Thursday, April 14, 2016

Will Medicare’s new Comprehensive Primary Care+ program truly be a Plus for primary care?

On Monday, the Center for Medicare and Medicaid Services (CMS) announced what it describes as the “largest-ever initiative to transform and improve how primary care is delivered and paid for in America."  Called the Comprehensive Primary Care Plus (CPC+) program, the initiative is modeled after the existing Comprehensive Primary Care Initiative (CPCI), a 4-year pilot of advanced primary care medical homes (PCMHs) that has been rolled out in 500 practices in 7 regions around the country.  CPCi is scheduled to wrap up in October of this year; its participating practices will have an opportunity to transition into the new Comprehensive Primary Care Plus program, and many more practices will be invited and eligible to join.

So how is the new program going to be a Plus for physicians and their patients compared to the current CPCi pilot and traditional fee-for-service Medicare?

For one thing, it’s Plus-sized: CMS envisions that the program will be available “in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve”—a 10-fold increase in the number of participating practices, and a nearly three-fold increase in the number of regions where the program will be offered.

CPC+ could also be a Plus for practices because it will offer more options.  Physicians and their practices can choose from two different participation tracks, with different care delivery requirements and payment methodologies that reflect how advanced they are in incorporating PCMH principles into their care delivery. Track 1 is for those that are less advanced in fully implementing the attributes of advanced Primary Care Medical Homes; track 2 is for more advanced practices.

CPC+ could be a Plus for practices, especially compared to traditional FFS Medicare, because it gives them more Medicare dollars upfront, which will be in addition to the amounts they get reimbursed for individual patient encounter (evaluation and management service) codes:
  • Track 1 practices will receive an average risk-adjusted payment of $15 per beneficiary per month; they can earn another $2.50 PBPM if they do well on metrics of quality and utilization. 
  • Track 2 practices would receive an average risk-adjusted PBPM payment of $27 and up to $100 PBPM for the highest risk patients); they can earn an additional $4 PBPM based on performance.

However, CPC+ also adds financial risk to the equation. If track 1 practices do not meet their performance metrics, they will have to repay Medicare for the $2.50 PBPM incentive payment.  If track 2 practices don’t meet their metrics, they would repay Medicare for the $4.00 PBPM incentive payment. 

My back-of-the envelope calculation shows how much more in upfront Medicare money this could mean for participating practices.  A track 1 practice with 1000 Medicare beneficiaries would on average receive $15,000 in monthly (PBPM) payments, or $180,000 over 12 months.  If they are able to keep the $2.50 PBPM incentive payment, it would be $17,500 per month, or $210,000 for the year. Track 2 practices with 1000 Medicare patients would on average get $27,000 per month in PBPM advance payments, or $324,000 for a year; with the additional $4 PBPM incentive payment, it would be $31,000 per month, or $372,000 for the year. 

For track 1 practices, these upfront PBPM payments would be in addition to getting 100% of their usual Medicare FFS payments for office visits and procedures billed a la carte.

It’s more complicated, though, for track 2 practices, because their upfront PBPM payments will be offset by reduced payments for separately-billed office visits and other evaluation and management services.  In an editorial published in the Journal of the American Medical Association, CMS officials explain how this will work:
“Track 2 practices will receive an up-front payment of a portion of their expected evaluation and management claims on a per capita basis, independent of claims.  Subsequent claims for evaluation and management services will be paid at a commensurately reduced rate. As the ratio of the hybrid payment is titrated up during the model, the reduced payment for billed evaluation and management services will pay practices for the marginal cost of an office visit, making practices ‘incentive neutral’ to the mode of care delivery and allowing them the flexibility to deliver care in the manner that best meets patients’ needs—without being tethered to the 20-minute office visit. Practices might offer non–face-to-face visits (e.g., electronic or telephone), offer visits in alternate locations, or simply provide longer office visits for patients with complex needs. CMS will monitor practices to ensure delivery of quality health care.” 
Their non-evaluation and management services would continue to be paid 100% of the usual rates.

So for Track 2 practices especially, it comes down to them deciding whether having a big pot of “bird-in-the-hand” upfront PBPM payments, and the financial support and flexibility it provides to manage things without being “tethered” to visits, is worth being paid commensurately less when they have to bill separately for a visit. 

Or, to put it another way, do they prefer getting more of their revenue upfront from risk-adjusted capitation and less downstream from FFS billings?

The Comprehensive Primary Care Plus program could also be a Plus for practices by giving them access to extra support and revenue from payers other than Medicare: CMS will be seeking formal commitments from non-Medicare payers to support participating practices, and will only launch the program in localities where there is such a commitment from enough payers.

