What’s up with the medical home in Texas – Part 2

In last month’s blog post I shared information about the number of recognized patient-centered medical homes in Texas. I also mentioned that in Texas, the overwhelming majority of the medical homes are sponsored/owned by health systems.

In last month’s blog post I shared information about the number of recognized patient-centered medical homes in Texas. I also mentioned that in Texas, the overwhelming majority of the medical homes are sponsored/owned by health systems.

Since then, I have learned that the percentage of physicians practicing in medical homes in Texas is not dissimilar to the national rate of about 20%. What is perhaps more interesting than that is the according to the Patient-Centered Primary Care Collaborative, roughly 43% of family physicians in the US are practicing in medical homes. I do not have statistics for internists and pediatricians but one can infer that their percentages are significantly smaller.

One of the original Joint Principles of the Patient-Centered Medical Home is that “practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.”

At least 4 organizations have programs that certify or recognize practices as patient-centered medical homes. The National Center for Quality Assurance (NCQA) was the first of these organizations to offer a recognition program in 2008. They have now revised and updated their standards 3 times. They have the largest share of the market with 59,278 clinicians working in 12,724 practices nationwide. There are now over 800 NCQA recognized PCMH practices in Texas.

The Joint Commission’s program, Ambulatory Care Accreditation, has accredited 1,418 sites nationally with 66 accredited sites in Texas. Of these, the overwhelming majority of practices are either Federally Qualified Health Centers or community health clinics. Only one private practice – Southeast Texas Medical Associates in the Beaumont area – is accredited by JCAHO.

Data for URAC and AAAHC, the other certifying organizations are not available on their public websites.

As promised, I am sharing information about the location and ownership of NCQA recognized practices in Texas (map courtesy of the NCQA):

The distribution of medical homes in Texas is fairly consistent with what is known about physician supply and distribution:

  • Texas ranks 47th in the US in active primary care physicians per 100,000 population.
  • Thirty-five counties (out of 254) have no physician at all.
  • Eighty counties have 5 or fewer physicians.
  • The physician workforce in Texas is disproportionately located in the state’s five most populous counties: Bexar (San Antonio); Dallas; Harris (Houston); Tarrant (Fort Worth); and Travis (Austin). (NTREC Merritt Hawkins Physician Workforce in Texas; 2015).

With regard to ownership of practices, in 2015 between 45 and 49% of all Texas physicians were individual practice owners compared to 30% nationwide. The number of private practices has continued to decrease in the last several years while there has been massive consolidation of markets in many Texas cities.

This graph shows the distribution of NCQA recognized medical homes by ownership in Texas:

Further analysis of the NCQA data shows that 11 Texas health systems own/sponsor 10 or more medical home practices.

Questions to consider:

1. Why are health systems disproportionately represented among NCQA recognized practices?

In part, it’s because becoming a recognized PCMH is costly in terms of personnel and resources so larger entities have an advantage. Also, larger systems are more likely to be in a position to leverage their PCMH status to gain more favorable insurance contracts that pay them for services like care coordination. Unfortunately, smaller practices rarely have the same leverage.

2. Why would a private practice embark on the journey of becoming a PCMH complete with recognition?

Funny you should ask.I am about to send a questionnaire to private practices that are recognized by NCQA to find out the answer to that question. Stay tuned! And if you get a request to complete the survey, please do! It will add greatly to our understanding.

3. The Joint Principles notwithstanding, can a practice become a medical home without being officially “deemed” as such by an outside organization?

I have no doubt that the answer to this is yes. However, I also believe that a PCMH needs to have a range of capabilities and processes that help it to deliver accessible patient-centered care. Proving this is accomplished through data. Bigger systems typically have more robust data gathering and reporting abilities.

4. And finally, and perhaps most importantly, how can practice culture be measured in a standardized format?

Practice culture that embraces teamwork; acknowledges the contributions of all team members; has strong clinical and administrative leadership ; a unified vision of what is means to be a PCMH and works tirelessly to continuously improve the delivery of care can’t be measured on a form. And only through true cultural change can the promise of the PCMH be fulfilled.

I invite your comments and thoughts.

Till next time.