Patient-Centered Medical Homes in New York: Updated Status and Trends as of July 2013

Transcription

1 Patient-Centered Medical Homes in New York: Updated Status and Trends as of July 213 A C H A R T B O O K

2 OFFICERS J. Barclay Collins II Chairman James R. Tallon, Jr. President Patricia S. Levinson Frederick W. Telling, PhD Vice Chairmen Sheila M. Abrams Treasurer Sheila M. Abrams David A. Gould Sally J. Rogers Senior Vice Presidents Michael Birnbaum Deborah E. Halper Vice Presidents Stephanie L. Davis Corporate Secretary DIRECTORS Richard A. Berman Jo Ivey Boufford, MD Rev. John E. Carrington Derrick D. Cephas Philip Chapman Dale C. Christensen, Jr. J. Barclay Collins II Richard Cotton Michael R. Golding, MD Josh N. Kuriloff Patricia S. Levinson David Levy, MD Howard P. Milstein Susana R. Morales, MD Robert C. Osborne Peter J. Powers Mary H. Schachne John C. Simons Michael A. Stocker, MD, MPH James R. Tallon, Jr. Frederick W. Telling, PhD Mary Beth C. Tully HONORARY DIRECTORS Howard Smith Chairman Emeritus Douglas T. Yates Honorary Chairman Herbert C. Bernard John K. Castle Timothy C. Forbes Barbara P. Gimbel Rosalie B. Greenberg Allan Weissglass United Hospital Fund The United Hospital Fund is a health services research and philanthropic organization whose primary mission is to shape positive change in health care for the people of New York. We advance policies and support programs that promote high-quality, patient-centered health care services that are accessible to all. We undertake research and policy analysis to improve the financing and delivery of care in hospitals, health centers, nursing homes, and other care settings. We raise funds and give grants to examine emerging issues and stimulate innovative programs. And we work collaboratively with civic, professional, and volunteer leaders to identify and realize opportunities for change.

3 Patient-Centered Medical Homes in New York: Updated Status and Trends as of July 213 Gregory Burke D I R E C T O R, I N N O V A T I O N U N I T E D H O S P I T A L F U N D 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

4 Copyright 213 by United Hospital Fund ISBN Free electronic copies of this report are available at the United Hospital Fund s website,

5 Introduction This chartbook tracks the growth of patientcentered medical homes (PCMHs) in New York State. It builds on analyses of National Committee for Quality Assurance (NCQA) data presented in two prior United Hospital Fund reports: The Patient-Centered Medical Home: Taking a Model to Scale in New York State (211) and The Evolution of Patient-Centered Medical Homes in New York State: Current Status and Trends as of September 212 (212). Like those earlier reports, this update describes trends in the number of providers in New York State working in NCQA-recognized PCMHs, provides insights into the adoption and spread of the PCMH model over the past three years, and identifies some issues for consideration by the provider community, payers, and the New York State Department of Health (NYSDOH) as the medical home movement matures. The following sections and the charts to which the narrative refers describe changes in the number of providers working at NCQArecognized PCMHs in New York from three perspectives: Status of PCMH adoption in New York as of July 213 (Figures 1-13) Growth in PCMH adoption between July 211 and July 213 (Figures 14-22) Year-by-year trends for each region, by practice type (Figures 23-34) Highlights New York State leads the nation in the adoption of the medical home model, as measured by the number of practices recognized by the NCQA as patient-centered medical homes and the number of PCMH providers that is, providers working in those practices. Roughly half of all PCMH providers in the state are in New York City and half are in non-nyc regions. Those regions (and, within New York City, the boroughs) vary markedly from each other in terms of the penetration of the PCMH model and the type of practice in which the PCMH providers work. After a period of rapid growth, the adoption of the PCMH model in New York State has slowed. Between 211 and 213, the number of PCMH providers in New York grew by 44 percent, from roughly 3,5 to nearly 5,. Most of that growth occurred between 211 and 212, much of it in upstate regions. Between 212 and 213, the number of PCMH providers in the state grew by only 5 percent. As of July 213, 8 percent of the NCQArecognized PCMH providers in New York State were recognized under NCQA s 28 standards. To maintain NCQA recognition, those practices will need to meet the NCQA s more rigorous 211 standards over the next few years. A substantial portion of the cohort recognized under NCQA s 28 standards, received recognition as a Level 1 or Level 2 PCMH. These practices (which include a large number of small practices) may have more difficulty retaining NCQA recognition. Acknowledgments This analysis would not have been possible without the support of Kate Bliss from the Office of Quality and Patient Safety in the New York State Department of Health. Kate was of enormous assistance in acquiring, scrubbing, and formatting the NCQA data files for this set of reports. This report was supported in part by the Altman Foundation, TD Charitable Foundation, EmblemHealth, New York Community Trust, and Excellus BlueCross BlueShield. Patient-Centered Medical Home Update, 213 1

