Wednesday, September 28, 2011

Has Medicare found a way forward for primary care?

Today, 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 has 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.”

Today’s question: What is your reaction to CMS’s Comprehensive Primary Care Initiative?


Harrison said...

What I see from your post is an influx of money to primary care practices with no down side. But their has to be an expectation and in order to reach the expectation there will have to be risk taking for the primary care practices. It seems likely that there will have to be population management expectations and these will be imposed on primary care practices through pay for performance mechanisms.
Those specifics will make or break this.
There is faith in the idea that primary care offices will be able to keep people out of the hospital, and keep people away from specialists, and keep people out of ER's.
If they can do that then there will be cost savings.
And there may also be improvements in patient population health outcomes.
But there is a culture to change to make these changes. Establishing primary care medical homes is a necessary part of that change but it is not sufficient, and if there is no committment to make this happen within our culture then the result will be that the investment in primary care practices will look like a waste of money 5 years from now and the next step will be harsh moves to put individual primary care offices at risk.
The ACP's advocacy of this will have to include active monitoring of how it is implemented, and to be sure that it does not become punitive.

w said...

My fearless prediction: it will fail.

Harrison said...

The pessimism relative to our health care system is daunting.
We pay the most and have huge problems with patient access and we are the wealthiest society the world has ever seen.
Countries with smaller per capita income and less industry do better with fewer resources. They cover patients better (everyone usually). They control health care inflation better. They control population health better.

Are we sicker?
More anxious?
More fearful?
More demanding?
More corrupt?
More inept?

Just what explains our inability to cover our population with adequate health care and at a reasonable cost when the rest of the developed world does it just fine?

I think that the people who oppose the ACA, and who oppose the reforms like PCMH and ACO's need to explain why that is.
Why are we inferior as a society to so many other countries when we historically are so much more innovative and so much wealthier even today.


ryanjo said...

I am not pessimistic. But I am tired of being lied to.

We have a problem with access to healthcare, it is true. The average person could not afford health insurance, because our government has let large insurance companies reap enormous profits by mismanaging care and keeping one-third of the premium dollar. Because government incompetence annually allows millions of dollars in fraud and waste from federal programs. Because our legislators are bought and sold by big Pharma to subsidize their research and keep their patents and prices high.

So the solution (supported by by ACP et al): let's have more bureaucracy and top down control...its those wasteful independent doctors after all, who we have to crush.

But it only serves the liberals who are advocating a complete transformation of US healthcare to another government department to believe that America has an inferior healthcare system. It all depends how those statistics are quoted:
-- For effective treatment of cancer, US is #1, France 3rd, UK 5th. For some common cancers, British mortality rates are almost twice American.
-- often quoted infant mortality statistics: the US reportedly lags, but all US births are counted. In Scandinavia, low birth weight infants are excluded statistically (thus Norway has the lowest mortality stats)
-- life expectancy: death by transportation accident or other violence is twice as likely in the US as other Western countries. This is not a health care system issue. Adjusted for injury rates, U.S. life expectancy is higher than in nearly every other Western nation.
-- WHO "quality" rating: the US is 37th, primarily because of lack of universal coverage and the financial burden on the average citizen. This is often quoted as a fault of our health care but is equivalent to saying that an expensive automobile must be poor quality because it costs more.

Feel free to wallow in guilt all you want. Swallow the ACA in all its tarnished glory. But just don't believe the lies any longer.

Steve Lucas said...


You make a valid point about cost and access. I personally trace this back to WWII. A number of years ago I was on a flight to Paris and my seat mate was a PhD physicist, we were exactly the same age. He was working on changing matter at the molecular level.

After a far ranging discussion we hit upon the differences in out lives. He made this very important point: Europe was bombed back to the dark ages by the US. The results were a very different life style, and priority system than in the US.

Europe has trains because the distances are shorter, France is about the size of Texas, and they put more people with lower skills to work.

The medical system was designed to treat the most people, with the most common issues, at the lowest cost. The US system was designed to treat people with insurance, for any issue, and generate a reasonable profit.

For me that system changed in the 80”s as someone discovered the profit potential in medicine and insurance. Hospitals started to look at the most profitable patients and the procedures that produced this profit. Insurance companies became investment vehicles and claims became a cost item, not the reason for being in business.

That concept has accelerated into the mess we have today. The results are an average of $15,000 per year insurance cost for a family making $50,000 per year. Our insurance costs are double those in most other countries and many Americans are insurance poor, i.e. medical insurance is their largest household expense.

To make this perverse system work doctors have been squeezed, resulting in shorter visits, more referrals, and thus high cost. Hospitals and insurance companies have become multi-billion dollar enterprises with executives that have no relationship, or desire, to recognize their reason for existence, the medical care of an individual.

This year we saw medical insurance cost increase while medical cost decrease. I am sure someone is very pleased with this increase in profit. As a business person I do not view profit as a dirty word, what I do view as perverse is the salaries of hospital executives and staff with little direct input into medical treatment. An insane insurance system that is designed to be a cost plus, and the bad decisions that result from that paradox, along with the equally insane drive to game the system for maximum profit.

There is a better system and it exists in other parts of the world. We have to be willing to set aside some of out preconceived notions and business models to make it work. One point was made over and over in business school: change is hard, even if something is wrong, people will continue to do it that way because that is the way things are done.

Steve Lucas

Jerry M said...

If you think that Comprehensive Primary Care Initiative will result in greater pay to
the Internist I have a nice bridge in Brooklyn you might like to buy. The whole idea is
to save the government money. The idea of using capitation plus a lower amount of
fee for service was a concept that was attempted in the 1980s as non staff model HMOs
and was the basis for “managed competition” promoted by Hillary Clinton’s fiasco. Patients learned to hate the concept because it was known to refuse services. It also
uses the Internist as a gate keeper to keep patients away from specialists.

ACP supports this concept along with practice guidelines because it’s leadership
wants to get the job of developing the guidelines. Just another industry to spend our
health care dollar on instead of patient care. We already have guidelines developed
by the many subspecialty colleges but CMS wants “guidelines” that they can use to
deny care.

I disagree that other countries have better medical care then the USA and cheaper.
If you have cancer or heart disease your prognosis has been shown to be best in the
USA. Over all longevity is a more complex subject which includes social factors
unrelated to medicine.

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