recent trends and future directions for the medical home

A N I S S U E B R I E F

Recent Trends and Future Directions for the Medical Home Model in New York

United Hospital Fund

The United Hospital Fund is a health services researchand philanthropic organization whose primary mission is toshape positive change in health care for the people of NewYork. We advance policies and support programs that promotehigh-quality, patient-centered health care services that areaccessible to all. We undertake research and policy analysisto improve the financing and delivery of care in hospitals,health centers, nursing homes, and other care settings. Weraise funds and give grants to examine emerging issues andstimulate innovative programs. And we work collaborativelywith civic, professional, and volunteer leaders to identifyand realize opportunities for change.

OFFICERS

J. Barclay Collins IIChairman

James R. Tallon, Jr.President

Patricia S. LevinsonJohn C. SimonsFrederick W. Telling, PhDVice Chairmen

Sheila M. AbramsTreasurer

Sheila M. AbramsAndrea G. CohenSally J. RogersSenior Vice Presidents

Anne-Marie J. Audet, MD, MScDeborah E. HalperVice Presidents

Amanda A. WilliamsCorporate Secretary

DIRECTORS

Michelle A. AdamsStephen BergerLori Evans BernsteinJo Ivey Boufford, MDRev. John E. CarringtonDerrick D. CephasDale C. Christensen, Jr.J. Barclay Collins IIMichael R. Golding, MDCary KravetJosh N. KuriloffPatricia S. LevinsonDavid Levy, MDHoward P. MilsteinSusana R. Morales, MDRobert C. OsbornePeter J. PowersJohn C. SimonsMichael A. Stocker, MD, MPHJames R. Tallon, Jr.Frederick W. Telling, PhDMary Beth C. Tully

HONORARY DIRECTORS

Howard SmithChairman Emeritus

Herbert C. BernardJohn K. CastleTimothy C. ForbesBarbara P. GimbelRosalie B. GreenbergMary H. SchachneAllan Weissglass

U N I T E D H O S P I T A L F U N D

Recent Trends and Future Directions for the Medical Home Modelin New York

Gregory BurkeD I R E C T O R , I N N O VA T I O N S T R A T E G I E S

U N I T E D H O S P I T A L F U N D

A u g u s t 2 0 1 5

Copyright 2015 by United Hospital FundISBN 1-933881-50-X

Free electronic copies of this report are available atthe United Hospital Fund’s website, www.uhfnyc.org.

Recent Trends and Future Directions for the Medical Home Model in New York 1

There is growing evidence that a higher-performing primary care system—one built onthe medical home model—will be critical toachieving the central aims of health reform:better care, lower costs, and improvedpopulation health. A substantial departure fromthe way traditional primary care practicesfunction, the medical home has shown greatpromise for improving access to and the qualityof care, with particular value in managing thecare of the complex, chronically ill patients whogenerate a disproportionate share of the healthsystem’s costs.

Since 2011, the United Hospital Fund hastracked the spread of the medical home model inNew York State, using a particular formulation ofit: the Patient-Centered Medical Home(PCMH) as defined by the NationalCommission on Quality Assurance (NCQA).New York State is now pursuing the design andimplementation of a “next-generation” medicalhome model, Advanced Primary Care, which willchallenge primary care practices to move beyondimproving their structures and processes of care,as specified by the NCQA criteria, to show thatthey are truly improving outcomes, in terms ofbetter health and reduced costs.

This report is the UHF’s fourth “census” ofPCMH providers in New York State. Over thepast four years we have noted New York’scontinued national leadership in adoption ofPCMHs, and seen the number of medicalhomes grow from a few demonstration projectsin isolated regions to broad acceptance as afoundational element in the State’s strategy forhealth care reform. Our analysis of growth from2013 to 2014 identifies a number of trends inthe spread of PCMHs:

• PCMH adoption continues to grow acrossNew York. Essentially all regions showedincreases in the number of providers workingin practices that have been recognized byNCQA as PCMHs. Much of that growthoccurred upstate; for the third year in a row,there was more growth in PCMH providersoutside New York City than in it. Much ofthe statewide growth was a result of theHospital Medical Home program, a Stateinitiative that supported adoption of thePCMH model in hospital teaching clinics.

