Patient-Centered Medical Home Definition And Requirements

OHIC’s affordability initiatives have emphasized the need for a strong primary care infrastructure and since 2011, OHIC has been promoting PCMH transformation to help strengthen Rhode Island’s primary care network. In 2015, OHIC worked with its Care Transformation Advisory Committee to define patient-centered medical homes and to set a year over year insurer target for PCMH adoption. OHIC also requires that insurers make supplemental payments to designated primary care practices to help finance PCMH transformation and operations.

The three-part definition of a PCMH requires demonstration of practice transformation, implementation of cost management initiatives, and clinical quality performance attainment or improvement. This three-part definition of PCMH also includes a provider reporting component.

Definition of Patient-Centered Medical Home:
OHIC's 2020 regulations outline the following three-part definition of PCMH against which RI primary care practices will be evaluated:

  • Practice is recognized by CTC-RI, participating for the first time in a formal transformation initiative (e.g., CTC-RI, PCMH-Kids, or an approved payer- or ACO-sponsored program) and/or practice is recognized by a national accreditation body (e.g., NCQA recognition. Practices meeting this requirement through achievement of NCQA recognition may do so independent of participating in a formal transformation initiative.
  • Practice has demonstrated clinical quality performance attainment or improvement. To promote measure alignment across statewide initiatives, measures selected to measure performance improvement will be selected from the OHIC multi-payer aligned measure set.
  • Practice has implemented a quality improvement strategy targeted at cost management. Beginning in 2021, OHIC is waiving this requirement for ACO-affiliated practices. Non-ACO-affiliated practices will need to separately implement one of OHIC's approved quality improvement strategies care coordination or cost-effective use of services to meet this requirement. These practices will be evaluated based on responses to an OHIC-administered survey.

Measures Included in the 2021 PCMH Measure Set

  • In 2021, practices will need to report on the following measures for the 10/1/20 – 9/30/21 measurement period.

Adult practices

  • Colorectal Cancer Screening (NCQA HEDIS, modified by CTC-RI)
  • Comprehensive Diabetes Care: Eye Exam (NCQA HEDIS, modified by CTC-RI)
  • Comprehensive Diabetes Care: HbA1c Control (<8) (NCQA HEDIS, modified by CTC-RI)
  • Controlling High Blood Pressure (NCQA HEDIS, modified by CTC-RI)*

*This measure has undergone significant specification changes for 2021 and will be reporting-only for 2021

Pediatric practices

  • Adolescent Well-Care Visits (NCQA HEDIS, modified by CTC-RI)
  • Developmental Screening in the First Three Years of Life (OHSU, modified by CTC-RI)
  • Lead Screening in Children (NCQA HEDIS, modified by RIDOH to define the attributed population)**

**Pediatric practices will not need to submit data to OHIC for “Lead Screening in Children”.  With practice permission, RIDOH will provide OHIC with practice reports for performance for the 10/1/2020 – 9/30/2021 measurement year for this measure.  OHIC will share these final performance data with practices once it receives data from RIDOH’s KIDSNET.  Practices can log onto KIDSNET on that date, or at any other time, to estimate performance on the measure.

Detailed specifications for these measures can be found in the following PDF: 

A practice seeking OHIC PCMH recognition status is required to demonstrate attainment or improvement by reporting:

  • practice performance at or above a pre-defined high-performance benchmark or 
  • improvement of at least three percentage points over one or two years. 

Given the likely continued impact of COVID-19 on 2021 performance, however, OHIC is revising the 2020-2021 high-performance benchmarks in the first component of this definition. It is modifying benchmarks using an “adjuster” (i.e., half the difference between the median rates for the 2018-2019 performance period and the 2019-2020 performance period) based on the assumption that 2020-2021 performance will be better than 2019-2020 performance.

In addition, OHIC is modifying the second component of this definition so that performance for the 2020-2021 performance period must simply be higher than 2018-2019 performance period; a three-percentage-point minimum increase will not be required.

Adult practices need to demonstrate attainment or improvement on at least two of the three adult measures. Pediatric practices need to demonstrate attainment or improvement on at least two of the three pediatric measures.  Practices that report on both adult and pediatric measures need to demonstrate attainment or improvement on at least two of the three adult measures and two of the three pediatric measures. 

Similar to prior years, practices reporting for the first time in 2021 will not be assessed by demonstrating attainment or improvement.  Instead, practices will meet the requirement simply by reporting performance on these measures.  Performance will be recorded as baseline data and will be utilized to assess performance improvement in future years.

The high-performance benchmarks for 2021 reporting are as follows:

Measure

2021 Benchmark

Benchmark Source***

Measures for Adult Practices

Colorectal Cancer Screening

Commercial: 59.70%
Medicaid: 47.39%

Commercial: National commercial 50th percentile
Medicaid: 80% of the commercial value

Comprehensive Diabetes Care: Eye Exam

49.39%

National commercial 50th percentile

Comprehensive Diabetes Care: HbA1c Control (<8)

Commercial: 62.96%
Medicaid: 56.64%

Commercial: National commercial 90th percentile
Medicaid: National commercial 66th percentile

Measures for Pediatric Practices

Child and Adolescent Well-Care Visits (adolescent age ranges only)

Commercial: 75.10%
Medicaid: 53.66%

Commercial: New England commercial 90th percentile
Medicaid: National commercial 75th percentile
(both adjusted down nine percentage points)

Developmental Screening in the First Three Years of Life

67.98%

2018 performance year benchmark (i.e., 25th RI percentile from 10/1/2016 – 9/30/2017)

Lead Screening in Children

73.11%

National Medicaid 50th percentile

***HEDIS national and New England data are from NCQA’s Quality Compass 2020 (CY 2019 or CY 2018 data). All benchmarks, except for Lead Screening in Children, have been modified using an “adjuster” (described above).  OHIC did not modify the benchmark for Lead Screening in Children because the “adjuster” actually increased the benchmark, as 2019-2020 performance was higher than 2018-2019 performance. 

Additionally, when assessing if a practice demonstrated improvement, OHIC excludes rates with a denominator of less than 30 and rates submitted for a performance period other than what is indicated.  OHIC, however, makes one-time exceptions to this methodology when measures move from reporting-only status to recognition status.  OHIC also excludes these rates when calculating statewide median performance.  It does not exclude these rates when assessing practice performance against the high-performance benchmark.

For more information or if you have any questions, please contact Cory King.