Costs of Transforming Established Primary Care Practices to Patient-Centered Medical Homes (PCMHs)

Neil S. Fleming; Briget da Graca; Gerald O. Ogola; Steven D. Culler; Jessica Austin; Patrice McConnell; Russell McCorkle; Phil Aponte; Michael Massey; Cliff Fullerton

doi:10.3122/jabfm.2017.04.170039

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Table 1.

Practice Characteristics for the 56 HealthTexas Provider Network National Committee for Quality Assurance Level 3 Patient-Centered Medical Homes That Obtained Recognition under the 2008 Criteria and Remained Open Throughout Our Study Period (October 2014 to February 2016)

PCMH recognition period
August 2010 to December 2011 (early adopters)	14 (25.0)
January 2012 to December 2012 (midterm adopters)	42 (75.0)
Practice size
Small (<5 physicians)	31 (55.4)
Midsize (5–16 physicians)	22 (39.3)
Large (17–33 physicians)	3 (5.3)
Practice type
Pediatric clinic	5 (8.9)
Community clinic	4 (7.1)
Senior center	3 (5.4)
Internal/family medicine	44 (78.6)

Data are n (%).

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Table 2.

Time and Activities for the HealthTexas Corporate Patient-Centered Medical Home (PCMH) Team for Initial National Committee for Quality Assurance PCMH Accreditation (2008 Criteria)

Role	Activities	Time	Annualized FTE^*	Mean Hourly Wage ($)^{^†}	Total Cost ($)
PCMH director	• Assemble program structure and write first application	0.50–0.60 FTE (first 6 months, January to June 2010)	0.28	79.00	45,185
	• Work with practice administrators and operations managers to get the guidelines/protocols/processes in place and the documentation needed for the application	0.10–0.15 FTE (July 2010–June 2012)	0.25		41,077
	• Develop standard practices and templates for the applications, put together a handbook to guide practices through the process; write applications; build and categorize the library of documents required for the application; write guidelines and protocols required by the standards, shepherding them through the approval process; teach leaders about PCMH	∼0.40 FTE (July 2010 to June 2012)^{^‡}	0.80		131,448
PCMH specialists	• Learn about PCMHs; learn the NCQA online tool through which applications are submitted; upload the first practice application; communicate with NCQA regarding inconsistencies or ambiguities in their instructions	1.0 FTE (first 6 months, January to June 2010)	0.50	28.38	29,512
PCMH specialists	• Work with practice administrators and operations managers to put together the documentation for the practice applications; write the applications	2 FTE (July 2010 to June 2012) + ∼0.1 FTE for 8 months + 0.2 FTE for 4 months^{^‡}	4.13		243,968
Physician executive leader	• Obtain board approval for HealthTexas-wide PCMH endeavor; get primary care physicians aligned and motivated; lead the physician champions; promote/hire administrative leaders and staff for the PCMH initiative	0.1–0.15 FTE for 12–18 months	0.17	146.40	51,386
	• Interpret NCQA PCMH criteria
	• Work with the decision support group to get the reports needed for PCMH accreditation
	• Work with physicians to write up the information for the 3 target conditions (diabetes, asthma, heart failure) and the evidence-based guidelines for those, and pull together patient education for those conditions
	• Work with the disease management group to build templates in the EMR; create physician checklists for patient visits involving the target conditions
	• Audit and review the applications (especially first, which was his practice, and other early ones); maybe 2 hours spent on this
Physician champions	• Engage and train primary care physicians, educating them on what PCMH is, what getting accreditation involves, and what they would need to do	0.6 FTE (a half day/week for each of 6 MDs) for ∼12 months	0.60	146.40	51,386
Physician champions	• Review the required 36 charts per practice for compliance with the criteria on the clinical side	1.0 FTE for July 2010 to June 2012 (20 h/week for 1 physician, 3–4 h/week for 5 physicians)	2.00		609,024
Informatics and disease management	• Coordinate changes in the EMR to facilitate PCMH (add/change content, change wordings, tag things so reports could be created; add more structured data to capture of all requirements as they related to the 3 PCMH target conditions); chair the clinical committee reviewing all protocols for the PCMH initiative	Physician: 0.2 FTE (first 6 months, January to June 2010)	0.10	130.65	27,175
	• Perform administrative and leadership tasks	Physician: 0.1 FTE (July 2010 to June 2012)	0.20		54,350
	• Program the changes in the EMR	Staff: 0.2 FTE (Jan 2010 to June 2012)	0.40	60.70	50,498
HealthTexas director of clinical informatics	• Spend supervisory time related to PCMH reporting work	0.25 FTE for 12 months	0.25	84.38	43,875
	Creating reports required to meet the PCMH criteria–both creation of new reports (eg, pre-visit planning), and tweaking existing reports so that they would include the necessary elements (eg, performance reports for asthma and diabetes) Data sources: EHR, HealthTexas data warehouse used SQL server reporting services Produce the reports (automated) Answer queries practices submit to the help desk regarding reports	Programming time: Previsit planning: 60 hours Demographics: 24 hours Priority conditions: 60–100 hours each if no pre-existing report^{^§}	0.16		27,338
		Negligible human time	0.00	0	0
		1.5 FTE for all helpdesk services; during application periods, ∼10% of queries are related to PCMH reports	0.15	24.29	7,579
Care coordination resource	• Identify and confirm gaps in preventive and chronic disease care, and schedule appointments to address these Note: We chose to focus on preventive services that can be billed for, ensuring that the care coordination resource pays for itself (under the FFS model)	8 FTE medical assistants^{^‖}	8.00	18.75	312,023
Care coordination resource		1 FTE manager^{^‖}	1.00	37.87	78,767