• Adoption of the PCMH model continues tobe centered in larger practices (e.g., grouppractices, hospital clinics, and federallyqualified health centers) that have the scalerequired to implement and sustain the addedcapacities and costs that the model demands.Adoption of the PCMH model in smallpractices remains low.

• There is some evidence of a correlationbetween payers who provide incentivepayments for PCMHs and higher numbers ofPCMH providers. For example, clinics thatcare for substantial numbers of Medicaidenrollees represent over half of the state’sPCMH providers and over 70 percent ofthose in New York City. Providers in regionswhere major payers are participating inmultipayer medical home demonstrations arealso more likely to work in a PCMH.

Looking ahead, New York’s experience to datewith promoting adoption of the PCMH modelshould provide both a strong foundation ofincreasingly high-performing primary carepractices on which to build Advanced PrimaryCare, and some important lessons.

Executive Summary

This analysis would not have been possible with-out the support of Kate Bliss from the Office ofQuality and Patient Safety in the New York StateDepartment of Health.

This report was supported in part by the ThePeter and Carmen Lucia Buck Foundation, theTD Charitable Foundation, and EmblemHealth.

Acknowledgments

2 United Hospital Fund

1 Patient-Centered Primary Care Collaborative. January 2015. The Patient-Centered Medical Home’s Impact on Cost & Quality: An AnnualUpdate of the Evidence, 2013-2014. https://www.pcpcc.org/resource/patient-centered-medical-homes-impact-cost-and-quality

2 Friedberg M, M Rosenthal, R Werner, KG Volpp, EC Schneider. June 1, 2015. Effects of a Medical Home and Shared SavingsIntervention on Quality and Utilization of Care. JAMA Internal Medicine.http://archinte.jamanetwork.com/article.aspx?articleid=2296117

3 The Joint Commission, “The Primary Care Medical Home” (web page). www.jointcommission.org/accreditation/pchi.aspx

4 URAC, “Provider Care Integration and Coordination: The Patient Centered Medical Home” (web page).www.urac.org/accreditation-and-measurement/accreditation-programs/all-programs/patient-centered-medical-home/

5 CMS, EHR Incentive Programs, Stage 2 Criteria. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html

There is growing evidence1,2 that a higher-performing primary care system—one built onthe medical home model—will help achieve thegoals of health reform articulated as the “tripleaims”: better care, lower costs, and improvedpopulation health.

A medical home is quite different from atraditional primary care practice. As medicalhomes, practices actively manage care byexpanding access, interacting more with patientsbefore and after visits, using dedicated caremanagers, and demonstrating a particular focuson high-risk, chronically ill patients, who are thehealth system’s most complex and costly.Supporting these efforts are evidence-based bestpractices, closer work with registries, and newprocesses for measuring and reporting outcomes.

Over the past four years, the United HospitalFund has followed the growth of the medicalhome model in New York State, monitoring aparticular formulation of the medical home: thepatient-centered medical home (PCMH) asdefined by the National Commission on QualityAssurance (NCQA). The growth in PCMHs hasbeen substantial: between July 2011 andOctober 2014, the number of New York Stateproviders working in PCMHs increased by over70 percent, from 3,400 to over 5,800.

NCQA’s PCMH program is not the only medicalhome recognition process; other such programsare sponsored by the Joint Commission3 andURAC,4 and certainly some practices operate

like a medical home but have not sought formalrecognition. However, it has been the mostwidely used method for defining and certifyingpractices as medical homes, and New York Statehas used the definition in its own efforts toencourage use of the medical home model.NCQA operates a national program grantingpractices PCMH recognition on the basis oftheir ability to document that their structuresand processes of care meet or exceed specificstandards. These criteria cover team-based care,expanded access, care coordination, the use ofregistries and care managers to help manage thecare of patients with multiple chronicconditions, and systems incorporating evidence-based approaches.

