Incentives: Making the Case for Your PCMH

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Last fall, I was talking with a practice manager at a small pediatric clinic in the South that just earned NCQA Recognition. This was his first time at the PCMH Congress. We talked for a while about a presentation we’d seen—on the transition to value-based care—and then he began to share some of the issues that arose when his practice tried to negotiate enhanced payment based on its recognition status. He asked me, “Who’s providing incentives for PCMH practices in my state?”

PCMH Incentives

It was a familiar conversation, and his question was straightforward—but the answer is considerably less so. In NCQA’s directory of payers that offer incentives for PCMH recognition, there’s a caveat: Incentives may not be available in all markets, or to all practices. This, my new friend had found out. Many factors go into a payer’s decision to offer enhanced reimbursement, and small practices often struggle to make a case for receiving it.

With the rapidly shifting payment environment, practices must learn to position themselves in a way that demonstrates their value and how their PCMH status helps them flourish in a value-based system. First and foremost, the PCMH model encourages all practice staff to work at the top of their license, saving practices time and money and increasing their operational efficiency. Superior tracking of tests and imaging results, performing medication reconciliation and better coordination of care increases patient safety. This not only appeals to payers, but also potentially sets the stage for a practice to pursue discounts on malpractice premiums.

The Case for PCMH

Medical homes are more likely to catch errors quickly, have better documentation and do a better job of educating their patients and engaging them as partners in their own care. By utilizing evidence-based decision support tools and routinely recalling patients for needed services, they’re more likely to see higher use of preventive care and improved management of chronic conditions, which reduces higher cost care down the road. Beyond that, with the medical home model’s focus on patient access, recognized practices tend to see higher rates of patient satisfaction—resulting in increased referrals and a reputation in the community as a high-quality partner in managing care for shared patient populations.

Additionally, the proliferation of clinically integrated networks and ACOs can give small practices the opportunity to partner with larger organizations that have increased bargaining power, with the potential to receive enhanced PMPM payments or shared savings. On the consumer side of the house, we see an increasing number of tiered networks as health plans use reduced co-pays to steer members to the providers that offer the highest value, taking into consideration medical home recognition, patient utilization rates, claims cost and other factors.

Yesterday’s Webinar*—Showing Payers the Value of PCMH Recognition—discussed securing incentives for recognition. Suzanne Madden, of The Verden Group, and an authority on physician reimbursement issues, provided insight into how payers approach value-based payment for PCMH. At the heart of many value-based contracts are HEDIS measures, particularly in adult care. Practices may be able to receive incentives if they can demonstrate high-quality performance, based on meeting HEDIS quality measures or on other factors such as self-reported measures, claims costs, patient utilization and other metrics. In some cases, payers include medical home recognition as a component of these programs. Some value-based programs award higher reimbursement rates based solely on PCMH recognition.

Making Your Case

In summary, the answer to “Who’s offering incentives?” might depend on how well a practice can make the case that delivery of higher-quality care deserves enhanced reimbursement.

Practices must have good data to support this claim (for example, documentation of incentives from other payers), and must demonstrate the value they provide, both within the context of the larger health care system and in the communities they serve.

We’ll have a recording of the Webinar available online soon. Check back for a link to the program. And for more information on incentives for recognition, visit The Recognition Program Resource Directory.

*Webinar presenters were Suzanne Madden (the Verden Group), Lori Francis (BCBS TN) and Dr. Kashyap Patel (Carolina Blood and Cancer Care).

Leah Kaufman
Leah is External Relations Manager for Recognition Programs at NCQA and has been with the organization since 2014. She connects primary and specialty care providers with resources to support practice transformation and movement towards value-based care delivery. She also manages strategic relationships with organizations focused on improving healthcare quality through patient-centered coordinated models of care.

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