CMS un­veils Pri­mary Care Plus

Modern Healthcare - - NEWS - By Vir­gil Dick­son

With less than a year to go in the Obama ad­min­is­tra­tion’s pub­lic-pri­vate push for bet­ter care man­age­ment among pri­mary-care providers, the CMS has rolled out a souped-up care-de­liv­ery model.

But get­ting the new five-year demon­stra­tion up and run­ning re­lies on the agency’s abil­ity to per­suade suf­fi­cient num­bers of com­mer­cial health plans and doc­tors that it’s worth the ef­fort.

The CMS is now re­cruit­ing physi­cian prac­tices and state and com­mer­cial pay­ers to test the new model in 20 re­gions of the country, en­com­pass­ing up to 20,000 doc­tors and 25 mil­lion pa­tients.

Its goal is noth­ing less than to up­end how pri­mary care is de­liv­ered and paid for. As CMS of­fi­cials de­scribed the ini­tia­tive in a piece pub­lished last week in JAMA, they want to make physi­cian prac­tices “in­cen­tive neu­tral” rel­a­tive to the mode of care they de­liver and ren­der them no longer “teth­ered to the 20minute of­fice visit.”

But state reg­u­la­tory hur­dles and bad ex­pe­ri­ences with the CMS’ ear­lier pi­lot pro­gram could lead to poor par­tic­i­pa­tion in cer­tain parts of the country. Ex­perts say the model also could steer providers away from other al­ter­na­tive pay­ment mod­els.

Un­der the Com­pre­hen­sive Pri­mary Care Plus (CPC+) ini­tia­tive un­veiled last week, the CMS and other pay­ers will pay providers a monthly fee for pa­tient care-man­age­ment ser­vices.

A sim­i­lar but smaller pi­lot pro­gram launched in 2012 that ends this year— the Com­pre­hen­sive Pri­mary Care ini­tia­tive, or CPC—re­duced to­tal monthly ex­pen­di­tures by 2% per ben­e­fi­ciary in Medi­care Parts A and B. Sav­ings at­trib­uted to the en­hanced care co­or­di­na­tion were nearly enough to off­set the costs of its fees, but it didn’t gen­er­ate any net sav­ings.

In the new CPC+ pro­gram, providers can par­tic­i­pate in one of two tracks. In the first track, the CMS will pay a risk-strat­i­fied monthly fee for each ben­e­fi­ciary’s care-man­age­ment ser­vices, in ad­di­tion to fee-for-ser­vice Medi­care pay­ments for pri­mary-care vis­its.

In the sec­ond track, physi­cian prac­tices will re­ceive re­duced Medi­care fee-for-ser­vice pay­ments and more gen­er­ous up­front care-man­age­ment pay­ments. The CMS says this “hy­brid” pay­ment model will give providers more flex­i­bil­ity to pro­vide care out­side of tra­di­tional face-to-face en­coun­ters. For ex­am­ple, clin­i­cal prac­tices might of­fer telemedicine vis­its or sim­ply pro­vide longer of­fice vis­its for pa­tients with com­plex needs.

In both tracks, in­stead of of­fer­ing prac­tices the po­ten­tial re­ward of shar­ing in the sav­ings they gen­er­ate, providers will have to re­turn in­cen­tive pay­ments (awarded per ben­e­fi­ciary, per month) if they fail to meet cost and qual­ity tar­gets.

The agency es­ti­mated that Track 1 will be bud­get-neu­tral and that Track 2 will save about $2 bil­lion over the ini­tia­tive’s five-year run, as­sum­ing physi­cians are will­ing to take the risk. The project will launch only in those re­gions where there is “a crit­i­cal mass of in­ter­ested pay­ers,” the CMS said, and ex­perts say many plans will be pro­hib­ited from par­tic­i­pat­ing in Track 2 be­cause of their state’s in­surance reg­u­la­tions.

Those reg­u­la­tions came in re­sponse to re­ports about poor qual­ity of care pro­vided by physi­cian prac­tices that re­ceived risk-based pay­ments in the late 1980s and early 1990s. Many states sub­se­quently passed laws restrict­ing those ar­range­ments to tightly reg­u­lated HMOs, said Dr. Peter Kongstvedt, a se­nior health pol­icy fac­ulty mem­ber at Ge­orge Ma­son Univer­sity.

But rel­a­tively few con­sumers are now en­rolled in com­mer­cial HMO plans, although state laws may pro­hibit other types of plans from par­tic­i­pat­ing.

Reg­u­la­tions aside, the new pro­gram’s re­liance on in­ter­est from com­mer­cial pay­ers means it may not reach cer­tain ar­eas of the country.

“The prob­lem is that the re­gions with the least payer in­ter­est will be the ones that need it the most,” said Dr. Kavita Pa­tel, a se­nior fel­low at the Brook­ings In­sti­tu­tion and a for­mer pol­icy di­rec­tor for the Obama ad­min­is­tra­tion.

Some pri­vate plans may be leery of the CPC+ ini­tia­tive be­cause of neg­a­tive ex­pe­ri­ences with the first CPC pro­gram. For ex­am­ple, last year Cigna Corp. wrote to the CMS ask­ing that the pro­gram not be ex­panded.

“Con­tin­u­ing (the pro­gram) would be a crutch for providers, and would re­duce in­cen­tives for them to join more in­no­va­tive and bet­ter-run provider groups who are con­tract­ing with pay­ers for more ad­vanced pa­tient-cen­tered med­i­cal homes and ac­count­able care ar­range­ments,” Cigna wrote.

An­other po­ten­tial pit­fall for the CPC+ ini­tia­tive is its po­ten­tial to mud­dle other ef­forts to over­haul care de­liv­ery and pay­ment. The Med­i­cal Group Man­age­ment As­so­ci­a­tion said last week that it was un­clear how the ini­tia­tive would mesh with the Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act, or MACRA, which will re­ward prac­tices for par­tic­i­pat­ing in al­ter­na­tive pay­ment mod­els, be­gin­ning in 2019.

“It’s very dif­fi­cult for physi­cian prac­tices to make a de­ci­sion to par­tic­i­pate,” said Anders Gilberg, the MGMA’s se­nior vice pres­i­dent of govern­ment af­fairs. “Th­ese mod­els are be­ing rolled out in a piece­meal fash­ion with­out any over­ar­ch­ing un­der­stand­ing of where they are go­ing to fit in with MACRA.”

“Th­e­se­be­ing a piece­meal rolled mod­els out arein fash­ion, with­out any over­ar­ch­ing un­der­stand­ing of where they are go­ing to fit in with MACRA.”

ANDERS GILBERG Se­nior vice pres­i­dent of govern­ment af­fairs MGMA

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