During the years that UHF has been trackingthe growing numbers of PCMHs in New York,NCQA’s standards for recognition as a PCMHhave evolved: NCQA’s original standards (issuedin 2008) were revised in 2011 to include newstandards focusing on patient experience,relationships with subspecialists, use ofelectronic medical records, and measurement ofcost and quality. NCQA’s 2014 standardsinclude an increased emphasis on team-basedcare; care management focused on high-needpatients; more focused, sustained QualityImprovement (QI) on patient experience, cost,clinical quality; alignment with CMS’sElectronic Health Records Incentive Programs(specifically, Stage 2 “meaningful use” criteria);5

and further integration of behavioral health.

Introduction

Even as the PCMH model has been adoptedmore widely, and as evidence for its effectivenessaccumulates, providers, payers, and regulatorshave expressed concern about variableperformance of NCQA-recognized PCMHs onmeasures of clinical quality, utilization, and costsof care. There are concerns that NCQArecognition might be inadequate as a measure oftrue practice transformation, or as a predictor ofimproved outcomes in terms of improved healthor reduced costs. As noted at the first meeting ofthe State’s Integrated Care Work Group, “Apractice meeting any ‘standards’ (NCQA orotherwise) is helpful, but not a sufficientguarantee of meaningful practice improvement.”6

There is increasing support for a model thatfocuses on outcomes, a practice’s performanceon measures of quality and cost, which can helpposition the State’s primary care practices toparticipate in various forms of value-basedpayment.

The New York State Department of Health(DOH), long a proponent of the NCQA’sPCMH model, recognized and responded to thisconcern. In its State Health Innovation Plan(SHIP) the DOH proposed adopting a morerobust model, Advanced Primary Care (APC)—which “will go beyond [PCMH’s] new structuresand capabilities to specify and measureprocesses and outcomes associated with moreintegrated care, including prevention, effectivemanagement of chronic disease, integration withbehavioral health, and coordination among the

full range of providers working together to meetconsumer needs.”7

The APC model is a central element in NewYork’s innovation efforts. One of the SHIP’sstated goals was that within five years, 80percent of the state’s population would receiveprimary care in an APC setting. APC also hasthe potential to figure prominently in other NewYork State strategies for health care reform,including the State’s recent Medicaid waiver, theDelivery System Reform Incentive PaymentProgram (DSRIP),8 and the state’s recentproposal to CMS to move toward value-basedpayment in the Medicaid program.9

The new APC model is also the central focus ofthe State Innovation Models (SIM) grant NewYork was recently awarded by the Centers forMedicare & Medicaid. Noting in its SIMapplication that “the APC model is consistentwith principles of NCQA Patient CenteredMedical Home (PCMH) criteria, but seeks tomove beyond structural criteria to achievedurable, meaningful changes in processes andoutcomes,” New York proposed to allocate $67million of the $100 million grant to support astatewide program of APC practicetransformation, providing regionally organizedtechnical assistance to help primary careproviders implement the APC model.10

Over the past six months, the State has begunimplementing the SHIP, establishing a number


6 New York State Department of Health. Presentation at first meeting of the Integrated Care Work Group, January 16, 2015. Slide 20.www.health.ny.gov/technology/innovation_plan_initiative/docs/2015-01-16_integrated_care_presentation.pdf

7 New York State Department of Health. December 2013. New York State Health Innovation Plan. Pages 13–14.www.health.ny.gov/technology/innovation_plan_initiative/docs/ny_state_health_innovation_plan.pdf

8 New York State Department of Health. DSRIP Project Toolkit.www.health.ny.gov/health_care/medicaid/redesign/docs/dsrip_project_toolkit.pdf

