 to 5 providers, 6 to 10 providers, and 11 or more providers); [11][12][13][14] practice single or multispecialty; practice designation as a patient-centered medical home; 11,14,24,25 practice part of an accountable care organization (ACO); [11][12][13][14]24 and whether the practice was located in a medically underserved area. 11,14,24 A sample of 30 practices that met the selection criteria was targeted for focus-group recruitment.…”

“…The final sample consisted of 16 focusgroups with a total of 70 participants, including physicians, advanced practice clinicians, practice managers, and other staff from the same practice. 23,[25][26][27] Focus-groups were conducted onsite at the practice location. The average number of participants per focus-group was around 4, ranging from 1 to 10 individuals (Table 1).…”

Transforming Primary Care in New York Through Patient-Centered Medical Homes: Findings From Qualitative Research

“…Qualitative studies that include patient and provider perspectives can elucidate progress toward patient-centeredness 11 and the relative significance of model components. 12 They can also reveal disconnects between documentation and implementation of PCMH model components—thereby informing operationalization and future iterations of the PCMH approach.…”