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FAQ

Why consider adopting the PCMH model?

Why should I develop a PCMH?

PCMH can help move Hawaii to a more sustainable health care system that provides greater access to affordable, quality care at the right time in the right place. It increases efficiency and gives PCPs more time to do what they do best: care for patients.

My practice is already operating as a PCMH. What's different from what I'm doing today?

Practices may be already meeting some of the PCMH requirements. Physicians should refer to the Population Health Management Levels and Requirements section of the PCMH Guide for more details on the level one requirement for completing a practice assessment within the first 90 days after the effective date of the PCMH agreement.

Getting Started: Eligibility

What are the eligibility requirements for patient-centered medical home (PCMH)?

To be eligible, you must be an HMSA PPO participating primary care provider (PCP) in general practice, internal medicine, pediatrics, or family medicine.

I am a specialist (not one of the four you have identified) and function as a PCP in Health Plan Hawaii. Am I eligible to participate in PCMH?

No. HMSA is only using the physician's PPO marketing specialty to determine eligibility. Some specialists are marketed as PCPs for HMSA's HMO program. Those physicians are currently not eligible for PCMH at this time.

Are other physician specialists, such as ob-gyns and geriatricians, eligible for PCMH?

Not at this time. The priority for 2011, the first year of this PCMH program, is to enroll only physicians with a PPO primary care marketing specialty of general practice, internal medicine, pediatrics, or family practice. HMSA is considering the inclusion of other specialties starting in 2012, but has not made a final decision yet.

Specialists should determine whether their current practice provides care for the whole person, including all preventive care screenings and disease management, or if it is focused on treating specific conditions only. HMSA is working with specialty societies to develop a pay-for-quality program for specialists to increase the alignment of goals between primary care, specialty care, and facility-based care.

Can advanced practice registered nurses (APRNs) and physician assistants (PAs) enroll in PCMH?

Yes, APRNs and Pas who are practicing as PCPs are now eligible to enroll in PCMH.

Selecting a PCMH Physician Organization

How do I enroll in PCMH?

Physicians must meet all PCMH eligibility requirements and work through a physician organization to be enrolled in HMSA's PCMH program. Independent physicians not currently aligned with a physician organization may want to contact one of the established HMO health centers or IPAs .

Must I affiliate with only one health center?

Yes, for purposes of PCMH, PCPs must affiliate with only one health center. However, in general, it is not required that they affiliate with only one health center for any other non-PCMH purposes.

Can I be in a PCMH by myself?

No. Integral to PCMH is the concept that physicians improve their practices by learning from each other. HMSA will work with physician organizations, such as health centers and IPAs, to serve as the leaders and facilitators of PCMH collaborations.

How do I choose a physician organization for PCMH purposes?

This is a personal choice that the physician would have to make based on the type of support that the physician organization is offering for PCMH.

Once I enroll in PCMH, how do I get started?

HMSA is working with each physician organization as they are contracted for PCMH to help develop their PCMH action plan. Please contact your physician organization directly for the next steps, as it will provide the leadership and overall support structure for its physicians.

If I affiliate with one physician organization for PCMH purposes, will I have to move all of my HMO patients to that physician organization?

No. HMO patients can remain in their selected health center for purposes of the HMO product, and the physician's HMO arrangement with the health center will not be impacted as it relates to PCMH.

Starting in 2011, the physician organization in which the physician is aligned for PCMH will receive a PCMH administration fee to handle the PCMH PCP's HMO and PPO patients. This fee relates to the health center supporting PCPs as they build their PCMH and not the HMO patients' actual health center.

Can I switch affiliations with physician organizations for PCMH?

Yes, but this process is done through the physician organization. PCPs may change their physician organization affiliation once during an open enrollment period and must commit to the physician organization for at least 12 months. The physician organization must notify HMSA monthly of any changes (including requests to adjust the PCP’s PCMH level) and must notify HMSA of any changes during the open enrollment period. Changes made during open enrollment December 1 to 15 will take effect January 1.

PCMH Payment

Will I receive a payment for PCMH participation?

Yes, PCPs enrolled in PCMH will receive payments per member on their patient panel each month (per member per month, or PMPM), with increasing PMPM amounts for higher levels of achievement within the program.

How is the provider per member per month (PMPM) payment for PCMH calculated?