↵* Number of full-time equivalents (FTEs) (eg, 1 FTE) multiplied by the number of months (eg, 24 months) over which those FTEs were sustained, divided by 12 months = the annualized FTE (eg, 2 FTEs).
↵† The mean hourly wage included a 22% fringe rate to account for the cost of employee benefits.
↵‡ This included 3 weeks spent putting together the corporate application (0.20 FTE for the PCMH director [with an associated cost of $1,896] + 2 FTE PCMH specialists [with an associated cost of $6,811]). The corporate application captured 44.25 of the 100 points required for accreditation; the remaining 55.75 had to come from individual practice applications.
↵§ HealthTexas had existing reports for 2 of the 3 priority conditions and was able to revise these to incorporate the PCMH criteria; for the calculation of time and cost, however, we assumed creation of 3 novel reports.
↵‖ Ongoing expense.
EMR, electronic medical record; FFS, fee-for-service; NCQA, National Committee for Quality Assurance.

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Table 3.

Time and Activities for HealthTexas Corporate Patient-Centered Medical Home (PCMH) Team for renewal of National Committee for Quality Assurance PCMH accreditations (2011 or 2014 criteria)

Role	Activities	Time	Annualized FTE^*	Mean Hourly Wage ($)^{^†}	Total Cost ($)
PCMH specialists	• Work with practice administrators and office managers to put together the documentation for the practice applications; write the applications^{^‡}	53.3 h/practice^{^‡}	1.44	28.38	85,018
PCMH specialists	• Conduct training on documentation in the EMR related to new standards (mostly related to replacing heart failure with depression as one of the priority conditions [required to have 1 related to mental health])	1–2 h/practice^{^§}	0.04		2,384
Physician executive leader	• Develop mechanism to identify high-risk patients	12 hours	0.01	146.40	1,757
Physician executive leader	• Lead development of new guidelines (depression) and metrics (to be built into EMR)	12 hours	0.01		1,757
Physician champions	• Educate primary care physicians about changes under the 2011 criteria	1–2 h/practice^{^§}	0.04	146.40	12,298
Physician champions	• Perform required chart reviews (under 2011 criteria, 48 patient charts per practice; under 2014 criteria, 30 charts per practice)^{^§}	10 min/chart (2011 criteria); 15 min/chart (2014 criteria)	0.18		55,486
Informatics and disease management	• Develop mechanism to identify high-risk patients; coordinate changes in the EMR related to the need to collect structured data for new metrics (mostly around depression, the new priority condition)	Physician: 0.05–0.1 FTE	0.08	130.65	20.381
Informatics and disease management	• Program the changes in the EMR	Staff: 0.1 FTE	0.10	60.70	12,625
HealthTexas director of clinical informatics	• Spend supervisory time related to PCMH reporting work	0.25 FTE	0.25	84.38	43,875
	• Create reports required to meet the PCMH criteria	Programming time: Depression: 60 hours Audit tool: 80 hours	0.07		11,813
	• Produce the reports (automated)	Negligible human time	0.00	0	0
