This study explored physician perspectives on PCMH-recognition by analyzing qualitative data gathered through telephone discussions with 20 pediatricians and family physicians. Respondents were staff at child-serving primary care practices that obtained NCQA-recognition prior to 2011 and therefore were among the first wave of practices in the United States to achieve such recognition. In theory, NCQA-recognition should be both acknowledgment and catalyst: an acknowledgement that certain procedures and processes are in place (some of which may have been implemented explicitly in order to obtain NCQA-recognition) and a stimulus for continued practice transformation through ongoing QI. Our findings suggest that NCQA-recognition is both, although with some qualifications.
Specifically, to most physicians in this study, PCMH-recognition meant that NCQA acknowledged that key health care delivery and organizational characteristics were in place; as a result, the recognition process itself led to few changes. Some of these physicians noted, however, that the process drove refinements of existing infrastructure and the standardization of important ongoing QI strategies. Practices that needed only to refine current systems to obtain PCMH-recognition typically were affiliated with larger parent organizations.
Physicians working in small, independently owned practices reported that they did not have many PCMH components in place when they began the recognition process and that obtaining recognition stimulated significant practice transformation. To support this transformation, most of these practices received external resources through participation in pilot or demonstration projects.
Our findings align with previous research that PCMH transformation is resource intensive and that external supports such as learning collaboratives, coaches, and financial incentives are important inputs.21, 22 We also found that practices were motivated to seek recognition by a combination of altruistic goals to improve patient care and practical goals to improve practice finances. Programs and policies seeking to transform primary care practice should continue to leverage both these motivations. This observation is especially salient for smaller practices, which are likely to be highly represented in future waves of practices seeking PCMH-recognition. Physicians also described ways that PCMH-recognition served as a springboard for participation in additional health system transformation activities, such as ACOs. This indirect benefit of recognition is underemphasized in prior studies and may be an additional motivation for practices in the future.
CSHCN are especially likely to benefit from high-quality primary care because, compared with other children, their medical conditions place them at higher risk for poor health outcomes and because they use more services. When asked whether recognition influenced the care provided to CSHCN, respondents noted that their practices had taken steps to improve referral tracking and other aspects of care coordination, either in preparation for or as part of the recognition process. Generalizing our findings is limited because our study included only a small sample of volunteer physicians from an even smaller number of parent organizations in two states. Moreover, our respondents worked at practices that were early-adopters of PCMH-recognition; their views may differ from those of physicians in practices that either choose not to obtain PCMH-recognition or that did so later, using NCQA's revised standards. Physicians who chose to participate in the study may be different (for example, may hold more positive PCMH beliefs) than physicians who did not participate or were not asked to do so. Finally, the data may be subject to recall bias because we asked physicians to consider activities that occurred in 2008, approximately four years before the time of our study.
Despite its limitations, this study offers physician voices and viewpoints on the NCQA-recognition process and suggests that PCMH-recognition can be both an acknowledgement of the strength of a practice's infrastructure and a marker of commitment to new and continued change. Given their complex, costly, and long-term needs, CSHCN and the practices that serve them will require particular attention as PCMH models are more broadly implemented.23 In addition to gathering data from a larger sample of physicians, future studies may consider potential differences between early-adopting and late-adopting PCMH practices and focus empirically on whether PCMH-recognition is an indicator of excellence, as measured by more appropriate service use, better care coordination, better care experience, and fewer adverse outcomes for CSHCN.