The Definitive Blog

CMS Gambles on Major Expansion of Comprehensive Primary Care Initiative

In 2012, CMS’ Innovation Center launched the Comprehensive Primary Care (CPC) initiative, a four-year pilot testing physician groups’ and payers’ ability to create the ideal patient-centered medical home (PCMH). Like most of CMS’ experiments with new payment and delivery models, the program so far has produced mixed results and earned more than a few critics. Even the center’s own reviews are expressly cautious. But with the end of the initiative approaching, CMS has decided to expand the model tenfold into what it calls Comprehensive Primary Care Plus (CPC+). The program could potentially include up to 5,000 physician groups and 25 million patients, making it one of the largest CMS Innovation models after the Medicare Shared Savings Program.

Though the data for all four years of the original care pilot have not yet been compiled, enough exists to question how effective CPC+ will be. The original program employed a monthly care management fee system, in addition to standard reimbursement, to support practices’ efforts to reduce utilization and costs. After two years, participating offices reduced Medicare expenditures by $11 per beneficiary per month, which CMS calls statistically significant but represents only a one percent decline. And while outpatient visits dropped slightly, declines in hospital admissions were insignificant. The lack of strong performance was one reason why Cigna, which participated in the pilot in Colorado, suggested that CMS not expand the program, commenting in a letter that its own accountable care initiatives produced better outcomes and that “continuing CPC would be a crutch to providers” by discouraging them from joining more effective pay-for-value arrangements.

Simplified results from Dale, et all., “Two-Year Costs and Quality in the Comprehensive Primary Care Initiative”

Despite the modest results of CPC so far, CMS has pushed ahead with the CPC+ model, which addresses some of the problems that arose in the pilot. The lack of useful data infrastructure inhibited many practices from effectively managing patient populations, so the new program will offer prepaid incentives rather than shared savings to encourage adoption of better IT systems and data sharing between payers and providers. The incentives must be repaid to CMS at the end of each performance period if physicians fail to meet clinical quality and cost benchmarks, playing to the loss-aversion strategy that may prove more motivating than a potential reward given later in the year. In addition, physician groups that select the Track 2 option, which is designed for practices experienced in care management and offers greater rewards, must acquire a non-legally binding statement from their vendors indicating their commitment to support their clients’ IT improvement efforts. Even so, effective communication and data sharing between providers and payers is expected to be a continuing challenge given that multiple parties must agree on vendors, capabilities, and data priorities.

The two-track structure of the program also offers greater flexibility for participating physician groups. Track 1 reimburses physicians on a regular fee-for-service basis, combined with a monthly care management fee and prepaid performance-based incentives. CMS expects this track to be budget neutral over the course of the five-year program and designed Track 2 to be more lucrative for practices in exchange for taking on more responsibilities. Though they receive higher care management and incentive payments and are allowed to use a more flexible reimbursement model, Track 2 practices are expected to manage a wider variety of services beyond primary care (such as behavioral health), employ a more thorough method of patient risk stratification, and offer a higher level of care management services. CMS hopes to attract the greatest interest in Track 2, which it expects could reduce spending by up to two billion dollars.

Even if CMS’ financial estimates don’t come to fruition, CPC+ will likely boost physicians’ experience with care management and drive closer collaboration between stakeholders, both critical aspects of today’s changing health system. It also creates an opportunity for vendors to demonstrate how their products lead to greater efficiency, reduce costs, improve patient outcomes, or otherwise help physicians and payers meet increasingly value-driven goals. It’s entirely possible that the program’s success may not just be defined by money saved, but how its participants rise to the challenge.

Definitive Healthcare has the most up-to-date, comprehensive and integrated data on hospitals, physicians and other healthcare providers. Our physician group database tracks over 186,000 physician groups and includes members, affiliations, procedure volumes, technologies utilized, and much more.

Related Posts