	• Answer queries practices submit to the help desk regarding reports	1.5 FTE for all helpdesk services; during application periods, ∼10% of queries are related to PCMH reports	0.15	24.29	7,579
Care coordination resource	• Identify and confirm gaps in preventive and chronic disease care, scheduling appointments to address these Note: We chose to focus on preventive services that can be billed for, ensuring that the care coordination resource pays for itself under the FFS model	8 FTE medical assistants^{^‖}	8.00	18.75	312,023
Care coordination resource		1 FTE manager^{^‖}	1.00	37.87	78,767

↵* Number of full-time equivalents (FTEs) (eg, 1 FTE) multiplied by the number of months (eg, 24 months) over which those FTEs were sustained, divided by 12 months = the annualized FTE (eg, 2 FTEs).
↵† The mean hourly wage included a 22% fringe rate to account for the cost of employee benefits.
↵‡ Unlike the initial recognition process, HealthTexas did not complete a corporate application for the renewals; an individual renewal application was completed for each practice.
↵§ By May 2016, 56 PCMHs that obtained initial recognition under the 2008 National Committee for Quality Assurance criteria had renewed (33 under the 2011 criteria, 23 under the 2014 criteria).
↵‖ Ongoing expense.
EMR, electronic medical record; FFS, fee-for-service.

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Table 4.

Numbers of Survey Respondents, by Job Role, Who Reported Being Involved in Specific Activities Related to Their Practices' Initial and Renewal Applications for National Committee for Quality Assurance Patient-Centered Medical Home Recognition (Survey Conducted January to February 2016)

	Physician		Practice Administrator		Office Manager		Other Personnel
	Initial (n = 11)	Renewal (n = 10)	Initial (n = 16)	Renewal (n = 15)	Initial (n = 9)	Renewal (n = 15)	Initial (n = 16)	Renewal (n = 14)
Review policies and procedures related to PCMH standards	4 (36.4)	3 (30.0)	13 (81.3)	5 (33.3)	8 (88.9)	11 (73.3)	3 (18.8)	2 (14.3)
Document for PCMH accreditation	3 (27.3)	3 (30.0)	10 (62.5)	5 (33.3)	4 (44.4)	11 (73.3)	4 (25.0)	1 (7.1)
Attend clinic team huddles/meetings	7 (63.6)	4 (40.0)	9 (56.3)	5 (33.3)	7 (77.8)	12 (80.0)	6 (37.5)	4 (28.6)
Conduct or participate in EMR training	4 (36.4)	2 (20.0)	11 (68.8)	2 (13.3)	6 (66.7)	10 (66.7)	5 (31.3)	4 (28.6)
Train staff on PCMH guidelines and procedures	2 (18.2)	3 (30.0)	10 (62.5)	3 (20.0)	7 (77.8)	8 (53.3)	1 (6.3)	1 (7.1)
Accommodate for care management related to PCMH	7 (63.6)	2 (20.0)	11 (68.8)	4 (26.7)	5 (55.6)	10 (66.7)	5 (31.3)	4 (28.6)
Adjust workflow to meet PCMH requirements	5 (45.5)	3 (30.0)	11 (68.8)	3 (20.0)	8 (88.9)	9 (60.0)	5 (31.3)	4 (28.6)
Meet with members of the corporate PCMH team	1 (9.1)	0 (0.0)	10 (62.5)	8 (53.3)	5 (55.6)	10 (66.7)	0 (0.0)	1 (7.1)
Patient tracking and registry functions	1 (9.1)	0 (0.0)	10 (62.5)	3 (20.0)	5 (55.6)	9 (60.0)	1 (6.3)	1 (7.1)
Performance reporting and improvement	2 (18.2)	1 (10.0)	13 (81.3)	4 (26.7)	7 (77.8)	11 (73.3)	2 (12.5)	0 (0.0)
Develop/approve standing orders	2 (18.2)	1 (10.0)	12 (75.0)	3 (20.0)	5 (55.6)	8 (53.3)	1 (6.3)	1 (7.1)
Other	0 (0.0)	0 (0.0)	1 (6.3)	1 (6.7)	1 (11.1)	0 (0.0)	1 (12.5)	0 (0.0)

