Can Medicare’s New Comprehensive Primary Care Plus Model Help PCPs to “Score” in the New Healthcare?

Oct. 5, 2016
CMS’s announcement last week of the new Comprehensive Primary Care Plus model sends a clear signal about federal healthcare officials’ intentions around physician payment

The announcement last week on the part of the federal Centers for Medicare & Medicaid Services (CMS) that the agency had created a new initiative, was a very important one. As HCI Senior Contributing Editor David Raths reported in his article on April 11, CMS “has announced a new initiative to transform how primary care is delivered and paid for in America. Building on the Comprehensive Primary Care initiative, the new Comprehensive Primary Care Plus (CPC+) model will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve.”

The agency said that it would provide participating medical practices with data on cost and utilization, and with a focus on healthcare IT. The program, CMS announced, would focus on supporting patients with serious or chronic disease to achieve their health goals; would give patients 24-hour access to care and health information; deliver preventive care; engage patients and their families in their own care; and work together with hospitals and with other clinicians, including specialists, to provide better coordinated care.

As Raths’ report noted, CMS has created two tracks, one involving the payment of a monthly care management fee to practices, and the other, in addition providing a monthly care management fee, and a hybrid of reduced Medicare fee-for-service payments, along with up-front comprehensive primary care payments for those services, in place of the usual full fee-for-service payments for evaluation and management services. Meanwhile, both tracks will provide upfront payments that they will either keep or repay based on their performance on quality and utilization metrics.

As Patrick Conway, M.D., CMS deputy administrator and chief medical officer said, in making the announcement, “Strengthening primary care is critical to an effective healthcare 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 healthcare system that results in healthier people and smarter spending of our healthcare dollars.”

I read all this with real excitement. First of all, this program is exciting in and of itself. It provides for the kind of support—both with regard to reimbursement incentives, and also in terms of providing practical supports for physician practices to engage in serious care management—that will give an additional push that will help finally convince many doctors who have not yet done so, to move forward at last into chronic care management.

Beyond that, CMS officials’ announcement of this program is yet further evidence—if anyone needed it—that those officials are, as they say, putting their money with their collective mouth is—in terms of pushing every policy and reimbursement lever they can, to push patient care organizations, and practicing physicians in particular, forward into care management, population health management, and new payment models. Along with the details of the MIPS (Merit-based Incentive Payment System), changes to the major accountable care organization (ACO) programs under Medicare, and other programs, this new one fills in one more area in which providers have needed help moving forward into the new healthcare.

As HCI Managing Editor Rajiv Leventhal noted in his Top Ten Tech Trends trend story on MIPS and MACRA (the Medicare Access and CHIP Reauthorization Act of 2015), industry experts see a lot of broad policy and payment hints in how the MIPS program has been architected. For example, he quoted Tom Lee, Ph.D., founder and CEO of Chicago-based consulting and software firm SA Ignite, as saying that providers can look at 2016 as a “dress rehearsal” year when it comes to MIPS, as 75 percent of the MIPS score in Year 1 will be from meaningful use and PQRS (Physician Quality Reporting System) quality, as measured by the value-based patient modifier (VBM), meaning that MIPS is absorbing into itself meaningful use and PQRS requirements that providers have been having to move to adopt in any case.

Leventhal also quoted Leslie Kriegstein, vice president of congressional affairs at the Ann Arbor, Mich.-based College of Healthcare Informatics Management Executives (CHIME), as noting that CMS is clearly pushing providers towards alternative payment models (APMs), as CMS officials have been saying more and more transparently of late. “I think in terms of long-term planning and preparations, you want to look at how you can ultimately transition into APMs, and not stick in the MIPS program, which is basically an aggregation of the existing quality programs,” Kriegstein told him. “In the near term, it’s about optimizing what you have on the books, and being aware how you’re doing in the existing meaningful use and PQRS programs, while digging into what CMS is thinking for clinical quality improvement.”

What seems clear is that CMS officials have been engaging with physician leaders and listening carefully to what they’ve been saying recently. And one thing that growing numbers of physician leaders have been saying (certainly not all of them, but at the very least, a very large plurality of thoughtful industry leaders who are physicians), is this: it may seem counter-intuitive, yet the fact is that, despite the massive grumbling by a considerably majority of practicing physicians in this country over the past couple of decades, physicians are among the entities in healthcare most amenable to modifying their behaviors based on reimbursement and policy incentives (and disincentives). And they have been looking for some time now for strong guidance from CMS.

And the Comprehensive Primary Care Plus program is exactly the type of federal program that offers enough of a combination of reimbursement and resource supports to push more practicing physicians into the active care management of Medicare patients with chronic illnesses. Haven’t we heard for years now from practicing physicians that it is a lack of reimbursement for care management activities that has kept them from participating in care management on behalf of their Medicare patients? Realistically, there are many tens of thousands of U.S. doctors who are not yet ready or willing to participate in ACOs or bundled payments, but who would be quite likely to seize the opportunity to receive both reimbursement and resource supports for participating in some very basic chronic care management activities on behalf of their patients.

And when one combines this new program with what is already happening under the MACRA legislation—that is to say, CMS giving physicians the option of either participating in MIPS or leaping into alternative payment models—the landscape around all this is incredibly clear: it is time for U.S. doctors to leave behind generic fee-for-service payment, and accept incentives that will push them into the new healthcare.

Physicians will need a heckuvalot of help with all this, including intensive help with clinical information systems (including clinical decision support tools), data analytics, and care management solutions, to make all this work. And once again, that fact really opens the door for healthcare IT leaders to become heroes. It is CMIOs, CIOs, and other senior healthcare IT leaders who can be major facilitators for practicing physicians who are in medical groups, including those owned by or affiliated with integrated health systems, who can be like the metaphorical college basketball coaches of would-be “Sweet Sixteen” NCAA teams—read here, practicing physicians in medical groups—urging their players to victory on the basketball court of medical practice. Perhaps extending the metaphor a bit further—maybe too far!—working together, healthcare IT leaders and senior clinician leaders can move teams of physicians forward in the way that the best point guards do—getting the ball to the right forwards and centers.

OK, so perhaps one could get too far into basketball metaphors here. But the simple reality is that healthcare IT leaders, working in concert with senior clinician leaders, have more of an opportunity than ever before to help position practicing physicians for success in the emerging new healthcare. And that goes doubly so for physician informaticists, who have a level of knowledge and of credibility with their fellow physicians, that is unparalleled.

The journey ahead is one that is inevitably going to prove challenging for practicing physicians. But the announcement of this new program on the part of senior CMS officials signals a new and meaningful inflection point in the forward evolution of the U.S. healthcare system, one that should not go unnoticed for all the many concurrent trends washing over the industry. Let’s all hope that CPC+ really does end up being a “plus” for physicians, and for their patients, as this is potentially a huge opportunity for advance going forward in the next few years.

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