Rich Daly | May 4, 2016
BIGGER FINANCIAL INCENTIVES AND PRACTICE-SPECIFIC MEASUREMENT ARE AMONG THE CHANGES THAT THE AGENCY HOPES WILL IMPROVE THE RESULTS.
May 4—Insurers and physicians have expressed “robust interest” in participating in a recently announced primary care payment model of historic size, according to a leader at the Centers for Medicare & Medicaid Services (CMS). And program tweaks are expected to provide better outcomes than the “disappointing” results of a predecessor model.
CMS has begun soliciting payer proposals to partner in the Comprehensive Primary Care Plus (CPC+) model announced April 11. The model will provide a non-visit-based care management fee paid per member per month and a chance to garner reward payments based on patient outcomes. The aim of the care management payments is to allow practices to create new workflows, hire care management staff, and develop new relationships for coordinating care.
“We never know until the rubber meets the road and people have to actually sign agreements, etc., but we are seeing robust payer and provider interest” in joining CPC+, Patrick Conway, MD, principal deputy administrator and chief medical officer at CMS, said at a media briefing this week.
The strong interest followed a mixed response from insurers submitting comments in the fall about the predecessor Comprehensive Primary Care (CPC) initiative, on which CPC+ is based.
For instance, Cigna asked CMS not to expand the program.
“After three years of participation in [CPC], we have not seen evidence of savings generated by the program,” Cigna wrote.
In contrast, the Blue Cross and Blue Shield Association, which had plans participating in all seven regions of CPC, supported expansion as long as CMS provided “greater multi-payer alignment through any future related initiatives.”
Weak Results
The weak results—so far—of the four-year CPC model have raised some concerns because it was the largest study of a version of a patient-centered medical home model.
At two years, the CPC initiative had yet to generate savings in Medicare Part A and B expenditures sufficient to cover the provided fees for care management, according to a recent reportby Conway and others in the New England Journal of Medicine. Additionally, although statistically significant but small improvements in two of six domains of patient experience were found, there were “no appreciable improvements in the quality-of-care measures,” the report stated.
Gail Wilensky, formerly the head of Medicare and Medicaid, described the lack of savings and quality improvement in the first two years of CPC as “pretty dismal.”
However, she noted in an interview, “If all of your pilot projects showed glowing results, then you’re probably not pushing the boundaries.”
John Ayanian, MD, director of the Institute for Healthcare Policy and Innovation at the University of Michigan, has studied Medicare’s efforts to obtain quality and cost savings.
“It was somewhat disappointing that the results weren’t stronger,” Ayanian said in an interview.
However, Ayanian noted that such models are trying to change practices that have emerged over the past 50 to 100 years under fee-for-service payment models, “so we shouldn’t expect that we can achieve better quality or lower costs in just a few years.” Such outcomes will require changes in the ways that practices are organized and in how patients utilize their primary care and other healthcare providers.
Katie Gilfillan, director of healthcare finance policy, physician, and clinical practice for HFMA, said the results reflect the challenge many physician groups face investing in changes in their practices to improve the experience of care for the patient, while also managing costs.
“Ultimately the CPC payment model allows primary care physicians to make the necessary changes to their practice to provide better experience and care to the patient; it may be that more time is needed to see significant outcomes as far as cost and quality,” Gilfillan said.
A Mathematica analysisof the program’s results found “the biggest improvements were in the delivery of risk-stratified care management and expanded access to care.”
In his comments on CPC at this week’s media briefing, Conway emphasized the ability of participating practices in the first two years to decrease hospitalizations and emergency department visits.
“That is very much trending in the direction we want our healthcare system to go,” Conway said.
Are Improvements Likely?
Although CPC+ is based on the CPC approach, Conway noted that there are differences. In addition to a vastly larger scale—growing from 500 practices to 5,000—CPC+ includes “tweaks” to its payment model to allow individual practices to be rewarded for performance. CPC, instead, rewarded entire regions if their overall quality improved.
“We heard from practices [saying], ‘That was challenging because what if my practice did well but the rest of Arkansas didn’t,’” Conway said. “From a behavioral economics standpoint, we think CPC+ is much more likely to be effective.”
Although about half of the practices in CPC+ are expected to enroll in Track 1, which is largely similar to CPC, the other half are expected to enroll in Track 2, which includes stronger financial incentives in exchange for taking on greater risk. Gilfillan highlighted the addition of up front PBPM payments, which incentivizes close monitoring of patient quality and utilization metrics in order to keep the payment.
“It’s possible that those stronger financial incentives will have more of an effect on the services that they are providing to patients and hopefully will achieve higher quality and potentially lower costs,” Ayanian said.
One challenge to the ability of the CPC+ model to improve patient outcomes, according to Ayanian, is that its scope is limited to primary care. He hoped future reforms would bring in specialty care and hospital services to encompass a higher share of total costs and care delivery.
“It’s at those transition points that problems often develop,” Ayanian said.
Gilfillan also noted that practice performance under the model will require CMS and other payers to provide “frequent and actionable feedback to physicians in order for them to act on that data, make changes necessary in their practice and retain those payments.”
One of the largest areas of improvement made by practices in the CPC program, Gilfillan noted, was among practices that started risk stratifying patients and then managing and monitoring high-risk patients.
“Learning how to do this effectively may be an area practices can focus on to improve patient care,” Gilfillan said.
Conway noted that in a four-physician practice participating in CPC+, population payments from all payers could reach $1 million annually. “In primary care, that’s real opportunity.”
Conway described how one practice has used the provided funds to hire a pharmacist and social worker “to help them with their medicines and social needs—and patients love it.” Flexibility in the program allows physicians not only to provide virtual visits but even to contract out telehealth services if they don’t want to provide those services themselves.
Source: HFMA