Early Results from the CMS Innovation Center's CPCi

The Comprehensive Primary Care Initiative, launched last fall by the Centers for Medicaid and Medicare Services (CMS) Innovation Center, offers an opportunity for health plans, providers and CMS to work together on a community-based and integrated approach to health management. Preliminary year-one results for the Comprehensive Primary Care initiative appear to be positive, Managed Care Executive reports.

It looked at several CPCi sites, including Colorado. Patrick Gordon, associate vice president of Rocky Mountain Health Plans, the technical assistance contractor for CPCi on the Western Slope, shared some insights. It's a tough program, he says, but "nobody has thrown their hands up and said 'this is too much. In Colorado, a “very high percentage” of providers are meeting milestones and none of the 74 primary care practices or 369 providers in Grand Junction have exited the program.

Participants report that while aligning payment incentives is important, the real value of the Comprehensive Primary Care Initiative might be getting providers, payers, and government agencies to collaborate on pathways for information exchange.  Payment reform cannot be accomplished, nor will it solve the problems of our health care system, unless greater data exchange capabilities can be achieved.

500 Primary Care Practices Announced for CMS Innovation Center Initiative

The CMS Innovation Center has selected five hundred primary care practices in seven geographic areas to participate in the Comprehensive Primary Care initiative. This represents over two thousand primary care doctors and nurse practitioners in seven markets across the country. NBCH has member coalitions in six of these seven geographic areas.

Under the Comprehensive Primary Care Initiative, CMS will pay primary care practices a care management fee to support enhanced, coordinated services on behalf of Medicare fee-for-service beneficiaries. Simultaneously, participating commercial, state, and other federal insurance plans are also offering enhanced payment to primary care practices that are designed to support them in providing high-quality primary care on behalf of their members.

This four year public-private partnership is designed to test a model of improved access to quality health care at lower costs by aligning public and commercial insurance payment. The 500 practices were selected through a competitive application process and will start delivering enhanced health care services this fall.

Many Americans See Specialists For Primary Care

Two in five adults in the U.S. are getting general health care from specialist doctors, according to a new study showing that figure held steady for nearly a decade.  Researchers found that in 1999 and 2007, approximately 59% of visits in the U.S. for primary care were to family physicians. The other 41% were to specialists, such as internists and obstetricians-gynecologists.

There is evidence that in health care systems where primary care doctors are the first point of contact, patients see better outcomes, according to the study's lead author.  A study from 2011, for example, found that seniors living in areas with more primary care doctors were less likely to be hospitalized with a preventable disease and had lower death rates.

On top of quality concerns, another issue is cost. A 2010 study found that primary care doctors earn about $60 per hour, which is much less than the $92 per hour and $85 per hour rates for surgeons and ob-gyns, respectively.

The researchers write in the Archives of Internal Medicine that there can be a few reasons people turn to specialists over family doctors for primary care. One may be a belief that specialists are better at treating specific conditions. Another reason may be that a shortage of family doctors in the U.S. drives people to specialists.

The 2010 health care reform legislation, the Affordable Care Act, contains provisions directed at alleviating that shortage, including incentives for doctors to choose to specialize in primary care.

The Cost-Saving Benefits of Direct Primary Care

This Forbes article describes the concept of Direct Primary Care (DPC), including its cost-saving benefits for employers. Proponents of DPC state that the best way to pay for healthcare is to pair DPC with a high-deductible wraparound policy. The idea is you use insurance what it's best for — rare items (house fires, cancer, major car accident). For day-to-day healthcare, DPC is paid for in a model that is akin to a gym membership — a flat monthly fee regardless of how much one uses it (though some have co-pays mainly due to state insurance regulations).

DPC is explicitly named as a potential type of Qualified Health Plan in the Affordable Care Act (section 1301(a)(3). The author argues that health plans should be seriously considering DPC when they think about their health insurance exchange strategies because the plans themselves can be relatively affordable for individuals. There are also good reasons for employers to look at DPC as a potential coverage option because it has the potential to keep rising health care costs in check, especially for younger and healthier populations.  