6 Methods To produce this analysis, UHF received three data files from the New York State Department of Health (originally generated by the NCQA) listing all providers working in NCQArecognized PCMHs as of three specific dates: July 1, 211; July 1, 212; and July 1, 213. These files included all providers in New York State working in practices recognized by the NCQA as patient-centered medical homes, along with basic demographics and descriptors, enabling us to assign them to geographic regions and practice type. For consistency, we have maintained the definitions of the metrics used in prior reports. PCMH Providers: This includes all providers listed as active in the NCQA reports: physicians (MD and DO) and mid-level providers (e.g., nurse practitioner and physician s assistant). 1 NCQA Standards and Level of NCQA Recognition: Practices have received three-year NCQA recognition under either the 28 or the 211 standards, along with level of recognition (Level 1, 2, or 3 PCMH).The original NCQA PPC-PCMH Standards, published in 28 (referred to in this report as the 28 standards), were used by the NCQA in its original recognition process for all PCMHs. In 211, the NCQA published and began to use a revised set of standards for PCMH recognition. The 211 standards include changes in the number of must-pass elements, and in the weighting and scoring of a number of measures that determine the different levels of recognition. Providers applying for PCMH recognition after January 1, 211, were reviewed using the 211 standards, as are those providers who were recognized under the 28 standards applying for recertification. New York State Regions: In these reports, we have used a variant of New York State s insurance regions as a way of grouping and analyzing PCMH Providers into seven regions: New York City (also analyzed at a borough level, given its size and diversity) Long Island Hudson Valley Albany/Northeast New York Rochester Area Syracuse/Central New York Buffalo/Western New York Practice Type: Providers who work within different practice contexts (large group vs. solo practice, for example) often have access to different infrastructure and resources e.g., electronic medical records and care managers and they face different challenges in achieving and sustaining PCMH recognition. In order to distinguish among these different settings (which in some cases are also markers for populations served) we use six different practice types first established in the 211 PCMH report: Group Practice: Large and small groups, with five or more physicians listed on the NCQA roster Health Center: Federally qualified health centers and state-licensed diagnostic and treatment centers HHC: New York City s Health and Hospitals Corporation Hospital Clinic: On-site or communitybased clinics of hospitals Hospital/AMC Practice: Private practices and faculty practice plans based in hospitals and academic medical centers (AMCs) Practice: Small private practices, with fewer than five physicians listed on the NCQA roster 1 This report updates the PCMH data published in The Evolution of Patient-Centered Medical Homes in New York State: Current Status and Trends as of September 212. That report was based on data received from the New York State Department of Health (NYSDOH), which inadvertently included a number of providers and practices whose NCQA recognition had expired, resulting in an overcount of providers working in NCQA-recognized PCMHs. In preparing this report we worked with NYSDOH staff to verify the active status of all practices and providers as of July of all three years (211, 212, and 213) and verified these figures with NCQA staff. 2 United Hospital Fund

