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Learn about NCQA


NCQA’s PCMH recognition is the most sought after of the available PCMH programs. Currently around ten percent of the nation’s primary care practices are recognized by NCQA as a PCMH. In South Carolina, over 400 clinicians along with their practices have achieved some level of NCQA PCMH recognition. Bigger doesn’t always mean better, though. In NCQA’s case there are additional reasons beyond its wide acceptance to embrace their version of PCMH.


One obvious reason is that the NCQA recognition has been accepted by two of South Carolina’s largest payors, Medicaid and Blue Cross. Both of these payors have developed programs that provide incentives to physicians who are recognized by NCQA as a PCMH. In Medicaid’s case, physicians get a per-member per-month (PMPM) bonus just for even trying. And when a practice achieves recognition status, the bonus can be as much as $2 PMPM, which in a practice with 5,000 Medicaid beneficiaries would equate to a yearly $120,000 payment increase. Remember, too, that Medicaid is planning to continue the 100% of Medicare payment rate for primary care physicians at least through June 30, 2015. Money is not the only reason why NCQA is a great choice for physician practices.


The core of NCQA’s standards emphasize the physician-patient relationship, help organize and streamline practice improvements, and lead to higher patient satisfaction and better health outcomes. The structural changes that are implemented will also prepare a practice to seamlessly plug in to accountable care organizations, and become instantly eligible for new Medicare payments for coordinating care and future Medicare payment incentives that are likely to replace SGR.



What does NCQA require for PCMH recognition?

NCQA has published a list of standards that it requires that practices meet in order to receive recognition as a PCMH. Realizing that physician practices have varying levels of sophistication and abilities to achieve practice transformation, NCQA has three levels of recognition, Level 1, Level 2, and Level 3; the higher levels are harder to achieve, but they generally also result in eligibility for richer incentives from payors. The use of electronic medical records (EMR) is not required for NCQA recognition, but EMR will assist in meeting many of the required standards.


There are six overall standards required by NCQA, and each of the standards contain numerous factors and elements related to the standards that are worth different levels of points. These points add up to a score that results in Levels 1-3 recognition. Although this may sound overly prescriptive, the NCQA standards are actually designed to give each practice flexibility within their own practice situation. For example, one of the factors requires a practice to provide same-day appointments, but gives the practice flexibility as to how many, what times, what clinicians, and the process by which patients are assigned. This is how most of the factors work, providing an outline of an approach and then allowing each practice to decide what works best for them.


The six standards are:


  1. Enhanced Access and Continuity – This standard addresses access during and after office hours, telephone and email communication with patients, the selection of a personal physician, and working together as a practice team to maximize care provision and workflow.

  2. Identify and Manage Patient Populations – This standard ensures that practices record important health and other information about patients to use that information to remind patients of and provide specific services.

  3. Plan and Manage Care – This standard sets up a process whereby practices identify patients with chronic and high-risk conditions and then proactively manage their care and medication.

  4. Provide Self-Care Support and Community Resources – This standard encourages a practice to assist patients in the management of their health by providing a self-care plan, tools, educational resources, and ongoing support.

  5. Track and Coordinate Care – This standard requires development of methods to track lab and imaging tests, referrals to specialists, and patient interactions with other health care facilities and providers.

  6. Measure and Improve Performance – This standard allows physicians to select a number of preventive care, chronic/acute care, and patient experience measures and develop practice goals for improvement, measure the progress, and report success.


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