Ideal Medical Practices: Open letter to the NCQA regarding their PCMH measure set

A number of colleagues and I have crafted an open letter to the NCQA in response to their request for comment on adding patient experience measures to their 'Patient-Centered Medical Home' rubric.

I will paste the entire letter below.

The letter has been sent to the NCQA. Thanks to all who contributed to this effort.

____________________________________

An Open Letter to the NCQA

We represent a national network of primary care clinicians with a strong interest in both providing great primary care and preserving/nurturing the moribund specialty that is primary care in the US.

We note with interest the call for public comment on refining the NCQA' s instrument for gauging the Patient Centered Medical Home (PCMH) into a more 'patient centric' tool. Before we comment on the specifics of designing a more ‘patient centric’ tool we would like to state a few of our major misgivings about the current NCQA tool:

1) Due to its significant administrative and infrastructure costs the current PCMH tool is extremely tedious to deploy in the overriding majority of small practices who actually provide the majority of primary care services in the US.
2) The tool appears to measure information technology infrastructure and tests the sophistication of EMR systems used but measures few patient-centered metrics and classifies these few measures as “non critical to pass,” which runs counter to the objective of measuring and certifying a patient-centered medical home.

By adding yet more practice tallied “patient centric” measures to further overwhelm the data collection capacities of practices, the NCQA will actually make matters worse and decrease the likelihood that small practices will be able to participate.

We believe in the power of patient reporting to guide patient centered care and as a byproduct supply practices with “experience” measures to improve care. In order to respond to your request for input surrounding the proposed “patient centric” measures, we have drawn on the data from 7000 of our patients who have completed both the HowsYourHealth (HYH) and the CAHPs measures. (The combined data analysis was performed by John Wasson, architect of the How’s Your Health survey, who has access to the pooled data for our group.)

We have four concerns. First, there are attributes of good care that make sense to us and which the Commonwealth Fund and others have reliably measured across countries. We can distill out of your list these measures of excellent primary care: access, efficiency, continuity, coordination of care and information. However, the redundancy of some measures worries us.

For example, the quality of access appears as: “getting routine care,” “getting care after hours,” and “access to help without making a visit.” John Wasson has provided data (Figure) which shows the above measures of access in our practices as comparisons between the 4 item CAPHS survey and the relevant HYH access question “How easy is it to get medical care when you need it?” If the question when asked once will provide an answer and it is congruent with the 3 questions above, then why not streamline the process for offices and patients and ask it only once?

Figure
An illustration of the correlation between HYH and CAHPS surveys using our 42 practices with each one having at least 15 responses.

The same concern holds true for a number of the other measures on the list. Communication quality and style of communication in CAHPS are highly inter-correlated and appear redundantly on the list as “listens and answers your questions,” and “explains care to you.” We find that single measures which are less generic and more specific for conditions perform well and provide us with insights about our management of the conditions. Continuity of care appears as “Respects you as a person,” “Seeing the same doctor or nurse,” and “Knows you well,” which we have measured through the question, “Do you have one person you think of as your personal doctor or nurse?”

Our point is not that these single items are “better” in psychometric terms. Our point is that primary care offices like ours are beset with administrative redundancy and inefficiency while we have little time or resources to waste.

We urge NCQA to use a single overarching access measure as the standard and to reserve the “drill down” measures as options that can be added if desired. We also encourage the NCQA to do the same thing for the other important primary care domains-- efficiency, continuity, coordination of care, and information.

Secondly, we cannot overemphasize the importance of patient confidence with self-management (self care) as a measure. Patient confidence is the single measure best correlated with good health care outcomes. Our practices have tested several methods to enhance patient confidence. Although the patient and not the practice is the final arbiter of the level of patient confidence, a practice providing patient centered care (via basic but vital practice measures such as excellent access, ample opportunities to provide information, permission and time for open-ended communication) will be able to, over time, enhance the general level of patient confidence. The two proffered measures (“help you manage your health,” and “has confidence in your ability to manage”) are un-interpretable as currently written though they appear to be written with underlying intent to gauge confidence. We urge you to consider the single measure we use, “how confident are you that you can control and manage most of your health problems?”

Thirdly, we strongly recommend the use of at least one overarching measure of patient-centered care. We routinely use two overarching measures – “perfect care” and “exactly the care” - as snap shots of how we are doing relative the absolute best care possible and for comparing and sharing with colleagues.

Finally, we urge NCQA to consider how the measurement should be done. The current measurement methodology is skewed to benefit larger organizations capable of bearing extensive data collection costs. Diane Rittenhouse’s study* demonstrated a striking correlation between the number of physicians in a group and attainment on the NCQA PCMH recognition scale. The net effect is to reward group size over quality. We urge you to mitigate this bias and consider methodologies that have proven value in solo and small practices.