7 Status of PCMH Adoption in New York State as of July 213 Total PCMH Providers New York State has led the nation in the adoption of the medical home model. Based on a recent review of NCQA data (which counts both NCQA-recognized practices and providers working in those practices), New York is home to one-sixth of the total number of NCQArecognized PCMHs in the nation (Figures 1 and 2). Examining only the number of PCMH providers (physicians and mid-level practitioners) who are working in practices that have achieved NCQA recognition as PCMHs is a more accurate measure of clinical capacity. As of July 213, NCQA data showed that there were 4,98 providers working in practices that had received NCQA recognition as PCMHs in New York. As shown in Figure 3, roughly half of the total (2,533 PCMH providers, or 52 percent) were in New York City, and half (2,375, or 48 percent) were in other regions of the state. Distribution by Region The number of PCMH Providers in New York State varied widely both by region of the state and within New York City, as shown in Figures 4 and 5. Distribution by Practice Type The PCMH model is not evenly distributed across different types of practices. Figure 6 depicts the distribution of providers working in PCMH practices by practice type for the state as a whole. Statewide, large group practices and health centers organizations with the scale and infrastructure to more readily support the PCMH model accounted for the largest numbers of PCMH providers, followed by the New York City Health and Hospitals Corporation, hospital clinics, and hospital/amc practices. Small practices (practices with fewer than five providers), which have the least scale and infrastructure, made up the smallest cohort. There were marked differences between New York City and the rest of the state in the composition of PCMH providers by practice type (Figures 7 and 8). Outside New York City, half of the PCMH providers worked in large group practices. In New York City, group practices were a far smaller proportion of the total (11 percent), while hospital clinics (including HHC) and hospital/amc-based practices and faculty practice plans were the dominant practice type (78 percent, in aggregate). The NYSDOH Hospital Medical Home program will likely increase the number of providers in hospital teaching clinics achieving NCQA recognition under the 211 standards over the next year. There is presently no equivalent program or initiative focused on providers working in other practice types. Distribution by practice site also varied significantly among regions in the state (Figures 9 and 1). Outside New York City, all regions showed a substantial proportion of PCMH providers in larger groups in 213; Hudson Valley and Albany had the largest cohort within health centers; and Syracuse and Rochester had the largest concentrations within hospital clinics and hospital/amc-affiliated practices, respectively. Patient-Centered Medical Home Update, 213 3

8 Similar differences existed within New York City. The HHC and health centers were consistently strong across the four larger boroughs, but there were differences among the boroughs in the importance of groups, hospital clinics and small practices. Manhattan had by far the largest concentration of PCMH providers within hospital/amc practices, largely a function of the adoption of the PCMH model by Manhattanbased medical school faculty practices. Year and Level of NCQA Recognition As is shown in Figure 11, 3,95 (8 percent) of the state s 4,98 NCQA-recognized PCMH providers worked in practices recognized at Level 1, 2, or 3 under NCQA s 28 standards. To maintain recognition, these practices will need to reapply for NCQA recognition under NCQA s more rigorous 211 standards. Of the PCMH providers recognized under NCQA s 28 standards, 588 (15 percent of the 28 total) work in practices that were recognized at Level 1 or 2, and they may have greater difficulty meeting or may be unwilling to meet NCQA s 211 standards, resulting in some practices losing NCQA recognition. As is shown in Figure 12, small practices face the most substantial challenge: many were recognized under the 28 standards at Level 1 or Level 2. These practices represent over onethird (37 percent) of all small practices with NCQA recognition as PCMHs (Figure 13). 4 United Hospital Fund

9 Growth in PCMH Adoption, July 211 to July 213 Overall Growth The number of providers working in NCQArecognized PCMHs grew by 44 percent over the three-year period, increasing from a statewide total of 3,399 in July 211 to 4,98 in July 213 (Figure 14). As shown in Figure 15, however, that growth was not uniform; it was different in New York City than in other parts of the state. While New York City had 2,54 PCMH providers in 211, its growth between 211 and 212 was only 15 percent, and between 212 and 213 the rate of growth fell to 7 percent. New York City accounted for 6 percent of the state s total PCMH providers in 211 but roughly 5 percent in 212 and 213. Regions outside New York City had a different trajectory. Non-NYC regions, which had 1,345 PCMH providers in 211, grew to 2,298 in 212, an increase of 71 percent. However, between 212 and 213 this rate of growth declined sharply, to only 3 percent. Non-NYC regions share of the state s total PCMH providers grew from 4 percent in 211 to roughly 5 percent in 212, and remained at that level in 213. Regional Differences in Growth Outside New York City, the number of PCMH providers grew substantially between 211 and 213 in all upstate regions, particularly in Syracuse (Figure 16). In New York City (Figure 17), there was less impressive growth, roughly equivalent across the boroughs, with the exception of Staten Island. Growth in the number of PCMH providers between 211 and 213 was evenly spread across all practice types (Figure 18), with the exception of the Health and Hospitals Corporation, which had already achieved NCQA recognition for essentially all of its primary care clinics by 211. Looking at the growth in PCMH providers on a year-by-year basis shows a somewhat different picture. As is shown in Figure 19, there are indications that, after rapid expansion in the adoption of the PCMH model between 211 and 212 (when the number of PCMH providers in the state grew by 37 percent), the rate of growth in the PCMH model leveled off in 213 to a rate of only 5 percent. That decline in the rate of growth was statewide: each of the non-nyc regions grew at roughly the statewide average between 212 and 213 (Figure 2) and with the exceptions of Queens and Staten Island in New York City (Figure 21). That phenomenon was evenly spread across practice types as well (Figure 22). Patient-Centered Medical Home Update, 213 5