CMS Finalizes CPCi Agreements with Payers

In a strong show of support for more effective, more affordable, higher quality health care, 45 commercial, federal and State insurers in seven markets today pledged to work with the Centers for Medicare & Medicaid Services (CMS) to give more Americans access to quality health care at lower cost.

Under the Comprehensive Primary Care initiative, CMS will pay primary care practices a care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services. Simultaneously, participating commercial, State, and other federal insurance plans are also offering an enhanced payment to primary care practices that provide high-quality primary care.

Insurers in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley Region, Ohio’s and Kentucky’s Cincinnati-Dayton Region, and greater Tulsa, Oklahoma signed agreements with CMS to participate in this initiative. The markets were selected based on a diverse pool of applicants from commercial health plans, State Medicaid agencies, and self-insured businesses who hoped to work alongside Medicare to support comprehensive primary care.

In order to receive the new care management fee from CMS and insurers, primary care practices must agree to provide enhanced services for their patients, including offering longer and more flexible hours, using electronic health records; delivering preventive care; coordinating care with patients’ other health care providers; engaging patients and caregivers in managing their own care, and providing individualized, enhanced care for patients living with multiple chronic diseases and higher needs.

The list of insurers in each market can be found on the CMS Innovations Center website.

Direct Primary Care Offers Employers New Wellness Option

A New York Times article profiles Becker Trucking's decision to pay $54 per employee per month to a primary care provider called Qliance. Employees get unlimited doctor visits, 24-hour e-mail access to the medical staff, and same-day or next-day appointments. There is no insurance involved in their primary care: no expensive premiums, no complicated claims, no mysterious denials. This type of health care model is called direct primary care, and it is getting a closer look not just from businessmen like Mr. Riordan, but also from researchers and government officials who see it as an effective way to lower costs.

Direct primary care derives from an unlikely source: the so-called concierge practices that began appearing a decade ago, catering primarily to the affluent. But this is more like concierge medicine for the masses. The idea is that routine, mundane primary care should not require expensive insurance and can be cheaper without it. Direct primary care practices charge $50 to $60 a month for adults, with lower fees for children. Depending on the practice, the monthly fee also may cover certain lab tests, basic X-rays and stitches for cuts.  But the fee does not cover anything beyond primary care. Typically employers combine direct primary care with high-deductible insurance plans, needed to cover hospitalizations and visits to specialists.

Even though Becker pays Qliance for primary care and pays half of each worker’s $5,000 annual deductible for insurance, the company’s costs dropped 11 percent in 2010. Costs had been rising about 14 percent annually.  Doctors who work for Qliance are salaried reducing the financial incentive to order unnecessary tests. Direct primary care practices keep costs low by sidestepping the bureaucracy associated with insurance and reducing unnecessary and expensive trips to the hospital or emergency room.  Direct primary practices are also less likely to refer to a specialist for something they can handle themselves.

Such practices already operate in 24 states, treating more than 100,000 patients, according to the Direct Primary Care Coalition.

Seven markets chosen for CMS Comprehensive Primary Care initiative

Today the CMS Innovation Center announced it has tentatively selected for implementation of the Comprehensive Primary Care (CPC) initiative seven markets from a pool of applicants. These markets are multi-payer and may include private health plans, state Medicaid agencies, and employers:

• Arkansas: Statewide
• Colorado: Statewide
• New Jersey: Statewide
• New York: Capital District-Hudson Valley Region
• Ohio: Cincinnati-Dayton Region
• Oklahoma: Greater Tulsa Region
• Oregon: Statewide

The participating payers in each market will be entering into a Memorandum of Understanding with CMS. Once the participating payers in each market have agreed to the terms and conditions of this MOU, the Innovation Center will then release a solicitation to primary care practices in these geographic areas wishing to participate in providing comprehensive primary care as part of this initiative. Approximately 75 primary care practices in each designated market will be selected to participate.

CPC is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients.