The Cost to Successfully Apply for Level 3 Medical Home Recognition

Jacqueline R. Halladay; Kathleen Mottus; Kristin Reiter; C. Madeline Mitchell; Katrina E. Donahue; Wilson M. Gabbard; Kimberly Gush

doi:10.3122/jabfm.2016.01.150211

Article Figures & Data

Tables

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Table 1. Patient-centered Medical Home Cost Categories: Making Practice Changes and Applying to the National Committee for Quality Assurance for Patient-centered Medical Home Recognition

Category	Definition	Examples
Nonpersonnel costs	Expenses to cover supplies and other fees not related to staff time	Application fees, website updates, software purchases (eg, Adobe Acrobat, patient satisfaction survey software)
Development phase	Staff time required to develop new PCMH processes	Developing new report in EHR, creating or writing policies or job descriptions, creating new documents or procedures
Implementation phase	Staff time required for implementing new processes	Staff training, incorporating new process such as previsit prevention planning; medication reconciliation; standing orders for flu vaccines, labs, etc.; quality improvement meetings; conducting patient satisfaction surveys; providing enhanced or new care management services
Maintenance phase	Staff time required to maintain new activities after application submitted	Logging after hours patient calls, care management visits, quality improvement meetings
Application document preparation	Time required to create application documents such as screenshots	Taking screenshots to provide evidence of activities, redacting patient health information from examples, annotating to demonstrate compliance with requirements
External consultant	Services provided by staff not on the practice payroll	Consultant time to complete chart review workbook, coach time guiding practice through the NCQA application process

EHR, electronic health record; NCQA, National Committee for Quality Assurance; PCMH, patient-centered medical home.

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Table 2. Practice Demographics for 4 North Carolina Primary Care Practices Receiving Patient-centered Medical Home Recognition in 2013 or 2014 via the National Committee for Quality Assurance 2011 Patient-centered Medical Home Standards^*

Practice ID	Provider FTEs^{^†}	Patient visits/year (n)	Medicaid (%)	Uninsured (%)	Commercial Insurance (%)	Nonwhite Patients (%)	Date of PCMH Level 3 Recognition	Study Interview Dates
1 (Pediatrics)	2.5	4,477	7	5	88	21	December 2013	March 2014
2 (Pediatrics)	10.5	39,172	43	0.3	57	53	January 2014	May 2014
3 (Pediatrics)	3.5	12,813	30	5	65	19	July 2014	August 2014
4 (Family medicine)	4	15,094	15	10	55	35	July 2014	November 2014

↵* Patient-centered medical home (PCMH) 2011 standards were released in the spring of 2011; the 2014 standards, in the spring of 2014. Depending on a practice's start date and initial PCMH level attained, practices could be working on 2011 standards up until 2018.
↵† Includes medical doctors, doctors of osteopathy, nurse practitioners, and physician assistants.
FTE, full-time equivalent.

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Table 3. Costs of Patient-centered Medical Home Recognition via 2011 Standards among 4 Practices

Practice	Costs By Category ($)
Practice	Nonstaff^* (Application Fees, Supplies)	Development Phase^* (Creating New Processes, Reports, Policies)	Implementation Phase^* (Providing Enhanced Care Services^{^†})	Application Document Prep^*^{^‡} (Screen Shots)	Total Costs to Apply^*^{^§}	Maintenance Phase (Ongoing Costs for Staff and Supplies), Annualized
1 (Pediatrics)	696	9,294	2,606	975	13,571	10,151
2 (Pediatrics)	419	7,249	3,649	137	11,453	7,789
3 (Pediatrics)	554	8,643	3,487	846	13,531	0
4 (Family medicine)	131	3,275	12,269	303	15,977	23,494

Costs are expressed as per full-time provider (nurse practitioner/physician assistant/DO/MD).
↵* Costs accrued from decision date to apply for patient-centered medical home status to application date. The time interval for the activities listed before the maintenance phase ranged from 9 to 18 months in this sample of practices.
↵† Includes both new hires and enhanced activities and training for existing staff.
↵‡ Does not include staff time dedicated to uploading and sending application to the National Committee for Quality Assurance.
↵§ Does not include practice level consultation costs listed in Table 4.

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Table 4. Costs of External Consultants (Per Practice)
Practice 1 (Pediatrics) $2700
Practice 2 (Pediatrics) $1050
Practice 3 (Pediatrics) $2600
Practice 4 (Family medicine) $750

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Table 5. Activities That Required the Greatest Time Investment^* and the Highest Value for Improving Patient Care

	Practice 1 (Pediatrics)	Practice 2 (Pediatrics)	Practice 3 (Pediatrics)	Practice 1 (Family Medicine)
Previsit planning and care coordination processes new work to pre-populate patient charts, prepare for visits, identify overdue or upcoming screening or other tests to recommend)	T^V	T^V		T^V
Defining 3 preventive care services, 3 different chronic care services and identifying patients not recently seen and patients on specific medications	T^V	T^V	T^V	T^V
Writing office policies defining processes to define work flows for following up on laboratory, imaging, and other care processes including drafting agreements with consultants; drafting job descriptions	T^V	T^V	T	T^V
Demonstrating that >50% of patients who request an e-copy of their information receive it within 3 business days	T	T
Establish patient satisfaction survey process	T^V	T^V	T
Starting new office meetings dedicated to quality improvement and working to complete NCQA application requirements		T		T
Creating and processing screenshots to demonstrate existence of required elements	T	T	T	T
Providing after-hours access to care (providing advice to patients electronically, and via phone, demonstrating hat afterhours advice is then incorporated into the patient record)	T	T		T
Workbook preparation and documentation	T	T	T	T
Clinical advice via secure messages during office (via establishment of a patient portal purchased for PCMH work)		T	T

↵* All activities required at least one full working day (8 hours) of staff time to complete. Many activities, especially regarding preparing policy documents, job descriptions, screenshots, documenting chart data into workbooks, and devising plans managing populations, took much longer than 8 hours.
NCQA, National Committee for Quality Assurance; PCMH, patient-centered medical home; T, greatest time investment; T^V, highest value for improving patient care.