The CPC+ program could also be a Plus for participating physicians and their practices because it should give them a big leg-up in qualifying for higher payments under the new MACRA law, either as an Alternative Payment Model (APM) or under the Merit-based Incentive Payment System (MIPS) created by the legislation.

Finally, the Comprehensive Primary Care Plus program would also be a Plus for patients, if it truly achieves its goals of providing practices with the “financial resources [needed] to implement the processes and hire the staff needed to deliver the 5 primary care functions: (1) access and continuity, (2) risk-stratified care management, (3) planned care for chronic conditions and preventive care, (4) patient and caregiver engagement, and (5) comprehensiveness and coordination of care.”

ACP, in a supportive statement, noted several features of the program that will be critically important for it to be successful in meeting the goals of supporting and strengthening primary care:

·       We strongly support the goal of ensuring that practices in each track will be able to build capabilities and care processes to deliver better care, which will result in a healthier patient population.
·       We agree with the need for payment redesign that offers the ability for greater cash flow and flexibility for primary care practices to deliver high quality, whole-person, patient-centered care and lower the use of unnecessary services that drive total costs of care.
·        We support the critical importance of obtaining commitments from other (non-Medicare) payers to join with Medicare to support CPC+ practices.
·       We are encouraged that CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data, to guide their decision making.

Yet ACP’s statement concluded with a cautionary note:  “The success of the Comprehensive Primary Care Plus program will depend on Medicare and other payers providing physicians and their practices with the sustained financial support needed for them to meet the goal of providing comprehensive, high value, accessible, and patient-centered care, with realistic and achievable ways to assess each practices’ impact on patient care.  The College is committed to working with CMS on the details of implementation to ensure that the program is truly able to meet such requirements of success.”

While the verdict is still out, the Comprehensive Primary Care Plus initiative truly is a big deal for primary care, potentially offering a way for practices that embrace the PCMH model—as long championed by ACP—to get more upfront payments from Medicare and other payers to help them make their practices more accessible and responsive to the needs of their patients, while accepting a degree of financial risk for achieving the desired results.

Today’s questions:  Do you think that the Comprehensive Primary Care Plus program will truly be a Plus for primary care physicians, their practices, and their patients?  Would you consider having your practice participate?

Thursday, March 17, 2016

A Limerick for Saint Paddy’s Day

Readers of this blog know that I am first-generation American of Irish descent. My beloved father, Jack Doherty, came over to this country at the age of 10.  My dad was born in a thatched cottage (with no plumbing and electricity) in Drumshambo, County Leitrim, Ireland.  After emigrating to the United States with his mother, Elsie, at the age of 10, they were reunited with his father, who they hadn’t seen for eight years.  Later, my Dad took over (and tended bar) at Doherty’s Bar in Woodside, Queens, NYC, after my grandfather passed away.  Jack Doherty later went on to get a bachelor’s degree and master’s degree at night while tending bar 6 days and one night a week, sold the bar, and became a public high school teacher for inner city kids in Brooklyn, New York.  The complete amazing immigration experience, in a nutshell.

 My Dad passed away almost eight years ago, but I remember him almost every day, especially on Saint Patrick’s Day.

In tribute to my Irish heritage, here is my annual Saint Patrick’s Day limerick (named after the city in Ireland), on a topic near and dear to physicians:
Oh, how MACRA has taken over our days
Each deadline, and rule, a cause for dismay.
We do our best, oh we try
But sometimes we ask, why?
Wouldn’t it have been simpler to let the SGR stay?
Today’s questions: How are you celebrating Saint Patrick’s Day?  Care to write a limerick for readers of this blog?

Wednesday, March 2, 2016

Performance [Measure] Anxiety, Part 2: What’s the Solution?

My most recent blog explained why three prominent Dr. Bobs—Bob Wachter, Bob Berenson, and Bob Centor—are raising important questions about the value of physician performance measures, which, ironically, are supposed to bring greater value to the healthcare system.  Their concerns include:

·         The proliferation of measures of dubious validity and the associated burden of reporting on them;
·         The difficulty,  even impossibility, of measuring elements of care, like physician compassion, that patients may value the most;
·          The risk of unintended consequences, like treating to the measure and disadvantaging physicians who treat the underserved.

All of these are very real and genuine concerns, shared widely by physicians, and not just those fortunate enough to be named Bob. 

The question I am left with, though, is 'What’s the solution to physicians’ anxiety about performance measures?' For practical reasons, I don’t see the country saying, never mind, measuring performance is an impossible or ill-advised task, let’s just repeal the new value-based payment system created by the Medicare Access and CHIP Reauthorization Act (MACRA), let’s abandon all efforts to link payments to performance.  Nor do I think it would be advisable for the medical profession to declare open warfare against performance measures.  For one thing, there are known gaps in quality and effectiveness of care, and measurement can be one way to identify areas for improvement and progress in achieving it.  Performance measurement can also help policymakers, the public, and physicians assess the impact of new delivery and payment models.  (To be clear, the Dr. Bobs weren’t completely calling for an end to performance measurement, but a better approach to measuring performance).

