July 24, 2016

Alternative Models and the Primary Care Initiative: Where Are We Now?

On the back of the Centers for Medicare and Medicaid Services (CMS) success with developing and implementing accountable care organizations and value-based payments, CMS is enjoying encouraging results from its Complete Primary Care (CPC) initiative. The CPC program is a shared-savings payment and service-delivery model that pays… Read More

On the back of the Centers for Medicare and Medicaid Services (CMS) success with developing and implementing accountable care organizations and value-based payments, CMS is enjoying encouraging results from its Complete Primary Care (CPC) initiative. The CPC program is a shared-savings payment and service-delivery model that pays clinicians to provide targeted patients with care management. Recent data show that the initial rollout — to about 500 practices serving 377,000 Medicare patients — has achieved a combined $24 million in gross savings. In addition, a recent NEJM study found that in the first two years, CPC helped practices improve management of high-risk patients, access to care, shared decision-making and patient empowerment, while slightly reducing the number of primary care visits.

Now, CMS is launching the “largest-ever multi-payer initiative to improve primary care in America”: Comprehensive Primary Care Plus (CPC+), which will expand to encompass up to 5,000 practices, 20,000 doctors and 25 million overall patients.

The first four years

To understand how CPC+ will work, it’s important to understand how it all began, with CPC. The four-year, multi-payer initiative, designed to strengthen primary care, was launched in October 2012. CMS collaborated with commercial and state health insurance plans in seven U.S. regions to offer population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five “comprehensive” primary care functions:

  • Risk-stratified care management
  • Access and continuity
  • Planned care for chronic conditions and preventive care
  • Patient and caregiver engagement
  • Coordination of care across the medical neighborhood

The initiative tested whether provision of these functions at each practice site — supported by multi-payer payment reform, the continuous use of data to guide improvement, and meaningful use of health information technology — could achieve improved care, better health for populations and lower costs. Thanks to positive early results, CMS will roll out CPC+ next year.

The five-year plan

CPC+ will have the same core philosophy as CPC at heart:

  • Support patients with serious or chronic diseases — those at the highest risk — to achieve their health goals through relationship-based care management services that improve outcomes
  • Give patients 24-hour access to care and health information, according to their preferences and needs (e.g. longer in-person hours, or phone and electronic access)
  • Deliver preventive care, taking advantage of data around quality and utilization of services to identify opportunities for improvements and new capabilities
  • Engage patients and their families in patient-centered care that recognizes the core roles patients and family members play and that actively engages patients to design care that best meets their needs
  • Work together with hospitals and other clinicians, including specialists, to provide better coordination of holistic care that meets the majority of patients’ physical and mental healthcare needs in a timely manner

However, building on CPC, the new program will run from 2017 through 2021 and present some key improvements and differences.

An additional track. There will be two tracks, with Track 2 providing an option for practices that are providing “advanced primary care” — that is, more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs.

Flexibility to tailor service delivery. According to CMS, “CPC+ will help practices move away from one-size-fits-all, fee-for-service health care to a new system that will give doctors the freedom to deliver the care that best meets the needs of their patients.” In Track 1, CMS will pay practices a monthly care management fee plus fee-for-service payments under the Medicare Physician Fee Schedule. In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-for-service payments, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services. This hybrid payment design will allow greater flexibility in how practices determine and deliver bundled care care outside of the traditional face-to-face encounter.

Up-front incentives. To promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. Performance will not be based on the volume of visits to services or tests, but rather on meeting targets for health outcomes.

Opportunities for data-driven change. Practices in both tracks also will receive data on cost and utilization. It will therefore be important to have in place optimal use of health IT systems and a robust learning system that supports the practice in making the necessary care delivery changes and improvements in care. Track 2 practices’ vendors will also be expected to get in on the act: They’ll have to sign a memorandum of understanding (MOU) with CMS that outlines their commitment to enhancing practices’ health IT capabilities.

Coming soon, to a practice near you

CMS will select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative. CMS will then enter into the MOUs with payer and vendor partners, to document the shared commitment to align on payment, data sharing, and quality metrics in CPC+.

“Strengthening primary care is critical to an effective health care system,” said Dr. Patrick Conway, CMS deputy administrator and chief medical officer. “By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars. The Comprehensive Primary Care Plus model represents the future of health care that we’re striving toward.”