The Potential of Patient-Centered Specialty Practice

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PearlSeptember 02, 2015Practice ModelsHealthcare ReformPatientsPearlsPhysician Productivity

 

What is PCSP?

Patient-Centered Specialty Practice (PCSP) is a recognition program from the National Committee for Quality Assurance (NCQA) that went into effect in 2013. The PCSP program was designed in many ways to complement the success of NCQA’s Patient-Centered Medical Home (PCMH) program and expand its reach. The goal of the program is to encourage excellent care coordination by specialty practices in the outpatient setting, leading to less duplication of procedures and fewer hospitalizations.

Much like the PCMH program, the PCSP program focuses on proactive coordination of care, information sharing among clinicians involved in a patient’s care, and a centering of care around the patient (versus around the care setting).

According to the NCQA, “Specialists who achieve NCQA PCSP Recognition will show purchasers (consumers, health plans, employers and government agencies) that they have undergone a rigorous and independent review to assess their capabilities and commitment to excellence in sharing and using information to coordinate care.” What this means practically is that practices that undergo the process will be better placed to meet the challenges of the marketplace.

The value-based era

With the implementation of the Affordable Care Act, the shifting of costs to consumers, and the advent of large deductibles and consumer-based plans, we have moved swiftly into an era of purchasers looking to obtain “value” for their healthcare dollars. Synonymous with value is “quality” and patients are being both incentivized and penalized based on the healthcare provider choices that they make. For example, certain employers and payers will waive all cost sharing (copays, deductibles) for patients in certain networks that choose to receive their care from PCMH-recognized practices. Conversely, patients may face higher copays and cost sharing percentages for not going to PCMH practices where there is availability to do so.

Additionally, just about all physicians in many payer networks are being “graded” based on their ability to meet quality, efficiency, and cost metrics (check out United Healthcare’s Premium Designation Program, Aetna’s Aexcel Program, or Cigna’s Care Designation Program). These grades affect cost-sharing the same way that PCMH-based benefit design does; if a patient chooses to go to a physician who has a low score, that patient may have a greater financial cost share because of it.

However, while the PCSP Program has been in place for a couple of years now, payers have been slow to recognize this program to the same extent as they now recognize PCMH. It took approximately three to five years for most payers to recognize PCMH and I expect it will take the same for PCSP to be as widely recognized.

The potential of PCSP

While it may take some time to be as widely recognized, PCSP offers payers the same opportunity to neatly categorize and recognize “high performing, high quality” practices across specialties. It is expensive for payers to build out performance metrics for each and every specialty and frankly, for many specialties it can be hard to quantify “quality” at all. Therefore, PCSP offers payers a way to incentivize practices and reap a better return on their investments with PCMH-recognized practices. The continuum of care for patients can be better coordinated under similar models of care across both primary and specialty practices.

In addition, transitioning to a PCSP model can help practices better position themselves for working within future “accountable care” type models and clinically integrated organizations (for more on this, read the article “Physician Reimbursement Changes: 5 Ways to Gain Control“). The bad news is that once higher performing practices become the new standard of care, practices that have not addressed their “grades” and/or participated in quality programs will not only face consumers making choices to avoid them, but are also likely to be hit with fee schedule cuts too.

How to obtain more information

The PCSP program hinges around asking practices to focus on the following areas:

  • Develop and maintain referral agreements and care plans with primary care practices.
  • Communicate timely information that helps practices agree on a plan for coordinating care
  • Share care management for patient referrals.
  • Provide superior access to care, including electronically, when patients need it.
  • Track patients over time and across clinical encounters to assure the patient’s care needs are met.
  • Provide patient-centered care, which includes the patient (and the patient’s family or caregiver, if appropriate) in planning and goal setting.

If you are interested in exploring the PCSP program further, you can find more information here.

If you are already participating in an NCQA program (such as the Diabetes Recognition Program (DRP) or the Heart/Stroke Recognition Program (HSRP), you will receive credit toward your PCSP scores for that. Also since the program is aligned with meaningful use, if you are participating in that you will already have several points and material that can count toward your score too.

Bottom line

Quality-care programs are here to stay and practices can expect to see more and more initiatives rolling their way in 2016. NCQA’s PCSP Program offers both a framework for transitioning to better care coordination and clinical integration with other providers, and an opportunity down the line to potentially reap incentives from payer plans once those hit the market. As achieving PCSP can take a year or more depending upon your organization’s size, don’t wait until payers begin paying for it. Instead, get started now and reach out to payers with which you participate to ask them how they are supporting (or plan to support) practices that achieve PCSP Recognition today and in the future. The more payers hear from you on this, the more important it becomes for them to incentivize those practices that are achieving this level of care. At the very least, it may help to get a negotiation started where no incentive is currently available.