EMR, electronic medical record; PCMH, patient-centered medical home.

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Table 5.

Total Time Reported and Associated Costs for Activities in Which Respondents Were Involved While Their Practice Was Obtaining and Renewing National Committee for Quality Assurance Recognition as a Patient-Centered Medical Home, by Job Role (Survey Conducted January to February 2016)^*

	Mean Hourly Wage ($)^{^†}	Initial Recognition			Renewal
	Mean Hourly Wage ($)^{^†}	N	Time Spent (Hours)	Associated Cost ($)	N	Time Spent (hours)	Associated Cost ($)
Physician	151.48	8	7.5 (4.5–18.0)	$1136 ($682–2727)	8	3.5 (2.0–27.5)	$530 ($303–4136)
Practice administrator	48.54	11	23.0 (18.0–33.0)	$1117 ($874–1602)	11	11.0 (50–24.0)	$534 ($243–1165)
Office manager	30.81	9	48.0 (29.0–96.0)	$1,479 ($893–2957)	11	22 (15.0–35.0)	$678 ($462–1078)
Other personnel
Clinical coordinator/ supervisor	41.47	1	120 (n/a)	$4,976 (n/a)	1	110.0 (n/a)	$4561 (n/a)
Medical assistant	18.24	4	17.5 (5.5–28.0)	$319 ($100–511)	2	8.0 (n/a)	$146 (n/a)
Physician office representative	16.81	1	0 (n/a)	$0 (n/a)	1	12.0 (n/a)	$202 (n/a)
Social worker	35.82	1	10.0 (n/a)	$358 (n/a)	1	15.0 (n/a)	$537 (n/a)

Data are median (interquartile range) unless otherwise indicated. The interquartile range was not reported when <4 responses were received (“n/a”).
↵* Three survey responses received from 2 senior health centers were not included because these practices did not use the electronic medical record.
↵† The mean hourly wage included a fringe rate to account for employee benefits and was based on 2012 levels, because that was the year with the greatest patient-centered medical home transformation activity.

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Table 6.

Time and Associated Costs Related to Patient-Centered Medical Home Recognition and Renewal for a Hypothetical 5-Physician Practice within HealthTexas (Based on Survey Data Collected January to February 2016)

	Mean Hourly Wage ($)^*	N	Initial Recognition				Renewal
			Time Spent (hours)^{^†}		Associated Cost ($)^{^†}		Time Spent (hours)^{^†}		Associated Cost ($)^{^†}
			Individual	Total	Individual	Total	Individual	Total	Individual	Total
Physician	151.48	5	7.5	37.5	1,136	5,680	3.5	17.5	530	2,651
Practice administrator	48.54	1	23.0	23.0	1,117	1,117	11.0	11.0	534	534
Office manager	30.81	1	48.0	48.0	1,479	1,479	22.0	22.0	678	678
Medical assistant	18.24	7.5	17.5	131.3	319	2,394	8.0	60.0	146	1,094
Total costs	—	—	—	239.8	—	10,669	—	110.5	—	4,957

↵* The mean hourly wage included a fringe rate, to account for employee benefits, and was based on 2012 levels, as that was the year with the greatest patient-centered medical home transformation activity.
↵† Estimated based on the medians reported in Table 5.