W. Colorado Moves Forward on Primary Care Initiative, Payers Resist

April 10, 2013
Practices are in full preparation mode for the start of the Comprehensive Primary Care (CPC) initiative, the public-private partnership to strengthen primary care that the Centers for Medicare & Medicaid Services (CMS) Innovation Center launched on Aug. 22. However, there has been some resistance on the payer side to embark on shared savings/shared risk payment models.

Practices are in full preparation mode for the start of the Comprehensive Primary Care (CPC) initiative, the public-private partnership to strengthen primary care that the Centers for Medicare & Medicaid Services (CMS) Innovation Center launched on Aug. 22. However, there has been some resistance on the payer side to embark on shared savings/shared risk payment models.

A roster of 500 primary care practices from seven regions were chosen to participate in this initiative, which includes participation by CMS, state Medicaid agencies, commercial health plans, self-insured businesses, and primary care providers. This rigorous three-year initiative kicks off Nov. 1 and will include several pass/fail milestones.

As Patrick Gordon, director of government programs for Rocky Mountain Health Plans and Colorado Beacon Consortium (CBC) program director, says, the CPC initiative is a freeway, not an onramp, and the eight CBC practices (at nine sites) in western Colorado that are participating will be making broad-based, comprehensive transformation and payment reform a reality in primary care. Colorado has a total of 73 participating practices and 335 participating providers.

The CPC initiative will test two models simultaneously: a service delivery model and a payment model. CMS is not being overly prescriptive on how to achieve the initiative goals or on skill mix at the practice level, says Gordon, but patients must be able to communicate with someone at the practice 24/7 and practices must have direct access to EHRs and real-time data. The CMS' Medicare payment model will include fee-for-service, a monthly care management fee, and shared savings.

Many of the western Colorado practices are early electronic health record (EHR) adopters, having developed basic functionality like data use competencies, e-prescribing, and results delivery. Those practices will now have to adopt more sophisticated systems with robust reporting functionality to leverage the clinical data collected to drive practice improvement.

“It’s likely, as it is in many of the western Colorado practices, that in addition to EHR support, they are going to need to adopt other advanced tools to support the population health management and care coordination functions of the program,” says Gordon. “So specifically, [they will need] patient registry support, risk stratification tools, patient engagement tools, and so on. I think there will be several good examples of how the skills, data use competencies and the technological tools will come together in this program to improve patient care.”

Care Coordination Capabilities Needed

Glenn Kotz, M.D., solo-practitioner at MidValley Family Practice, one of the CPC initiative sites, says “the basic EHRs need to beef up their processes.” He adds that the federal government has not mandated that EHRs perform specific patient-centered medical home processes. “That information, that kind of process within the EHR, all the vendors need to spend a lot money to get what we need in there,” Kotz adds. “We need more care coordination templates or workflows. Our biggest first step is going to be how do we get consults or data in from outside sources, and push it into our EHR in a way that makes sense for us to process that.”

Many of the western Colorado practices are working to develop their own patient registries, and also receive additional data available to them from western Colorado’s health information exchange, Quality Health Network (QHN). Gordon says that QHN will be deploying registry functionality with aggregated practice-level and community-wide data.

“Another area in which the practices are adopting additional support is in the realm of predictive modeling and patient risk stratification,” says Gordon. “In our community we are deploying the Archimedes tool, and a small but growing number of practices are implementing that tool and developing competency.”

Kotz’s practice already uses an EHR (the Centricity Practice Solution from the Waukesha, Wis.-based GE Healthcare) and uses Clinical Content Consultants (CQIC) templates and forms. His practice will be implementing the Crimson (from the Washington, D.C.-based The Advisory Board Company) and IndiGO (from the San Francisco-based Archimedes) products to help enhance care coordination. He also plans to make enhancements to his patient portal to help activate patients.

Culture Shift Necessary to Move Payers Toward Risk-Based Payments

As part of the CPC initiative, CMS has set general parameters to create a baseline for the payment model being tested, with primary care practices receiving an upfront, non-volume based care management fee, initially set at $20 per beneficiary per month, which will allow them to integrate and strengthen their capacity to implement practice-wide quality improvement on behalf of Medicare fee-for-service beneficiaries. Beyond that, practices will develop their own shared savings and gain sharing opportunities and arrangements with private payers.

“As we move forward, we will move from basing our risk adjustment on traditional methods, to practice-based methods like where the practice-based system is generating the risk stratification,” says Gordon, whose employer Rocky Mountain Health Plans is taking part in the initiative. “We’re accepting those scores because they’re credible and highly predictive; and we’re basing our payments on that model, rather than our claims history exclusively.”

There are seven private payers in western Colorado participating in the initiative; however, both Gordon and Kotz agree that a cultural change will be necessary to get to a tipping point.

“The insurance companies really need to have that cultural change to come the table and [realize] that primary care is underpaid,” says Kotz. “That’s going to be like the atomic bomb going off in their organizations; and if they don’t do it, this will fail.”

Kotz says in the first two years his practice will have a mixed payment model, with a care management fee, as well as fee for service. The next two years will involve shared savings/shared risk arrangements. Kotz admits it’s been a painful process getting payers on board to collaborate in this initiative.

“Until the healthcare system accepts the fact that transformation is a lot of work, and we need to continue to have coaches, that financial support for all Beacons around the country and all coaching around the country needs to continue,” concludes Kotz. “Unless the [IT] systems are mandated the system will be fragmented still.”


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