PCMH payments to providers are set at $2.00 PMPM for level one, $3.00 PMPM for level two, and $3.50 PMPM for level three.p>

What is required of me in exchange for receiving this payment?

Details on requirements for meeting each level for PCMH are listed in the Population Health Management Levels and Requirements section of the PCMH Guide. These expectations are to be met annually and are cumulative (i.e., level one requirements must be met as part of levels 2 and 3, and so on).

Can I start PCMH at level two if I'm using an EMR?

No. All physicians will start at level one for PCMH since it is important to demonstrate sustained achievement of each of the level one requirements before adding level two requirements. Once physicians can demonstrate sustained success in meeting all of the level one requirements, they should coordinate with the physician organization to process a request to move to level two.

Who will determine whether I have successfully met the requirements to move to the next level for PCMH?

Your physician organization will be working with you to review and document how you have met each of the requirements for Level 1, 2, or 3. That information will then be forwarded to HMSA for final review and to make any recommended changes.

What will happen if I do not meet level one requirements after about a year?

Physician organizations are required to notify HMSA when they become aware that a physician is not meeting PCMH requirements. HMSA will work with the physician organization to notify the noncompliant physician that they will no longer be in the program unless they develop and execute a plan to meet the requirements.

If I pursue NCQA recognition for PCMH, how will that impact my level within HMSA's PCMH program?

NCQA recognition demonstrates a practice's commitment to providing patient-centered care. Obtaining that recognition provides a good foundation for level one within PCMH. HMSA is considering a closer integration of NCQA recognition into the PCMH population health management levels in the future.

Resources

How do I access pay-for-quality reports?

Log on to Cozeva to review the pay-for-quality reports. HMSA is committed to providing you with more timely data to support your work toward greater quality of care for your patients. Cozeva is a reliable communication tool to share data with providers, engage with patients, and provide feedback to HMSA.

For Cozeva support, contact Applied Research Works at 1 (888) 448-5879 toll-free.

How can I learn more about PCMH?

Physicians may choose from a variety of sources to learn more about PCMH. The provider section of hmsa.com provides links to useful articles on PCMH including how other independent practices have implemented patient-centered care. PCMH is developing a PCMH and pay-for-quality training curriculum for this year. Physicians may also want to inquire with their physician organization on any training, speakers, or forums that the organization may be planning.

Physician organizations may also facilitate a set of learning collaborations for all of their PCMH physicians to enable them to work on quality improvement in smaller groups and learn from one another.

PCMH Guide

Who do I contact with questions on pay-for-quality or PCMH?

Check the pay-for-quality or PCMH program guide in the provider section of hmsa.com. Physician organizations can also help you with certain inquiries.

In addition, the following websites provide more information on PCMH:

HMSA has a well-being improvement center to support providers with care management components of PCMH, such as care registries, and can help you and your patients with health management issues.

For additional pay-for-quality program support, please contact HMSA's Provider Relations and Advocacy unit at (808) 948-6511 on Oahu.

What care resources are available to help me with PCMH?

HMSA has developed the PCMH program guide as a resource on PCMH. In addition, the following websites provide more information on PCMH:

Your physician organization may also have additional resources and information on PCMH. Finally, our care support hub is designed to help physicians with the care management components of PCMH, such as care registries, and can provide assistance to you and your patients on health management issues.

How will HMSA educate members about PCMH?

HMSA will continue publishing articles in Island Scene to help educate members about PCMH and members’ crucial role in taking charge of their own well-being. Member education also focuses on concepts supporting PCMH (i.e., the value of choosing and having a long relationship with a PCP, how to prepare for a doctor's visit, the importance of preventive screenings, and the impact of PCMH on quality and costs).

In addition, HMSA has created printed materials on hmsa.com that can help you talk to your patients about PCMH.

How do I connect to the Well-Being Improvement Center?

For Providers
Phone: 1 (855) 765-PCMH (7264) toll-free.
Fax: 440-7010 on Oahu or 1 (800) 470-8418 toll-free on the Neighbor Islands.
Hours of operation: Monday through Friday: 8 a.m. to 7 p.m.

For HMSA Members
Phone: 1 (855) 329-5461 toll-free.
Hours of operation: Monday through Friday: 8 a.m. to 7 p.m., Saturday: 8 a.m. – 5 p.m.