In Rhode Island, health care comprises a small fiefdom. Reasonable population levels of income and education, a small geographic footprint, two out of three of the major insurers under ‘local’ control, and a relatively ‘beneficent’ attitude towards primary care from the state health department and the Office of the Health Insurance Commissioner (OHIC) are the factors that have allowed a variety of primary care delivery systems to coexist.
Micropractices have proliferated in RI. At current there are 8 insurance-based micropractice physicians and 2 ‘direct’ micropractice non-concierge physicians. In 2013, six of our micropractice doctors aggregated into a loosely knit practice group under the moniker ‘RIIMPS” so that we could enter the state’s multipayer quality ‘Care Transformation Collaborative (CTC)’.
In order to participate the in CTC, we had to drink their quality Kool-Aid – a sloshy mixture of NCQA’s PCMH, quarterly HEDIS measures, and CAHPS surveys, along with a goodly sprinkle of directed ‘nurse care manager’ usage.
The dolor and drudgery of collecting interminable metrics which flat-out miss the quality mark was infuriating enough to galvanize us to action. By March 2015, Jean Antonucci and I co-authored an article about our experience of taking the NCQA PCMH ‘test’ http://www.annfammed.org/content/13/3/269.full . I realize now that actually being forced to complete NCQA radicalized my conversion into an anti-established-metric zealot. As distasteful and time consuming qualifying as a PCMH through NCQA was, the experience had handed me a platform to riff off of.
Since the inception of the 2006 national IMP collaborative project, some of us had been using HowsYourHealth (HYH) as a tool to measure practice quality. When compared to the NCQA platform, HYH comes out smelling like roses in terms of cost, ease of use, utility and derivation from patient voice.
Over the past 6 months, I’ve met with moderate success in introducing the ‘proof of concept’ of HYH as a clinically useful tool for practices and patients to the CTC, and some success in suggesting the substitution of HYH data for some of the existing CTC practice requirements. For example, the CTC requires practices to document depression screening (with PHQ2), fall risk screening, and smoking status quarterly. A HYH survey imported into the chart within the required time frames counts as proof of completion of these screenings.
My next small battle will be using the HYH-embedded CAHPS survey to replace the required annual CAPHS surveys. This week, John Wasson, HYH author/originator, will be coming to address the CTCs required quarterly physician ‘breakfast of champions’ (don’t go looking that up in the Urban Dictionary!) to discuss use of HYH as a population management tool. It appears that the CTC leadership is ‘in favor’ of use of HYH by practices but some stakeholders are not willing to substitute the current quality platform with HYH. I think it will be another stake through the heart of primary care to insist on use of yet ANOTHER quality tool without jettisoning some of the current quality baggage, and that HYH should replace NCQA’s medical home evaluation platform.
Rhode Island is a bellwether of CMS’ proposed payment reform scheme, and we are scheduled to go to 80% ‘value based payment’ by the end of 2018. As such, the state is scrambling to find a method to engage 50% of primary care physicians in small practices that have not been coopted under the CTC umbrella for payment via value-based care. HYH, in conjunction with the state’s all-payer claims database, could be one such method to demonstrate value. (Another option would be to deny payment, and thus extinguish all of primary care not coopted into a large medical groups or ACOs.) I know I will have won my quality metric war when a separate parallel pathway that is based on HYH as its foundation exists to qualify a small practice for payment as a medical home in RI.