By John DeGaspari
The Center for Medicare and Medicaid Services (CMS) on Aug. 22 announced a roster of 500 primary care practices in seven regions that will participate in its Comprehensive Primary Care Initiative, a public-private partnership to strengthen primary care. The initiative includes participation by CMS, state Medicaid agencies, commercial health plans, self-insured businesses, and primary care providers.
Under the initiative, CMS will pay primary care practices a care management fee, initially set at $20 per beneficiary per month, to support enhanced coordinated services on behalf of Medicare fee-for-service beneficiaries. At the same time, participating commercial, state, and other federal insurance plans are also offering enhanced payment to primary care practices to support high-quality care for their practices.
The initiative started in the fall of 2011, when CMS solicited a pool of commercial health plans, state Medicaid agencies, and self-insured businesses to work with Medicare to support comprehensive primary care. Public and private health plans in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley region, Ohio, Kentucky’s Cincinnati-Dayton region, and the Greater Tulsa region of Oklahoma signed letters of intent with CMS to participate in the program. The markets were selected in April of this year, based on the percentage of the total population covered by payers who expressed interest in joining the partnership.
Practices were invited to participate and start delivering enhanced healthcare services this fall. The practices were chosen in a competitive selection process, based on their use of health information technology, the ability to demonstrate recognition of advanced primary care delivery by selected clinical societies, service to patients covered by participating payers, participation in practice transformation and improvement activities, and diversity of geography, practice size, and ownership structure.
At a conference call announcing the selection, Richard Gilfillan, M.D., director of the Center of Medicare and Medicaid Innovation at CMS, said the focus of the initiative was to provide better primary care, resulting in improved health and lower costs. The primary care practices selected in this latest stage of the initiative represents “over 2,000 doctors, nurse practitioners and other physician extenders, serving 300,000 Medicaid beneficiaries, and hundreds of thousands more people who have private health insurance or coverage through Medicaid or the states’ health insurance program,” he said.
“The initiative aligns our resources to one goal: better health, better care and lower costs to improvement,” Gilfillan said. To do that, “we have to look to the front-line doctors and nurses and support them and give them the tools they need to deliver better care,” he added.
“With the aligned approach of Medicare, Medicaid, private insurers, and large self-insured employers, we can no longer penalize doctors for spending extra time with patients, but reward them for spending extra time with patients, coordinating with the specialists, managing medication, or taking the time to sit down with a patient to develop a plan to help a patient to lose weight or manage their cholesterol or blood pressure,” he said. “In this partnership, all doctors’ payments, not just Medicare payments, will compensate them for being accessible after hours, for fully coordinating electronic health records into their care coordination efforts, instead of simply doing more procedures and more tests.” He added that for patients, this will mean valuable extra time with their doctors to talk with them on how to lead healthy lives and take of their chronic conditions.
MEASURING SUCCESS
Gilfillan said CMS sees great potential to spread the program widely, once the initiative gets started in October, to begin testing to evaluate how the model works and when they see causal results, to be able to spread it broadly across the country.
He said success will be determined by a set of quality metrics similar to those used to measure the success of accountable care organizations. Total cost of care of services such as ED visits and hospitalizations will be evaluated, as will be satisfaction surveys by beneficiaries receiving treatment from the primary care practices. According to Gilfillan, the $20 reimbursement figure will gradually decrease to $15. “That provides coverage for a set of services that can deliver the kind of outcomes we are after. Net investment will be on the order of $300 million over three and a half years, and we think there will be a positive return,” he said.
He added: CMS needs to demonstrate that this model improves or maintains care quality and results in decreased expenditures, noting that the significant patient population CMS has identified will serve as a realistic test over the next 18 to 24 months before it expands the program nationally.
Participation of public and private insurers in the selected markets was a critical selection criteria. “We looked for effective participation from other insurers, and the distribution of practices,” Gilfillan said. Another selection criterion was practices that had fully implemented electronic health records. “This will be a well-identified community, one of the largest with full electronic health capability, with a lot of interesting analysis will to understand what EHRs bring to the effort,” he said.
A PRACTICING PHYSICAN WEIGHS IN
One physician who is participating in the initiative is Stacy Zimmerman, M.D., an internal medicine and pediatrics physician from Clinton, Ark., who is a practitioner at Ozark Internal Medicine and Pediatrics. Zimmerman has recently converted her practice to a patient-centered medical home (PCMH), following a two-year pilot project. The PCMH concept embodies many of the goals of the CMS initiative.
“When I started my practice nine years ago, I was motivated to improve healthcare in an underserved area,” she said. It wasn’t long before she was bogged down in patient charts. While she purchased an electronic health record, she found that even a great computer program could not instantly fix everything or make her patients well. “It became obvious that the health and welfare of my patients depended on a partnership between the patients, the physician, and the healthcare team.” This was the foundation of the transition of her practice to patient-centered care, she said.
She outlined some results of the transformation:
Zimmerman said that since implementing these features, the practice has seen “a marked decrease in ED visits and a marked decrease in the hospital readmission rates compared to other clinics in its geographic area. This model demonstrates how a clinic can decrease healthcare costs.”
A HEALTH PLAN’S EXPERIENCE
John Bennett, M.D., is president and CEO of the Capital District Physicians’ Health Plan (CDPHP), a health plan located in upstate New York, which is a participant in the initiative. Five years ago, the CDPHP board of directors came up with a directive to save primary care. “The local medical school was no longer graduating and sending significant numbers of physicians to choose primary care as a career,” he said.
CDPHP launched its Enhanced Primary Care Initiative, which uses the PCMH features of patient-centered care and combines it with a global payment model, he explained. “It allows primary care physicians to be rewarded for better health, better care, and lowering costs,” he said. The initial pilot of three practices has been successful. An independent analysis of its Enhanced Primary Care Initiative showed per member per month savings of $8 per member per month, resulting from a 9-percent reduction in emergency room visits and a 15-percent reduction of inpatient admissions, he said.
He added that, as a regional payer, CDPHP participates in all lines of business, both commercial and New York State funded and federally funded Medicare Advantage plans. “We found this [to be] true of the population as a whole,” he said. As a result of that, the health plan’s Enhanced Primary Care Program is thriving, and it will soon cover close to half of all 400,000 CDPHP members within the next year, he said.
An example of its success from a population health level, was an Albany, N.Y. practice whose physicians have achieved a drastic improvement in blood glucose levels in their diabetic patients, as measured by their hemoglobin A1C levels, he said.
He said that, as a regional plan, CDPHP has engaged the local business community by introducing a Shared Health product portfolio that rewards employers to promote healthy lifestyles and behaviors. “We believe that better health and better care leads to lower costs, and we are seeing it every day,” he said.