Abstract
Objective: The patient-centered medical home (PCMH) is emerging as a key strategy to improve health outcomes, reduce total costs, and strengthen primary care, but a myriad of operational measures of the PCMH have emerged. In 2009, the state of Oregon convened a public, legislatively mandated committee charged with developing PCMH measures. We report on the process of, outcomes of, and lessons learned by this committee.
Methods: The Oregon PCMH advisory committee was appointed by the director of the Oregon Department of Human Services and held 7 public meetings between October 2009 and February 2010. The committee engaged a diverse group of Oregon stakeholders, including a variety of practicing primary care physicians.
Results: The committee developed a PCMH measurement framework, including 6 core attributes, 15 standards, and 27 individual measures. Key successes of the committee's work were to describe PCMH core attributes and functions in patient-centered language and to achieve consensus among a diverse group of stakeholders.
Conclusions: Oregon's PCMH advisory committee engaged local stakeholders in a process that resulted in a shared PCMH measurement framework and addressed stakeholders' concerns. The state of Oregon now has implemented a PCMH program using the framework developed by the PCMH advisory committee. The Oregon experience demonstrates that a brief public process can be successful in producing meaningful consensus on PCMH roles and functions and advancing PCMH policy.
The patient-centered medical home (PCMH) is a promising strategy to achieve the triple aim of improved health outcomes, better patient experiences, and reduced per-capita costs by strengthening primary care.1⇓⇓–4 Professional organizations representing US primary care physicians have developed 7 principles that outline the core elements of the PCMH: a personal physician, physician-directed medical practice, whole-person orientation, coordination and integration of care, attention to quality and safety, enhanced access to care, and payment that appropriately recognizes the value of the PCMH.5 Coalitions of insurers, employers, professional organizations, and others have endorsed these principles, leading to broad agreement about general concepts underlying the PCMH.6 As the PCMH moves from concept to reality, many entities have developed detailed operational PCMH definitions and measurement strategies based on the needs of their particular stakeholders.7⇓⇓⇓–11 This diversity of operational definitions has led to a range of projects all bearing the same generic name “medical home.”2,4,12
The most widely used tools to measure attributes of a medical home are the PCMH recognition programs developed by the National Committee for Quality Assurance (NCQA).3,8 The 2008 version of the NCQA criteria has been criticized for a variety of reasons: the administrative burden and expense required to achieve recognition, a failure to emphasize practice characteristics associated with short-term improvement in outcomes, an absence of cost or quality measures, an insufficient emphasis on core primary care functions such as continuity and comprehensiveness of care, an absence of a patient-centered focus, and a lack of emphasis on practice improvement over time.2,7,10,13⇓⇓⇓⇓⇓–19
States and insurers have approached perceived shortcomings of the NCQA and other recognition criteria in a variety of ways to create operational PCMH measures that meet the unique needs of their local environments. Strategies have included creating “wrap around” outcome measures for medical homes in addition to NCQA recognition,20⇓–22 requiring recertification or paying improved rates for higher levels of NCQA recognition,20⇓–22 or creating independent medical home measures.9,23,24
Oregon has a history of producing innovative, community-based solutions to health policy challenges through public engagement of its citizens. In the late 1980s, Oregon developed the Oregon Health Plan (OHP). 25,26 A centerpiece of the OHP was development of a prioritized list of health services27 to guide coverage decisions under Oregon's Medicaid program. During the process of implementing the OHP, and continuing over the last 2 decades, the state has held hundreds of public meetings and developed deep experience in engaging its citizens to develop new health policies.
In 2009, the Oregon Legislature passed comprehensive health reform legislation.28 This law established a single agency, the Oregon Health Authority, to oversee all public health care programs within the state, with the goal of consolidating state and local government purchasing power (approximately one third of the insured population in Oregon younger than age 65) to align quality and payment standards and drive delivery system change. The law paid particular attention to primary care, directing the state to develop a program to promote the development of PCMHs, which Oregon's law termed patient-centered primary care homes (PCPCHs).
While many articles comment on PCMH policy and payment reform,3,4,29⇓–31 little has been written about how operational PCMH measures are developed in a policymaking context. Few existing medical home measures were developed in a public forum with input from a broad set of community stakeholders. This article reports on the process and lessons learned during the development of PCPCH standards and measures for the state of Oregon.
Methods
Oregon House Bill 2009 created a 15-member public advisory committee to guide PCPCH policy development. The law delegated 3 specific tasks to the Oregon Office for Health Policy and Research and the PCPCH Advisory Committee32:
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Define core attributes of the PCPCH.