9 New York State Department of Health, Medicaid Redesign Team. April 2015. A Path toward Value-Based Payment: New York StateRoadmap for Medicaid Payment Reform. .www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/revised_draft_vbp_roadmap.pdf

10 CMS CMMI. July 21, 2014. Model Test Application: New York State. Pages 4–6.http://www.health.ny.gov/technology/innovation_plan_initiative/docs/ny_sim_project_narrative.pdf


of multi-stakeholder workgroups, including theIntegrated Care Workgroup. This body isresponsible for advising the State in defining theproposed APC model, developing a method forallocating the funds available under the SIM forpractice transformation to help primary carepractices across the state adopt and implementthe APC model, and working with payers todevelop payment methods that recognize andsupport primary care provided by a practice thathas achieved APC status.

As of this writing, the detailed definition of theAPC model proposed in the SHIP remains awork in progress. It appears likely that the modelthat emerges will combine elements of NCQA’s2014 PCMH Standards with a set of clearlydefined measures of clinical quality andperformance. This will then become the modelthat is disseminated via New York’s SIM-fundedconsulting and technical assistance. If APC is tobecome a sustainable model, it must also be amodel that the payers are willing to support.

Even as the working definitions and standards ofmedical homes are changing, it remainsimportant and useful to track the growth of theNCQA’s PCMH model in New York State.Whatever the eventual definition of APC,PCMH recognition by NCQA is a good markerfor primary care practice transformation andperformance improvement. Providers that haveset up the structures, processes, andcompetencies required for NCQA recognition asa PCMH will be positioned well to succeedunder a measures-based payment system such asAPC.

In this quantitative report, we analyze the spreadof the PCMH model in New York several ways:looking at PCMH adoption statewide, by region,by specific NCQA program and recognitionlevel, and by practice type. In the appendix atthe end of this report, we also present moredetailed region- and borough-specific profiles ofthe changes in the number of PCMH providersbetween 2013 and 2014, by provider type.

11 Under NCQA’s PCMH recognition process, a practice can receive recognition as a PCMH at one of three levels (Level 1, 2, or 3,with Level 3 being the highest), depending on their total points and performance on the “must-pass” elements. The vast majority (85percent) of the state’s PCMH providers have received recognition under NCQA’s 2011 Standards, and most of those (90 percent)have been recognized at Level 3. For the purposes of this report, we are treating NCQA recognition as a single measure, notdifferentiating providers in terms of the year of the NCQA Standards under which they received recognition (2008 vs. 2011), noraccording their level of recognition.

NCQA Recognition: In this report, we trackthe adoption and use of the medical home modelby primary care practices across New York Statebased on NCQA recognition as a PCMH. Asnoted above, NCQA’s standards for recognitionas a PCMH have been evolving: NCQA’s 2008standards were replaced by a more rigorous setof standards in 2011, and those have beenfurther refined in its 2014 to includerequirements for ongoing quality improvementand reporting.11

Though APC is expected to become the mainyardstick for measuring the spread of medical

homes, for now NCQA data remain the mostconsistent and comprehensive means ofmeasuring statewide progress. They are alsocomparable across prior years, enabling analysisof changes over time.

PCMH Providers: Rather than tracking thenumber of practices recognized as PCMHs(which vary greatly in size, obscuring the relativeavailability of PCMH services), we have used thenumber of providers reported by NCQA asworking in practices so recognized, a bettermeasure of the impact and reach of the medicalhome model.

Methods and Definitions


Geography: To provide a sense of thegeographic spread and variation in adoption ofthe PCMH model, we grouped practices andproviders by the 11 regions used by the NewYork’s Population Health Improvement Program(PHIP) initiative, shown in Figure 1. WithinNew York City, we analyzed data and trends byborough.

