The announcement on May 18 that the federal Centers for Medicare and Medicaid Services (CMS) had added four new regions of the United States in which it was encouraging participation on the part of primary care practices, was significant in several different ways.
To begin with, CMS officials, in making their announcement last Thursday, noted that 2,891 primary care practices had already been participating in Round 1 of the Comprehensive Primary Care Plus program, known informally as CPC+. What’s more, 54 payers were already involved in Round 1 of CPC+, working in nine regions, some of which were states. This map/guide lists the regions and the health insurers involved, which included Arkansas, Colorado, Hawaii, Greater Kansas City (three counties in Missouri and two in Kansas, in the Kansas City metropolitan area), Michigan, Montana, New Jersey, the North Hudson-Capital Region of New York (14 counties), the Ohio and Northern Kentucky region (all counties in Ohio, plus four counties in Kentucky), Oklahoma, Oregon, the Greater Philadelphia Area (five counties in southeastern Pennsylvania), Rhode Island, and Tennessee. Now, adding Louisiana, Nebraska, North Dakota, and the Greater Buffalo Region (Erie and Niagara Counties) in New York state, will significantly expand CPC+’s footprint nationwide.
But it’s far more than geography of significance here. To begin with, there are the program’s core payment elements, as CMS officials quote them on their website. As they explain, “To support the delivery of comprehensive primary care, CPC+ includes three payment elements:
1. Care Management Fee (CMF): Both tracks provide a non-visit-based CMF paid per-beneficiary-per month (PBPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for the practice’s specific population. The Medicare fee-for-service (FFS) CMFs will be paid to the practice on a quarterly basis.
2. Performance-Based Incentive Payment: CPC+ will prospectively pay and retrospectively reconcile a performance-based incentive based on how well the practice performs on patient experience measures, clinical quality measures, and utilization measures that drive total cost of care.
3. Payment under the Medicare Physician Fee Schedule: Track 1 continues to bill and receive payment from Medicare FFS as usual. Track 2 practices also continue to bill as usual, but the FFS payment will be reduced to account for CMS shifting a portion of Medicare FFS payments into Comprehensive Primary Care Payments (CPCP), which will be paid in a lump sum on a quarterly basis absent a claim. Given our expectations that Track 2 practices will increase the comprehensiveness of care delivered, the CPCP amounts will be larger than the FFS payment amounts they are intended to replace.”
And even though Comprehensive Primary Care Plus is still quite a new program—the Round 1 performance program began on January 1 of this year—it builds on the advances made in the original Comprehensive Primary Care program, launched in October 2012. As a report from Mathematica noted in April 2016, meaningful, if modest, gains were made through that program. A very large team of researchers, led by Deborah Peikes, sorted through what had been learned in the original CPC program, as of April of last year.
As the authors wrote in their report on CPC, “As is to be expected at this stage of the initiative, practices have experienced some challenges in changing care delivery and have more work to do during the remaining two years of the initiative. Qualitative data collected from a small number of practices show several common challenges of transformation, such as difficulties in changing workflows and procedures, incorporating new staff roles such as care managers into the primary care team, and communicating with other providers when a lack of interoperability exists. Despite being only midway through the four-year initiative,” they noted, “CPC’s care delivery improvements are generating small improvements in outcomes for Medicare FFS [fee-for-service] beneficiaries, the focus of our quantitative evaluation. Between its first and second year, CPC appears to have had small, statistically significant favorable effects on the percentage of respondents in CPC practices choosing the most favorable ratings for three of six composite measures of patient experience over time relative to respondent ratings of comparison practices: (1) getting timely appointments, care, and information (2.1 percentage points, (2) providers supporting patients in taking care of their own health (3.8 percentage points); and (3) shared decision making (3.2 percentage points). Thus, the findings suggest that the substantial changes in CPC practices’ staffing, care processes, and workflows did not worsen patient experience in the short run, and even improved it modestly.”
Those may seem like relatively small advance, but it’s also true, the Mathematica researchers found, that “CPC reduced average monthly Medicare expenditures without care management fees by a statistically significant $11 per beneficiary per month (PBPM), or 1 percent, over the initiative’s first two years, with [that] $11 per beneficiary per month translat[ing] to an estimated cumulative savings in Medicare expenditures without fees of $91.6 million. These cost reductions are driven by reductions in service use, especially hospitalizations and skilled nursing facility. While not a large component of total expenditures, there was also a 3 percent reduction in primary care visits, non-billable calls, emails, and care management interactions, supported by the CPC fees, may have supplanted or reduced the need for primary care office visits. There was no effect on visits to specialists,” the authors of the study added.
Meanwhile, a different, also large, team of researchers looked at the initial Comprehensive Primary Care program, publishing an article online on August 5, 2016, in NEJM Catalyst, a section of The New England Journal of Medicine. Led by Stacey B. Dale, the team’s article was entitled “Two-Year Costs and Quality in the Comprehensive Primary Care Initiative.”
“We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices,” the article’s authors wrote. Those researchers emphasized the small differences in utilization and costs, writing in their conclusion that, “Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience.”
Now, here’s a particularly important section in the NEJM Catalyst article: “The practice survey and site visits indicated that efforts to undertake transformation were often challenging. Common challenges included refining workflows and procedures for the purpose of implementing, documenting, and reporting initiative requirements, trying to incorporate new staff roles (such as that of care manager) into the primary care team, and trying to overcome the incompatibility of EHRs [electronic health records] when attempting to communicate with other providers,” the researchers wrote. “Initiative practices began to stratify patients according to risk systematically and hired or repurposed staff to help manage the care of high-risk patients, particularly with respect to providing patient education, monitoring the care of patients with chronic conditions, and providing follow-up after discharge from the hospital or emergency department. To improve patients’ access to care, practices worked on increasing patients’ use of patient portals, decreasing wait times for appointments, increasing telephone access to the practice, and increasing after-hours access to clinicians by means of e-mail, telephone, or in-person visits.”
All of these findings, from both articles written by both teams of researchers, about the original CPC, speak to the opportunities and challenges facing the participants in the new CPC+ program. Interoperability, communications among clinicians and patient care organizations, and refining workflows in order to perform the intensive data collection, measurement, and data reporting underpinning this program, remain huge challenges. And they speak to some of the core challenges facing all primary care practices in the United States going forward, whether they participate in CPC+ or not—the need to reengineer physician practice-patient communications, engage patients, and rework care management at some fundamental levels.
But therein lie many opportunities as well. What CPC program participants have been learning, and what CPC+ program participants will be learning going forward, could help reshape care delivery at the primary care level—the potential here is enormous. And healthcare IT leaders will need to be broadly and deeply involved at all levels, working as a team with clinician leaders and frontline clinicians to get it done. And, given the five-year framework of CPC+, you can bet we’ll be hearing about developments in this critical initiative going forward. Meanwhile, there’s not a moment to waste for the healthcare IT leaders and professionals working with the leaders of primary care practices involved in CPC+, in order to make rapid advances to show that it can be done. I’m excited by the prospects, and will be watching the forward evolution of this program very closely, in the coming months and years.