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Establish a simple and uniform process to identify PCPCHs.
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Develop uniform quality measures for PCPCH performance.
The selection and meetings of the PCPCH Advisory Committee were conducted in accordance with Oregon's Public Meetings Law.33
Committee Selection
The director of the Oregon Department of Human Services appointed the PCPCH Advisory Committee in October 2009. Committee members were identified through service on prior state committees and a public call for nominations. Committee members included individuals with a diverse range of experience, including several practicing primary care physicians (Table 1).
Committee Meetings and Staff Support
The committee held seven 2-hour meetings over a period of 3 months. Meetings were public, time was allotted for public comment, and all meeting materials were posted online. Committee members communicated frequently and reviewed committee work with professional colleagues and patient advisory groups. Staff for the committee included individuals experienced in leading public meetings and familiar with PCMH concepts and the overall direction of health reform in Oregon.
Materials Development and Decision Making
Oregon Office for Health Policy and Research staff conducted extensive background research on methods for measuring primary care and PCMH functions. Initial committee discussions focused on identifying PCPCH core attributes based on the PCMH joint principles5 and core primary care principles.34 After the committee agreed on language for core attributes, discussions focused on defining categories of measurement (standards) within each core attribute and proposed measures within each standard. Committee staff relied on a number of sources to develop draft standards and measures, including measures developed by the NCQA, other organizations, primary care researchers, and other states.8,9,11,23,24,35⇓⇓⇓⇓⇓⇓–42
Results
Initial committee discussions focused on whether to adopt an existing PCMH measure set for use in Oregon. In general, the committee felt that the PCMH measures available in late 2009 did not adequately address the needs of Oregon stakeholders. Committee members echoed many concerns about extant PCMH measures that have been cited in the literature (see the introduction of this article). Furthermore, committee members felt that local buy-in from both health care professionals and the public would be essential for Oregon's PCPCH criteria to be accepted and used. Given these concerns, the committee decided the best approach for PCMH measurement was to engage Oregonians in the development of PCPCH measures for use in our state, rather than importing a set of measures developed elsewhere. A by-product of this decision was a series of public meetings and discussions about the PCMH that helped build consensus and provided visibility to the committee's work.
The committee developed a total of 6 PCPCH core attributes, which comprise 15 standards and 29 measures of PCPCH processes and outcomes. An overview of Oregon's PCPCH core attributes, standards, and measures is shown in Table 2. Recognizing the importance of patient-centeredness as a core concept, the committee described PCPCH core attributes and functions in patient-centered language that would be accessible to policymakers and the general public. For example, “Access to Care” became “Be there when we need you.”
Tables 3 and 4 provide examples of detailed language for 2 of the 6 core attributes, Access and Accountability, including specific standards and measures. The full committee report containing specific measures for all 6 core attributes can be found online.43
The committee developed a 3-tiered framework of basic, intermediate, and advanced measures. Within this framework, basic measures describe functions that are foundational to the PCPCH care model and that most primary care clinics could meet without additional resources. Intermediate measures describe functions requiring additional investment or infrastructure, and advanced measures describe the optimal performance of a high-functioning PCPCH clinic. The goal of the 3-tiered measurement framework was to engage the broadest possible number of primary care clinics at the entry level and create incentives for improving a limited number of PCPCH processes and outcomes over time.
When developing measures, the committee was guided by a desire to give clinics some flexibility in how they demonstrate PCPCH processes and improved outcomes. For example, the committee did not endorse a specific measure for Appointment Access (eg, the third next available appointment), but developed a framework that focused first on measuring access, then on setting goals for improvement, and ultimately on demonstrating high performance through excellent access scores on a patient survey (Table 3). Similarly, measures for Performance Improvement (Table 4) require a clinic to first choose performance measures and set improvement goals appropriate to its patient population, then to demonstrate improvement toward performance goals, and finally to meet benchmarks for national clinical quality indicators.
For some PCPCH functions, a basic standard was established without a requirement for performance improvement. For example, under the Telephone and Electronic Access standard, continuous telephone access to a clinician is a basic PCPCH function. Likewise, under the Comprehensive Whole Person Care attribute, availability of comprehensive medical and preventive care services is a basic function. Finally, in addition to the required measures, the committee identified a number of additional measures that describe “value-added” PCPCH functions (eg, offering extended office hours [Table 3]), for which PCPCH clinics could earn additional recognition and payment.