Practice Type: As in prior reports, we used aprovider-level database from NCQA to identifyall providers in New York State working inNCQA-recognized PCMHs (in this case, sorecognized as of October 2014), and groupedproviders according to the type of practice withinwhich they worked. As there is no standarddefinition for practice type, we developed and

used the following methodology to categorize thepractices within which the providers worked:

1. Hospital Clinic: Clinics licensed underArticle 28 as a hospital outpatient clinic or asan off-site clinic (“extension clinic”)—excluding those operated by the New YorkCity Health and Hospitals Corporation(HHC).

2. HHC: Hospital clinics, extension clinics, andcommunity-based Diagnostic and TreatmentCenters (DTCs) operated by HHC; herebroken out as a separate category because ofthe scale of their participation in the NCQAPCMH program.

Figure 1. Regions Used in New York State’s Population Health Improvement Program

Long IslandNew York City

Mid-Hudson

Capital Region

Mohawk Valley

Tug Hill SeawayNorth Country

Central New York

Southern TierFinger Lakes

Western New York


3. Hospital Practice: Private practices owned bya hospital or medical school (not licensedunder Article 28, but operating as a “facultypractice”).

4. Health Center: Clinics licensed under Article28 as a DTC and extension clinics sponsoredby a DTC. This group includes federallyqualified health centers (FQHCs), FQHC“look-alikes,” and other health centerslicensed under Article 28 as DTCs.

5. Group: Practices that have five or moreproviders included in the NCQA’s PCMHprovider database, but that are not listed ashospital clinics, health centers, or hospitalpractices.

6. Small Practice: Practices that have four orfewer providers included in the NCQA’sPCMH provider database, but that are notlisted as hospital clinics, health centers, orhospital practices.

Current Status of PCMH Adoption in New York StateNew York has been a national leader in theadoption of the medical home model. NCQAdata show that New York continues to have byfar the largest number of practices andpractitioners working in NCQA-recognizedPCMHs—over 14 percent of all PCMHpractices and practitioners in the country (Table1).

GeographyAs of October 2014, there were 5,832 New YorkState primary care providers working in practices

recognized by NCQA as PCMHs (Figure 2).These providers were roughly evenly splitbetween New York City and the rest of the state(45 and 55 percent of the state total,respectively).

Practice TypeThe PCMH model is not evenly distributedacross different types of practices. As is shown inFigure 3, NCQA recognition in New York tendsto be concentrated in practices with “scale”—group practices, health centers, and

Total in State % of U.S. Total

New York 7,608 14%

California 3,483 7%

Pennsylvania 3,300 6%

North Carolina 2,765 5%

Texas 2,470 5%

Florida 2,391 5%

Massachusetts 2,090 4%

Other States 28,802 54%

U.S. Total 52,909 100%

Source: NCQA Physician Directory (http://recognition.ncqa.org/index.aspx ), accessed January 13, 2015.

Note: The NCQA data presented in this table combines the number of practices recognized as PCMHs with the number of providersworking in those practices. All other tables and charts report unduplicated numbers of providers working in PCMH practices.

Table 1. PCMH Practices and Providers in New York and Other States, January 2015


institution-based providers. PCMH adoption bysmaller practices which lack the scale to put inplace the required infrastructure, is far lower.

There are substantial differences by region (andby borough, in New York City) in the number ofPCMH providers working in practices that haveachieved PCMH designation, and the providertype of those practices (Figures 4 and 5). This

variation may reflect underlying regionaldifferences in composition of their primary careproviders. For instance, in some areas (e.g.,Western New York, Mid-Hudson, and theCapital Region), physician group practices aremore prevalent, while in in others (e.g.,Manhattan and Rochester) more of the hospital-affiliated primary care physicians are organizedas faculty practice plans.

Figure 2. PCMH Providers in New York State, by Region, October 2014

Figure 4. PCMH Providers Outside New York City, by Region and Practice Type, October 2014

Figure 3. PCMH Providers in New York State,by Practice Type, October 2014

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Growth

After growing by 37 percent between 2011 and2012, the number of providers working inPCMHs in New York grew by only 5 percentbetween 2012 and 2013. Between 2013 and2014, however, the state experienced anotherperiod of substantial growth, with a year-over-year increase of nearly 20 percent (Figure 6).