10 Year-by-Year Trends for Each Region Notwithstanding the modest rate of growth over the past year, essentially every region in New York showed a substantial increase in the number of PCMH providers between 211 and 213. As is shown in Figures 23-34, the regions varied considerably from one another in numbers of PCMH providers, the types of practices adopting the PCMH model, and patterns of growth. In Albany/Northeast New York, where the PCMH census was evenly spread among practice types in 211 (with groups the largest cohort), there was marked growth in groups and hospital clinics in 212, which held in 213 (Figure 23). In Buffalo/Western New York, where the PCMH census was dominated by groups in 211, there was further growth in groups, as well as in health centers and practices in 212 and 213 (Figure 24). In the Hudson Valley, which was dominated by groups and health centers in 211, there was further growth in both types in 212, and in groups in 213 (Figure 25). Long Island which had the lowest PCMH penetration of any region, largely composed of groups there was slight growth in 212, which leveled off in 213 (Figure 26). In Rochester, where the PCMH census was relatively evenly spread in 211 among Groups, Health Centers, Hospital Clinics, and Hospital/AMC Practices, there was substantial growth in 212, driven in large part by an increase in Hospital/AMC practices (Figure 27). In 211, Syracuse/Central New York had a comparatively low PCMH penetration; it increased considerably in 212, driven by a major increase in hospital clinics and groups (Figure 28). Within New York City, the boroughs were similarly diverse in the composition and growth trajectories by practice type between 212 and 213. In 211, New York City as a whole (Figure 29) had a PCMH profile that was quite broadly based, with HHC, hospital clinics, health centers, and hospital/amc practices all accounting for substantial proportions of the total. In 212 each showed overall growth, with the largest absolute growth in health centers, HHC, and practices. The Bronx, whose PCMH profile was more institutionally based in 211 (including health centers, HHC, hospital clinics, and hospital/amc Practices), grew in both health centers and HHC (Figure 3). Brooklyn, which in 211 had the largest proportion of its PCMHs in HHC (and fewer in groups, health centers, hospital clinics, and practices), showed growth in health centers and hospital clinics (Figure 31). Manhattan (Figure 32), which in 211 had a relatively even spread of PCMHs across health centers, HHC, and hospital clinics (and the state s largest cohort of hospital/amc practices), grew slightly in all practice types. (Note: the number of PCMH providers shown for hospital clinics in 211 was overstated as a result of some duplicate reporting; when corrected for that overcount, the net growth in hospital clinics between 211 and 213 was in line with that of the other boroughs.) Queens (Figure 33), which has a stronger presence of groups and small practices than the other boroughs, experienced most of its growth between 211 and 213 in small practices. Staten Island (Figure 34), which had the smallest number of PCMHs of any borough, was spread between groups and practices in 211, both of which grew slightly in 212 and United Hospital Fund