Discussion
A number of states and payers are working to promote medical homes and develop new payment mechanisms for primary care. In many states, developing a shared operational definition for a “medical home” has been a stumbling block in this process. With little evidence to define empirically the “right” way to measure and pay for medical homes, the Oregon PCPCH Advisory Committee sought to develop a set of measures that reflected the values of Oregon stakeholders. We do not think that our standards are better than anyone else's, but the process of public conversation created a shared vocabulary and ownership of the PCPCH in Oregon that helped to move medical home policy forward. The following lessons learned during our process may be valuable to others seeking to develop community-based strategies to promote medical homes.
Patient-Centeredness as a Strategy for Building Consensus
The decision to describe PCPCH core attributes and standards in the patient voice (Table 2) was a prominent success of the committee's work. This approach helped crystallize key concepts in succinct, understandable language without debates over terms, such as “integration” and “team-based care” that have taken on specific meanings among certain stakeholders. The patient-centered focus also facilitated conversations about the scope of services that should be available to patients without engendering interprofessional conflicts (eg, between nurse practitioners and physicians or primary care clinicians and specialists) that have bogged down PCMH discussions in other states.
Breadth of Representation
The opportunity for a facilitated dialogue among a diverse group of Oregon stakeholders (patients, clinicians, and payers) helped the committee balance a number of tensions inherent in developing PCPCH policy. As committee members shared their unique perspectives, the group was able to achieve consensus on a range of PCPCH measures that addressed the primary care needs of specific patient populations (eg, children and individuals with mental illness) and the policy needs of specific stakeholder groups (eg, payers and small, rural primary care practices). Examples of challenging areas where the group was able to achieve consensus include integration of mental health, developmental screening and addictions assessment, and treatment capacity in PCPCHs, describing care coordination in terms of key functions rather than specific job titles or practice staffing arrangements and including cost and utilization outcomes in PCPCH measures.
Time-Limited Tasks, Experienced Committee Members, and Knowledgeable Staff
The committee was able to accomplish a significant amount of work in a short time frame. The time-limited nature of the committee assignment helped keep the group moving forward and allowed the participation of practicing clinicians. Committee members entered the process with experience working together, and veterans of prior public committees helped maintain an aspirational but pragmatic focus to group discussions. Finally, the presence of dedicated committee staff and selected content experts helped drive the work of the committee while still allowing an open and public process.
Moving from Policy Development to Implementation
The work of the committee described in this article was limited to creating a definition and measurement framework for the PCPCH in Oregon and did not extend to implementing PCPCH measurement or developing payment methodologies to support the PCPCH care model. After the development of the PCPCH measures, the Oregon Health Authority convened a number of additional committees and public meetings to develop administrative rules and an operational plan for its PCPCH program.
In November 2011, the Oregon Health Authority launched a PCPCH program based on the standards reported here.44 The PCPCH recognition process is free of charge to primary care clinics and requires clinics to attest to meeting PCPCH criteria and submit performance data for key measures. Clinics recognized as PCPCHs will earn enhanced payment for enrollees in Oregon's Medicaid Program. Future expansion of the PCPCH program to other public and private payers is anticipated.
Conclusions
The criteria used to define and measure the performance and outcomes of the PCMH likely will continue evolving for years to come. In the time since the Oregon PCPCH Advisory Committee completed its work, NCQA has updated its PCMH measures and a number of other national organizations have announced their own “medical home” recognition programs.45⇓–47
We believe that others can learn from the process and results produced by the Oregon PCPCH Advisory Committee, but significant differences in primary care systems and stakeholder preferences across the country will lead to different policies to promote medical homes. Although some states might face a greater challenge reaching public consensus on medical home policy, we feel the process of identifying and improving medical homes cannot simply be built by a partnership between health plans and provider groups at the national level.
As has been the experience in a number of states, strong state leadership is important in promoting uniform measurement of medical homes and tying payment reform to standard measures of success. The process used to develop PCPCH standards and measures in Oregon suggests that public engagement of key stakeholders can quickly create the shared policy framework necessary to strengthen the primary care delivery system on the basis of accountability for key outcomes. As federal health reform is implemented, there must be flexibility for states to implement meaningful and unique delivery system reforms supported by multiple payers and guided by the input of local stakeholders.
Notes
This article was externally peer reviewed.
Funding: none.
Conflict of interest: none declared.
- Received for publication February 11, 2012.
- Revision received February 11, 2012.
- Accepted for publication March 26, 2012.
