Medicare Initiative Hopes To Support And Sustain Primary Care

Last week, Medicare’s Center for Medicare and Medicaid Innovation announced a Comprehensive Primary Care (CPC) Initiative, which asks private payers and state Medicaid programs to join with Medicare to “help doctors work with patients to ensure they:

1. Manage Care for Patients with High Health Care Needs;

2. Ensure Access to Care;

3. Deliver Preventive Care;

4. Engage Patients and Caregivers; and,

5. Coordinate Care Across the Medical Neighborhood,”

according to an email from CMS’s press office. The initiative will provide qualified practices with risk-adjusted, per patient per month care managements payments, in addition to traditional fee-for-service payments, along with the opportunity to share in savings achieved at the community level.

I believe that the Initiative is a potential game-changer in helping to support and sustain primary care in the United States. But not just any primary care: practices will need to demonstrate that they have the above five functional capabilities aligned with Patient-Centered Medical Homes and be accountable for reporting on the results.

What makes this initiative different from so many other PCMH and primary care pilots?

First, it recognizes that primary care physicians can’t be expected to transform themselves into PCMHs without all payers getting behind them to offer substantial and sustained financial support. Instead of Medicare, or one or two payers trying to go it alone, CMS recognizes that everyone must have some skin in the game to help primary care:

“Without a significant enough investment across multiple payers, independent health plans– covering only their own members and offering support only for their segment of the total practice population– cannot provide enough resources to transform entire primary care practices and make expanded services available to all patients served by those practices.” The CPC initiative offers a way to break through this historical impasse by inviting payers to join with Medicare in investing in primary care in 5-7 selected localities across the country.

Second, the potential revenue for qualified practices could be substantial. CMS would pay risk-adjusted average of $20 per beneficiary per month for a qualified practice (the monthly payment would range from $8 to $40, depending on a patient’s health risk classification). These payments would be in addition to regular Medicare fee-for-service payments.

If state Medicaid programs decide to join in, there would be additional monthly capitated payments for Medicaid enrollees. And, private insurers who wish to participate will have to submit a “plan for enhanced support for comprehensive primary care aligned with the goals of this initiative.” Practices could be able to share in Medicare savings, calculated at a community (not practice) level associated with the initiative.

Third, practices would have “discretion to use this enhanced, non-visit-based compensation to support non-billable practitioner time, augment care teams (e.g. care managers, social workers, health educators, pharmacists, nutritionists, behavioralists) through direct hiring or community health teams, and/or invest in technology or data analysts.”

Fourth, they’d have access to data sharing from Medicare, Medicaid and other participating health plans on cost and utilization associated with their patients.

Fifth, if it is successful, the Affordable Care Act gives CMS the authority to expand it throughout Medicare, well beyond the 75 practices expected to be selected in five to seven markets for the initial four years of the initiative. It could, in time, show the way to new ways for Medicare and other payers to sustain and support well-functioning comprehensive primary care on a long-term basis.

Most importantly, Medicare’s Comprehensive Primary Care Initiative could improve care for patients, by giving practices the support they need to implement proven best practices to manage care for patients with high health care needs, ensure patient access, deliver preventive care, engage patients and caregivers, and coordinate care across the medical home neighborhood, which CMS correctly defines as “the framework for comprehensive primary care.”

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