A recent analysis published by healthcare experts at the Brookings Institution was one that I found very compelling. Paul Ginsburg, Margaret Darling, and Kavita Patel of Brookings on May 31 published their analysis, “CMMI’s New Comprehensive Primary Care Plus: Its Promise and Missed Opportunities,” which looked at the Comprehensive Primary Care Plus (CPC+) initiative, announced on April 11 by the Center for Medicare and Medicaid Innovation (CMMI), a division of the federal Centers for Medicare & Medicaid Services (CMS).
Let’s begin by providing some background on the CPC+ initiative, as many readers may not yet be familiar with it. When it was announced on Apr. 11, the CMS announcement included a statement by Patrick Conway, M.D., CMS deputy administrator and chief medical officer. In the statement, Dr. Conway said that “Strengthening primary care is critical to an effective health care system. By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists, we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars. The Comprehensive Primary Care Plus model represents the future of health care that we’re striving towards.”
Among the key elements of the initiative, which itself is built on the Comprehensive Primary Care initiative launched in late 2012, the five-year CPC+ model will, among other things, “support patients with serious or chronic diseases to achieve their health goals; give patients 24-hour access to care and health information; deliver preventive care; engage patients and their families in their own care; work together with hospitals and other clinicians, including specialists, to provide better coordinated care,” according to the Apr. 11 press release. Primary care practices will participate in one of two tracks, with both tracks requiring those practices to perform the functions and meet the criteria for the program, but those practices in Track 2 will also “provide more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs,” according to the CMS announcement.
What’s more, there is a major health IT element to the program. As CMMI noted, “To promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. The payments under this model encourage doctors to focus on health outcomes rather than the volume of visits or tests.” In that context, “Practices in both tracks also will receive data on cost and utilization. Optimal use of Health IT and a robust learning system will support them in making the necessary care delivery changes and using the data to improve their care of patients. Track 2 practices’ vendors will sign a Memorandum of Understanding (MOU) with CMS that outlines their commitment to supporting practices’ enhancement of health IT capabilities. These partnerships will be vital to practices’ success in the care delivery work and align with the Office of the National Coordinator for Health IT priority to ensure electronic health information is available when and where it matters to consumers and clinicians.”
Now, onto the Brookings Institution analysis. As Ginsburg, Darling, and Patel write, “Track 2, the more interesting part of the initiative, is for practices that are already capable of carrying out the primary care functions and are ready to increase their comprehensiveness. In addition to a higher monthly care management fee ($28), practices receive Comprehensive Primary Care Payments. These include a portion of the expected reimbursements for Evaluation and Management services, paid in advance, and reduced regular fee-for-service payments. Track 2 also includes larger rewards than does Track 1 for meeting performance thresholds. The combination of larger per beneficiary monthly payments and lower payments for services is the most important part of the initiative,” they write. “By blending capitation (monthly payments not tied to service volume) and FFS (fee-for-service), this approach might achieve the best of both worlds.”
The challenge, they write, is that “[T]here are two downsides to the CPC+. One concerns the lack of incentives for primary care physicians to take steps to reduce costs for services beyond those delivered by their practices. These include referring their patients to efficient specialists and hospitals, as well as limiting hospital admissions. There are rewards in CPC+ for lower overall utilization by attributed beneficiaries and higher quality, but they are very small.” They go into some detail on this first perceived downside. Then they go onto say this: “The second downside concerns the inability of physicians participating in CPC+ to participate in accountable care organizations (ACOs). One of CMMI’s challenges in pursuing a wide variety of payment innovations is apportioning responsibility across the programs for beneficiaries who are attributed to multiple payment reforms. As an example, if a beneficiary attributed to an ACO has a knee replacement under one of Medicare’s bundled payment initiatives, to avoid overpayment of shared savings, gains or losses are credited to the providers involved in the bundled payment and not to the ACO. As a result, ACOs are no longer rewarded for using certain tools to address overall spending, such as steering attributed beneficiaries to efficient providers for an episode of care or encouraging primary care physicians to increase the comprehensiveness of the care they deliver.”
Most explicitly, they write, “Keeping the physician participants in CPC+ out of ACOs altogether seems to be another step to undermine the potential of ACOs in favor of other payment approaches. This is not wise. The Innovation Center has appropriately not established a priority ranking for its various initiatives, but some of its actions have implicitly put ACOs at the bottom of the rankings.”
So there seem to be some genuine, built-in contradictions in how this new program is structured. If that’s true, it is particularly unfortunate, since this program is very data-intensive, as are all the Medicare ACO programs. One would think that federal healthcare officials would have harmonized the details of these programs better, if the Brookings Institution analysts are perceiving all this correctly.
Meanwhile, a fundamental truth is this: the CPC+ is yet another program that will require the mastery, on the part of physicians in practice, of extensive data usage, analytics, and reporting, and the fulfillment of many requirements.
And here’s a really basic question: to what extent are practicing physicians prepared to participate in all these programs? Clearly, there is a spectrum of preparedness out there in the U.S. physician community. What’s more, data will be at the core of any success in any of these programs. So, not surprisingly, physicians are going to be turning more and more to the senior healthcare IT executives at the hospital-based organizations, integrated health systems, and large medical groups that are supporting their employed and affiliated doctors.
So while I believe that CMS officials really need to look at some of the downsides mentioned in the Brookings experts’ analysis—the issue of excluding physicians participating in CPC+ from also participating in ACOs, in particular—it’s also very clear to me that CMS officials are conceptually “putting the pedal to the metal,” as they say colloquially. This trend is not going away or reversing; instead, it is only intensifying and accelerating now. Within a few years, “pure” fee-for-service reimbursement, either from Medicare, or most likely from private health insurers as well, will likely have disappeared, with a very few exceptions.
So the next few years really will be a time of great challenge, but also opportunity, for healthcare IT leaders. Facilitating success with data, for physicians in practice, will become not just important, but vital to survival. So the bottom line on all this is that CMS’s announcement of its new Comprehensive Primary Care Plus program is yet another signal—as if anyone should really need any more signals—that the U.S. healthcare system has reached a tipping point on delivery and payment models, and we’re not going backwards. And that the time for healthcare IT leaders to step up and get proactive is already here.