11 Conclusion While New York State continues to lead the nation in the adoption of the PCMH model of care, and the medical home model is continuing to grow in New York, that growth appears to be leveling off. In addition, while the statewide growth trajectory has been impressive, it masks substantial variation in the adoption of the PCMH model by practice type and region. To date, the model s greatest penetration has been among larger practices that have the scale and infrastructure required to operate as a medical home. Considerable investment and effort and better alignment between payers and providers will be necessary to increase the adoption of the medical home model among smaller practices, which often lack the resources to mount and sustain the PCMH model. Similarly, the substantial variation across the state in the distribution and spread of the PCMH model reflects a series of region-specific factors, including (and perhaps especially) the underlying composition of the regions primary care systems. This argues for the use of regionspecific approaches to stimulating and supporting further growth in medical homes across the state. Further discussion of these issues is included in an accompanying issue brief, Advancing Patient- Centered Medical Homes in New York, available on the United Hospital Fund s website, Patient-Centered Medical Home Update, 213 7

12 8 United Hospital Fund Figures 1-13: PCMH Status as of July 213

13 Figure 1. NCQA-Recognized PCMHs, New York vs. Other States, 213 Other States, 3,86 83% NYS PCMH, 6,276 17% Note: Includes both practices recognized as PCMH and providers working in those practices. Data as of October 213; all other figures in this report show data current as of July 213. Source: National Committee for Quality Assurance. Available at (accessed October 7, 213). Patient-Centered Medical Home Update, 213 9

14 Figure 2. PCMHs (Practices and Providers) in New York, Other States, and the United States State 28 Standards 211 Standards Total in State Pctg. of U.S. Total California 218 2,227 2,445 7% Florida ,14 3% Illinois ,133 3% Massachusetts ,53 4% Michigan % New Jersey % North Carolina 1, ,487 7% Pennsylvania 1, ,589 7% New York 4,859 1,417 6,276 17% Texas 1, ,668 4% Washington % Other States 7,63 7,811 15,441 42% U.S. Total 21,54 16,28 37,82 1% Note: NCQA data include practices recognized as PCMHs and providers working in those practices. Source: NCQA Recognition Directory. Available at (accessed October 7, 213). 1 United Hospital Fund

15 Figure 3. New York State Providers in PCMHs, July 213 NYC, 2533, 52% Non-NYC, 2375, 48% Patient-Centered Medical Home Update,

16 Figure 4. Non-NYC Providers in PCMHs, by Region, July Albany/NE NY Buffalo Area Hudson Valley L.I. Rochester Area Syracuse/Cent NY 12 United Hospital Fund

17 Figure 5. NYC Providers in PCMHs, by Borough, July 213 1,2 1, Bronx Kings New York Queens Richmond Patient-Centered Medical Home Update,

18 Figure 6. New York State Providers in PCMHs, by Practice Type, July 213 Practice, 472, 9% Hosp Px, 583, 12% Group, 1459, 3% Hosp Clinic, 875, 18% HHC, % Health Ctr, 973, 2% 14 United Hospital Fund

19 Figure 7. Non-NYC Providers in PCMHs, by Practice Type, July 213 Hosp Px 194 8% Practice 187 8% Hosp Clinic % Group 1,181 5% Health Ctr % 18 Patient-Centered Medical Home Update,

20 Figure 8. NYC Providers in PCMHs, by Practice Type, July 213 Practice % Group % Hosp/AMC Px % Health Ctr % Hosp Clinic % HHC % 16 United Hospital Fund 1

21 Figure 9. Non-NYC Providers in PCMHs, by Region and Practice Type, July Albany/NE NY Buffalo Area Hudson Valley L.I. Rochester Area Syracuse/Cent NY Group Health Ctr HHC Hosp Clinic Hosp Px Practice Patient-Centered Medical Home Update,

22 Figure 1. NYC Providers in PCMHs, by Borough and Practice Type, July 213 1,2 1, Bronx Kings New York Queens Richmond Group Health Ctr HHC Hosp Clinic Hosp Px Practice 18 United Hospital Fund

23 Figure 11. New York State Providers in PCMHs, by NCQA Program and Level, July 213 Level 1: 1 (%) Level 2: 57 (1%) Level 3: 936 (19%) Level 1: 45 (8%) Level 3: 3,317 (68%) Level 2: 183 (4%) Patient-Centered Medical Home Update,

24 Figure 12. New York State Providers in Practices Recognized Under NCQA s 28 Standards as Level 1 and Level 2 PCMHs (N=588 Providers) Group Health Ctr Hosp Clinic Hosp Px Practice Level Level United Hospital Fund