As is shown in Table 2, the rate of growth inPCMH providers between 2013 and 2014 varied

substantially between New York City and therest of the state.

To better understand the characteristics anddrivers of that growth, we compared the numberof PCMH providers reported as of July 2013 tothe corresponding counts as of October 2014. Asis shown in Figures 7 and 8, different regionsacross the state increased the number of PCMHproviders at different rates, between 2013 and2014.

2013 2014

Year-Over-Year Change

PCMHProviders

% of NYSTotal

PCMHProviders

% of NYSTotal

NYC 2,533 51.6% 2,660 45.6% 5.0%

Rest of State 2,375 48.4% 3,172 54.4% 33.6%

New YorkState Total 4,908 5,832 18.8%

Table 2. PCMH Providers and Growth, New York City vs. Rest of State, 2013–2014

Figure 6. Growth in PCMH Providers in New York State, 2011–2014

Figure 7. Changes in PCMH Providers Outside New York City, by Region, 2013–2014

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Changes by Provider Type

One of the major factors that appears to havecontributed to the growth in PCMH providersbetween 2013 and 2014 was the implementationof the Hospital Medical Home program,12 a two-year, $250-million quality demonstrationprogram funded under a CMS 1115 waiver.

This program focused on increasing the numberof hospital teaching clinics (a major source ofprimary care for Medicaid enrollees, and trainingsites for hundreds of medical residentsstatewide) that are recognized as PCMHs underNCQA’s 2011 Standards. It supported practicetransformation efforts at 62 of the state’steaching hospitals (32 in New York City, and 30elsewhere in the state), which enabled theirprimary care teaching clinics to be recognized asPCMHs. As is shown in Figure 9, statewide

growth in the number of PCMH providersbetween 2013 and 2014 was largely driven byincreases in hospital teaching clinics andhospital-owned practices. Over 70 percent of theyear-to-year growth was due to an increase in thenumber of such providers.

Growth in PCMH providers in settings otherthan hospital clinics was modest: Statewide, thenumber PCMH providers in all other practicetypes grew by only 7 percent between 2013 and2014, from 3,326 to 3,547. However, as is shownin Figures 10 and 11, this measurement differedbetween New York City and the rest of the state.Outside New York City, the number of non-clinicPCMH providers increased by 19 percent; inNew York City, the number of non-clinic PCMHproviders actually decreased by 10 percent overthe same period.

12 www.health.ny.gov/health_care/medicaid/redesign/hospital_medical_home_demonstration_project.htm

Figure 9. Changes in PCMH Providers in New YorkState, by Practice Type, 2013–2014

Figure 10. Changes in PCMH Providers Outside NewYork City, by Practice Type, 2013–2014

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Another trend identified in our 2013 report onPCMHs continued: slow growth (and in recentyears, even erosion) in the number of PCMHproviders in small practices. Between 2013 and2014, the number of providers at small practicesdecreased by 10 percent, from 476 to 430. Manysmall practices face big challenges in achievingNCQA recognition, and in the absence of broadpayer support for medical homes many find itdifficult to meet the PCMH’s added costs andchoose not to reapply to the NCQA when theircurrent recognition lapses.

Regional Variation in Growth ofPCMHs by Practice TypeAs noted above, the different regions of the state(and, within New York City, the boroughs)exhibit substantial differences in their numberand proportion of PCMH providers by practicetype. Between 2013 and 2014, the regions alsoshowed quite different patterns of distribution

and growth in PCMH providers, by providertype. Charts depicting those region and borough-specific trends are included at the end of thisreport.

