Purva Rawal, Ph.D., on Why Primary Care is Key to CMMI’s Goals

May 18, 2023
“We can’t work on things like specialty integration, coordination, behavioral health — the other big challenges facing us — without us really strengthening primary care as our foundation,” says chief strategy officer of CMMI

Speaking to a May 18 meeting put on by the advocacy group Primary Care for America, Purva Rawal, Ph.D., chief strategy officer at the Center for Medicare and Medicaid Innovation, described why primary care is so central to the overall transformation of healthcare.

Rawal said CMS’ first key objective is to drive accountable care. Its goal is to have 100 percent of its Medicare fee for service beneficiaries in accountable care relationships, the foundation of which is an advanced primary care relationship, whether that's in an advanced primary care practice, or in an ACO with advanced primary care practices.

The second objective is health equity. “We really view value-based payment as an enabling mechanism and a key mechanism for advancing equity,” Rawal said. “It's really difficult to do under traditional fee-for-service incentives that don't necessarily unlock access and redirection of resources to places where we've had historical under-investments.” She said CMMI has already started to design and redesign models to be able to use all the levers that it has available to try to redirect those resources and advance equity including in its ACO REACH model. “We can't really achieve those objectives and vision without a strong primary care system. We can’t work on things like specialty integration, coordination, behavioral health — the other big challenges facing us — without us really strengthening primary care as our foundation.”

Rawal was asked about how CMMI is thinking about the integration of behavioral health into primary care. “We have had a long history in our primary care models of testing different facets of behavioral health integration to varying levels of success,” she admitted. “But we've had a lot of learnings there. We've been thinking a lot about behavioral health integration, but in a progressive way. When you have practices that might be newer to value, safety net providers, they may not have the care delivery infrastructure, the capability, the team-based infrastructure yet to really address folks’ behavioral health needs. How are we supporting practices in increasing their ability to address behavioral health all the way up to behavioral health integration? We need to make sure we're giving people the upfront support that they need, and then moving them to more stable revenue structures that allow them to integrate key members of the team that can help address behavioral health issues.”

She said CMS also can start to use quality measures to start to move in that direction. “We're also thinking about future models in the behavioral health space that focus on community-based behavioral health providers.” She noted they have not yet had a model targeting community-based behavioral health providers. “As a former psychologist, I had a lot of patients that had a number of chronic disease issues, but their primary issue was that they had moderate to severe behavioral health issues. They were presenting first in the psych ER or in one of our outpatient psychiatric clinics, and their physical health needs weren't being met. One of the things we needed to do was connect folks back to a primary care doctor to make sure that their hypertension, and diabetes were also being taken care of,” she said. “So I think we need to create more of those bi-directional linkages and make sure that no matter where someone is presenting, we've set up the incentives in the system for their needs to be met.”

Looking ahead at the rest of the year, Rawal said CMMI’s goal is to announce three to four new models. “It takes 18 to 36 months to design a model and we kicked off our new strategy just about 18 months ago, so stay tuned,” she said. “The heart of the strategy is around accountable care and equity. I think between the Enhanced Oncology Model and the changes we made to ACO REACH, you get a nice blueprint for how we are going to approach model design. We have a huge focus on increasing safety net provider participation by FQHCs in our models, so hopefully in the near future we'll be able to announce a new advanced primary care model that's really focused on equity, increasing safety net participation, and supporting more providers in entering value-based agreements.”

A little over a year ago, CMS leaders released a paper about using the Medicare Shared Savings Program as a chassis for innovation. “We're thinking about future ACO model opportunities that strengthen primary care, move to hybrid payment models, and increase investments in primary care,” Rawal said. “We also have more coming in the specialty space. There are some areas where ACOs right now are not in the best position to take care of certain specialty conditions, so we're going to continue to look at some specialty specific models that hopefully test new care delivery pathways that can be scaled into global total-cost-of-care approaches as well. Dementia is one space in particular that that we're really interested in and the it's a priority for the administrator and CMS.”