We have used the methodology of "patient-entered web-based practice surveys”. Through many publications and our experiences we have validated the methodology and made it “evidence-based”. We believe that the NCQA should consider the use of this methodology that lays minimal or no extra burden on small and solo practices as they struggle to maintain solvency in today's toxic climate for primary care. We encourage the NCQA to provide this methodology as an alternate to the current process-heavy but not patient-centered recognition pathway.

*Health Affairs, 27, no. 5 (2008): 1246-1258
doi: 10.1377/hlthaff.27.5.1246

Thank you for considering our input into your improvement process.

John Brady MD, Newport News VA
L Gordon Moore MD, Seattle WA
Nancy Guinn MD, Albuquerque NM
Jean Antonucci MD, Farmington ME
Angela Egly MD, Sandwich IL
Kevin Egly MD, Sandwich IL
Sharon McCoy George MD, Irvine CA
Donald Stewart MD, Sammamish WA
Jessica Davis MD, Stillwater NY
Norbert Goldfield MD, Springfield MA
Kristina Garrido ARNP, Issaquah WA
John Watts Haresch MD, Kill Devil Hills NC
Timothy Malia MD, Fairport NY
Craig Amnott MD, Philadelphia PA
Ramona G. Seidel MD, Arnold MD
Sofia Fernandez MD, Hacketstown NJ
Gary Seto MD, S Pasadena CA
Myria Emeny MD, Westerlo NY
Elaine Chu MD, Glendale CA
Deanna Tolman MS FNP-BC, Centennial CO
Brian Pierce MD, Rockport ME
Lynette Iles MD, Washington IA
Tim Scheffel DO, Homer AK
Judith Zettek RN BSN, Rochester NY
Emily Queenan MD, Rochester NY
Ron Edwards MD, Topeka KS
Christopher Wenner MD, Cold Spring MN
Joanne Holland MD, Drain OR
Paul Spilseth MD, Stillwater MN
Jack Shepherd MD, Charlotte NC
Kathleen R Patton MD, Boston MA
Tom Hastings MD, Chesterfield MO
Rebecca Price CPHQ, San Diego CA
Jessica T Ellsworth MD, Scottsdale AZ
Fred Grover Jr. MD FAAFP, Denver CO
Michael Barron MD, St Louis MO
Mark Tanenbaum MD, Atlanta GA
AnnaMaria Izquierdo-Porrera MD PhD, Rockville MD
Bridget Early MD, Ashland MO
James Bloomer MD, Exeter NH
Jeff Belden MD, Columbia MO
Anne Fitzsimmons MD, Columbia MO
Lonna Larsh MD, Santa Cruz CA
Gerald Miller MD, Havertown PA
Dr. Carolle Silney, Columbia MO
Peter Koopman MD, Columbia MO
Carla Gibson MSN FNP, Missoula MT
Jose Battle MD, NYC NY
Sid Robin MD, Austin TX
Kristin L. Oaks DO, Worthington OH
David Gordon MD, Denver CO
Elise Leland MD, Vancouver WA
Kelly Locke MD, Basalt CO
Cynthia Cote' MD, Maple Valley WA
Sangeetha Murthey MD, SanDiego CA
Karen Pratt, San Ramon CA
Sharlene Kinney MD, Berkshire NY
Liza Sampson MD
Gretchen Reis MD, Circleville OH
Benjamin Chan MD, Albuquerque NM
Rainer Berk MD, Andalusia AL
Scott Brown MD, Albuquerque NM
Susan Miller MD, Richmond VA
Janice Pegels MD, Vestal NY
Christine Harter MD, Phoenix AZ
Beth Sullivan DO, Commerce GA
Michelle Eads MD, Colorado Springs CO
Helen Yang MD, Chapel Hill NC
Melissa Weakland MD, Seattle WA
Richard S. Gitomer MD, Atlanta GA
J. Kevin Richter MD, Berryville AR
Scott Clemensen MD, Boulder CO
Stanley Frochtzwajg MD, Ventura CA
Margaret M. Coughlan MD,Millbrook NY
Carolyn Brumm McCormick MD FAAFP, Lumberton NC
Linda Eckhardt, MD, Northampton PA
Michael Jongerius MD, Peoria IL
Bruce Hopper MD, Philadelphia PA
Leigh Saint-Louis MD, Eugene OR
Matthew Levin MD, Monroeville PA

Comments

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Here is the very nice reply from the NCQA:

Dear Dr. Moore,

Thank you for your thoughtful suggestions. We will most definitely consider the recommendations of the group as we talk with our Advisory Committee members and weigh other recommendations.

Please don’t hesitate to contact us if you or your group have additional comments.

Best regards,
Johann

________________________
Johann Chanin, RN, MSN
NCQA
Product Development

Posted by: Gordon Moore | March 12, 2010 at 03:18 PM