Staffing the Medical Home: TheRole of Mid-Level PractitionersNCQA data includes both physicians and mid-level providers (nurse practitioners and physicianassistants). Using licensure as reported in theNCQA database, we analyzed the role played bymid-level providers in PCMHs statewide and byregion. As shown in Figure 12, 16 percent ofPCMH providers in the state were mid-levelpractitioners, while roughly 84 percent werephysicians (MDs and DOs).

As is shown in Figures 13 and 14, the numberand proportion of PCMH providers who are NPsand PAs varies substantially by region andborough.

Figure 14. Mid-Level Practitioners in New York City, by Borough, 2013–2014

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Figure 12. Physicians and Mid-Level Practitioners Working in New York PCMHs

Figure 13. Mid-Level Practitioners Outside New York City, by Region, 2013–2014

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PCMH Penetration Rate

In order to assess the penetration of the PCMHmodel across regions in the state, we used thenumber of physicians (MD and DO) working ina region’s PCMHs as the numerator, and anestimate of the total number of primary carephysicians in that region as of 2010 as thedenominator.13 Overall, the 4,923 physiciansworking in PCMHs represents roughly 25percent of all primary care physicians; but, as isshown in Figures 15 and 16, that proportionvaries widely by region, ranging from 44 percentin the North Country to 10 percent in LongIsland.

A similar variation occurs across the boroughs ofNew York City. While the city’s overall PCMHpenetration rate (24 percent) is the same as thestate’s overall rate, the borough-specific PCMHpenetration rate ranges from 44 percent in theBronx to 8 percent in Staten Island.

Drivers of PCMH Adoption: Organizational Capacity and Financial Incentives Two factors appear to correlate with PCMHadoption by practices of different types.

The first is practice size and availableinfrastructure, the capacity of a practice tomount and sustain a medical home model. APCMH focuses on organizing care teams, onmeaningful use of electronic medical records, onusing registries to identify complex patients whoare at risk for poor outcomes and potentiallyavoidable high-cost care, and using dedicatedstaff to help manage their care. These arecapacities that require organizational scale andexpertise, easier to achieve in organized systemsand larger practices than in smaller, independentpractices. The smaller uptake of the PCMHmodel among the state’s small practices appearsto attest to that difficulty.

13 For the total number of physicians in a region we used the most recent data available from the New York State Center for HealthWorkforce Studies. chws.albany.edu_archive_uploads_2012_07_nyphysprofile2010

Figure 15. PCMH Penetration Outside New York City, by Region, 2013–2014

Figure 16. PCMH Penetration in New York City, by Borough, 2013–2014

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The second major factor likely affecting thecomposition of the state’s PCMH adopters is theextent to which financial incentives are availableto providers who achieve NCQA recognition.Such incentives fall into two broad (and, to adegree, overlapping) categories: whether specificpayers are making additional or increasedpayments to providers who have adopted thePCMH model or whether they are participatingin a medical home demonstration project.

The single largest driver of PCMH adoption inNew York State has been the existence ofspecific payments (e.g., care managementpayments) to primary care providers that haveachieved NCQA recognition as a PCMH.Medicaid is by far the largest payer routinelyproviding enhanced payments based on PCMHstatus; providers primarily serving Medicaidenrollees are extraordinarily well-representedwithin the state’s overall roster of PCMHproviders. As is shown in Figure 17, over half ofall PCMH providers statewide (and over 70percent in New York City) practice in hospitalclinics, including HHC, and in health centers.

Another characteristic that appears to beassociated with PCMH uptake is participation ina regional medical home demonstration project.The Adirondacks and the Hudson Valley (whichspans the Mid-Hudson and Capital regions) areeach home to a multipayer medical homedemonstration; and the Finger Lakes is the siteof a multiyear grant from the CMS InnovationCenter (CMMI) working to increase thepenetration of the medical home model, partlyby direct financial support to the participatingpractices.