In my opinion, Dr. Yul Ejnes, a former chair of the ACP Board of Regents, offers a wise and appropriate balance in his commentary in today’s @KevinMD blog:

I have a "like-hate” relationship with clinical metrics, performance measurements, and other such things. By now, almost all physicians live with them in the form of insurer “report cards,” PQRS, and “meaningful” use. Some of us have even more exposure to them by participating in patient-centered medical homes and accountable care organizations.

Why “like”? Because I believe they can help you to know how you’re doing. Happy patients, full schedules, phones ringing off the hook with new patient requests, and the belief that you’re doing a good job delivering care aren’t enough. Few things are more sobering than seeing data on the percentage of your diabetes patients who are not at goal, those with hypertension whose pressures are not under control, or those who haven’t undergone colon cancer screening. I know that many question the relevance of some of the clinical measures, which often look at intermediate and perhaps less meaningful outcomes or report on process, but they can be more informative than the gut sense that we have on how we’re doing our jobs.

What I hate about the measures is that they also get in the way of patient care. I’ve written about this in earlier columns — concern about measures distracting us from our primary jobs, the administrative burdens of “capturing” data so that it can be counted, and the effect of all of this on the quality of clinical documentation are some examples. Add to this the open question of whether the current version of performance measures truly improves quality of care.

Instead of rejecting performance measurement, Dr. Ejnes calls for 'a more thoughtful approach to measurement and for EHR products to make [them] more seamless and less intrusive. The American College of Physicians’ (ACP) 2012 paper on performance measurement had many recommendations that, if followed, would prevent much of our current suffering. For example, minimizing burdens in collecting data, using EHRs to facilitate (not complicate) the process, and most importantly, that “performance measures that have not been shown to improve value to include higher quality, better outcomes, and reduced costs (and higher patient and physician satisfaction) should be removed from performance–based payment programs.”'

Yesterday, ACP did exactly what the good Dr. Ejnes ordered, and what our 2012 paper (which is still right on the mark!), calls for, which is to call on CMS  to “reimagine” performance measurement—starting with scrapping  the measures currently used for Medicare’ existing Meaningful Use, PQRS, and Value-Modifier programs: 

"The College strongly recommends that CMS actively work to improve the measures to be used in the quality performance category of MIPS. Therefore, we believe that CMS should NOT consider the existing quality measure sets within Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBM), and Meaningful Use (MU) as the starting point for its measure development plan.

In the short term, ACP recommends that CMS utilize the core set of quality measures identified and recently released by the America’s Health Insurance Plans (AHIP) collaborative . . . Further, the College recommends that CMS consider the recommendations made by ACP’s Performance Measurement Committee with regard to measure selection within MIPS.

Over the longer term, ACP stresses that it will be critically important for CMS to continue to improve the measures and reporting systems to be used in MIPS to ensure that they measure the right things; move toward clinical outcomes, patient- and family centeredness measures, care coordination measures, and measures of population health and prevention; and do not create unintended adverse consequences.”

Further, ACP identified the need to “constantly monitor the evolving measurement system to identify and mitigate any potential unintended consequences, such as increasing clinician burden and burn-out, adversely impacting underserved populations and the clinicians that care for them, and diverting attention disproportionately toward the things being measured to the neglect of other critically important areas that cannot be directly measured (e.g., empathy, humanity).”

In other words, the solution to physician anxiety over performance measures is for the medical profession to work with policymakers to fix performance measurement so that we are measuring the right things without creating unintended consequences and without increasing clinician burden, not to do away with them.  As ACP first articulated in its 2012 paper and reaffirmed in yesterday’s letter to CMS, the medical profession must insist that measures be:

  • Reliable, valid, and based on sound scientific evidence
  • Clearly defined
  • Based on up-to date, accurate data
  • Adjusted for variations in case mix, severity, and risk
  • Based on adequate sample size to be representative
  • Selected based on where there has been strong consensus among stakeholders and predictive of overall quality performance
  • Reflective of processes of care that physicians and other clinicians can influence or impact
  • Constructed to result in minimal or no unintended harmful consequences (e.g., adversely affect access to care)
  • As least burdensome as possible
  • Related to clinical conditions prioritized to have the greatest impact on improving patient health

Or, as Dr. Ejnes so aptly put it, “It was supposed to be that if we provided high-quality care to our patients, the measurements would reflect that. Instead, the mantra is that if we score well on our measures, then that means that we provided high-quality care. In other words, the cart has become the horse. It’s time to fix that.”

Today’s question: How would you fix performance measurement?