25 Figure 13. Proportion of New York State Providers in Practices Recognized Under NCQA s 28 Standards as Level 1 and Level 2 PCMHs, July 213 4% 35% 3% 25% 2% 15% 1% 5% % Group Health Ctr HHC Hosp Clinic Hosp Px Practice 28 Levels 1 and 2 6% 11% % 17% 11% 37% Patient-Centered Medical Home Update,

26 22 United Hospital Fund Figures 14-22: Growth in PCMH Adoption, July 211 to July 213

27 Figure 14. Number of New York State Providers in NCQA-Recognized PCMHs, 211 and 213 6, 5, 4, 3, 2, 1, PCMH Providers in NYS 3,399 4,98 % Growth 44% Patient-Centered Medical Home Update,

28 Figure 15. Growth in PCMH Providers, NYC vs. Rest of State, , 2,5 2, 1,5 1, 5 NYC Non-NYC 211 2,54 1, ,366 2, ,533 2, United Hospital Fund

29 Figure 16. Changes in Non-NYC PCMH Providers by Region, Albany/NE NY Buffalo Area Hudson Valley L.I. Rochester Area Syracuse Central NY Patient-Centered Medical Home Update,

30 Figure 17. Changes in NYC PCMH Providers by Borough, ,2 1, Bronx Brooklyn Manhattan Queens Staten Island 26 United Hospital Fund

31 Figure 18. Changes in New York State PCMH Providers by Practice Type, ,6 1, ,2 1, Group Health Ctr HHC Hosp Clinic Hosp Px Practice Patient-Centered Medical Home Update,

32 Figure 19. Number of New York State Providers in NCQA-Recognized PCMHs, , 5, 4, 3, 2, 1, PCMH Providers in NYS 3,399 4,664 4,98 % Growth vs Prior Year 37% 5% 28 United Hospital Fund

33 Figure 2. Changes in Non-NYC PCMH Providers by Region, Albany/NE NY Buffalo Area Hudson Valley L.I. Rochester Area Syracuse Central NY Patient-Centered Medical Home Update,

34 Figure 21. Changes in NYC PCMH Providers by Borough, Bronx Brooklyn Manhattan Queens Staten Island 3 United Hospital Fund

35 Figure 22. Changes in New York State PCMH Providers by Practice Type, ,6 1, ,2 1, Group Health Ctr HHC Hosp Clinic Hosp Px Practice Patient-Centered Medical Home Update,

36 32 United Hospital Fund Figures 23-34: Year-by-Year Trends by Region,

37 Figure 23. Albany/Northeast New York Group Health Ctr Hosp Clinic Practice Patient-Centered Medical Home Update,

38 Figure 24. Buffalo Area Group Health Ctr Hosp Clinic Hosp Px Practice United Hospital Fund

39 Figure 25. Hudson Valley Group Health Ctr Hosp Px Practice Patient-Centered Medical Home Update,

40 Figure 26. Long Island Group Health Ctr Hosp Px Practice United Hospital Fund

41 Figure 27. Rochester Area Group Health Ctr Hosp Clinic Hosp Px Practice Patient-Centered Medical Home Update,

42 Figure 28. Syracuse/Central New York Group Health Ctr Hosp Clinic Hosp Px Practice United Hospital Fund

43 Figure 29. New York City Group Health Ctr HHC Hosp Clinic Hosp Px Practice Patient-Centered Medical Home Update,

44 Figure 3. Bronx Group Health Ctr HHC Hosp Clinic Hosp Px Practice United Hospital Fund

45 Figure 31. Brooklyn Group Health Ctr HHC Hosp Clinic Hosp Px Practice Patient-Centered Medical Home Update,

46 Figure 32. Manhattan Group Health Ctr HHC Hosp Clinic Hosp Px Practice Note: The number of PCMH providers shown for hospital clinics in 211 was overstated as a result of some duplicate reporting; when corrected for that overcount, the net growth in hospital clinics between 211 and 213 was in line with that of the other boroughs. 42 United Hospital Fund

47 Figure 33. Queens Group Health Ctr HHC Hosp Clinic Practice Patient-Centered Medical Home Update,

48 Figure 34. Staten Island Group Practice 44 United Hospital Fund

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