For practices that are neither large Medicaidproviders, nor participating in regional medicalhome demonstrations or shared savingsarrangements, there are fewer financialincentives to adopt and maintain a more costlymedical home model. These factors may partlyexplain why the PCMH model has been adoptedless in other parts of the state and by primarycare providers that do not serve a substantialMedicaid population.

Figure 17. Percentage of New York PCMH Providers in Hospital Clinics and Health Centers

0%10

5%7

0%5

71%

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5%2

0%

tr CthaleH HCH

56%

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56%

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43%


The current level of adoption of the PCMHmodel in New York is, by national standards,remarkable, and the number of PCMH providersin the state continues to grow. The distributionof PCMH providers varies substantially acrossthe state, and among the different practice types.Not surprisingly, the trends on uptake of themodel appear to be related to two simple factors:whether given practices have the scale andinfrastructure to support a medical home, andwhether enough of the payers in a given regionprovide them with financial incentives foradopting this more effective but more costlymodel.

To date, the main adopters of the PCMH modelhave been larger practices and those associatedwith hospitals and health centers—organizationswith scale. Finding a way to adapt this model tothe state’s small practices will be critical toachieving the hoped-for spread. Similarly, themain adopters of the PCMH model so far havebeen those whose major payers support themedical home model through augmentedpayments, either providers largely reliant onMedicaid or those participating in ongoingregional medical home demonstrations. Overall,certain practices—those with scale, and those

with substantial payer support for the model—appear to have been more willing to undergo thecost and disruption of practice transformation,and to maintain the medical home model overtime.

New York State is in the process of designing anew medical home model—Advanced PrimaryCare—that builds on the PCMH model, butrelies less on external certification of thestructures and processes of care, and more onthe ability of a practice to achieve, maintain, andbe able to demonstrate improved outcomes—high levels of performance on measures ofquality associated with better health outcomesand lower utilization and cost.

It remains to be seen precisely how the newAPC model will relate to the NCQA’s evolvingPCMH model; how the model will apply to thesmall practices that remain major providers ofcare to populations across New York State; andwhether a new, more outcomes-based APCmodel will be broadly accepted and supported bypayers beyond Medicaid. Those are among thechallenges facing the State in its efforts tospread this new model, statewide.

Looking Ahead


Appendix: Changes in PCMH Providers by Practice Type, by Region and Borough, 2013–2014

Figure 18. Capital Region

0

50

100

150

200

250


2013 2014

A

Figure 19. Central New York

0

20

40

60

80

100

120


2013 2014

F

Figure 20. Finger Lakes

0

50

100

150

200

250


2013 2014

F

Figure 21. Long Island

0

20

40

60

80

100

120

140

160


2013 2014

F


Figure 22. Mid-Hudson

0

50

100

150

200

250

300

350

400


2013 2014

F

Figure 23. Mohawk Valley

0

30

60

90


2013 2014

F

Figure 24. North Country

0

10

20

30

40

50

60

70


2013 2014

F

Figure 25. Southern Tier

0

30

60

90

120

150

180


2013 2014

F

Figure 26. Tug Hill Seaway

0

10

20

30

40

50


2013 2014

F

Figure 27. Western New York

0

50

100

150

200

250

300

350


2013 2014

F

Appendix: Changes in PCMH Providers by Practice Type, by Region and Borough, 2013–2014 (continued)


Figure 28. New York City (Total)

0

100

200

300

400

500

600

700

800


2013 2014

F

Figure 29. Bronx

0

50

100

150

200

250

300

350


2013 2014

F

Figure 30. Brooklyn

0

50

100

150

200


2013 2014

F

Figure 31. Manhattan

0

50

100

150

200

250

300


2013 2014

F

Figure 32. Queens

0

20

40

60

80

100

120


2013 2014

F

Figure 33. Staten Island

0

4

8

12

16


2013 2014

F

Appendix: Changes in PCMH Providers by Practice Type, by Region and Borough, 2013–2014 (continued)

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recent trends and future directions for the medical home

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