CMS primary care project not for the timid

A multi-payer initiative aimed at improving care management and controlling costs by boosting the role of the primary care provider is showing promise just one year in. The Comprehensive Primary Care Initiative, launched last fall by the Center 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.

Under the four-year project initiative, primary care practices are reimbursed with a per-beneficiary, per-month management fee of a national average of $20 so they can take the lead in coordinating care across the medical neighborhood. Forty-three payers in seven regions signed on to invest in the program, which also requires a significant data-sharing component.

In the third and fourth years of the project, the CMS management fee drops to an average of $15. By that time, however, providers and payers will have the chance to share in any Medicare savings. CMS cites studies that show it costs less to provide healthcare to patients through primary care practices with comprehensive services.

CMS chose 497 primary care practices in Arkansas, Colorado, New Jersey, New York, the Cincinnati-Dayton region of Ohio and Kentucky, the Tulsa region of Oklahoma, and Oregon. A total of 2,347 participating providers serve about 315,000 Medicare beneficiaries.

Patrick Gordon, associate vice president of Rocky Mountain Health Plans based in Grand Junction, Colo., says the initiative provides the opportunity to leverage its prior efforts to boost competencies among its providers, which were carefully selected for their ability to manage patients with high needs, ensure access to care, and engage patients and caregivers, among other criteria. He says he sees “several measures of success” of the initiative, but admits the requirements for providers are hard work. Likewise, providers must adhere to complex reporting requirements and form patient advisory committees for feedback.

“They are being asked to implement an entirely new financial system, account for revenue, develop a budget and think of business operations in a very different way,” Gordon says. “It’s very different for your average primary-care provider.”

Such hurdles aside, he says, a “very high percentage” of providers are meeting milestones and none of the 74 primary care practices or 369 providers in Grand Junction exited the program.

To help providers, Rocky Mountain Health Plans brings practices together quarterly in a community learning collaborative to talk about their experiences, work through barriers, offer training, and help motivate them. The healthcare community has long been recognized as a leader in patient-centered medical homes and care collaboration, but Gordon says the CMS project is different.

“Many practices are receiving very significant funding, but it is really hard,” he says. However, “nobody has thrown their hands up and said ‘this is too much.’”

In Tulsa, Okla., the MyHealth Access Network information exchange launched in 2010 and has helped to link payers to accomplish the tasks required by the CMS initiative.

Carter Kimble, Oklahoma Health Care Authority public affairs representative, says the initiative aligns incentives for electronic records, payment models and care coordination, with an emphasis on dual-eligible members. The model moves away from a traditional fee-for-service payment and streamlines the care coordination process, enabling the primary-care provider to be paid for time spent following up after specialty appointments, checking that pharmacy benefits are managed correctly, and verifying that patients are following treatment plans.

“We think aligning payment models with our coverage partners in the marketplace is smart dollars. It makes too much sense to ignore,” Kimble says. “Having said that, it’s too early in the game for us to really see what has come from it.”

In Tulsa, the per-beneficiary, per-month payment ranges from $4 to $8 depending on the characteristics of each patient. High-needs adults and children typically generate higher fees, he says.

The real value of the Comprehensive Primary Care Initiative might be getting providers, payers and government agencies to collaborate on pathways for information exchange. Gordon says it’s the first of its type in which Medicare, Medicaid and multiple payers collaborate, and it requires a “very robust data sharing” among the seven markets.

“The payers and the government programs are literally going to be sharing their data and sharing in the cost of data sharing,” Gordon says. “Outside of a few arcane projects, CMS has never shared data or participated collaboratively.”

Providers must be able to access data in order to hit milestones and determine where they stand on a normalized basis, he says.

“As payers and investors, we need them to achieve measurable results. We know it’s going to be much, much more difficult for them to do that if they can’t access the data they need efficiently in one place.”

And it’s a significant undertaking for CMS and the participants.

Gordon and Kimble agreed that the collaborative effort seems to be working to save the system money and improve healthcare for patients.

“I’m convinced, having seen the inner workings of it, that, while it may not be perfect, it’s got very valid merit in going forward,” Kimble says.

Primary care is the key component to a higher performing healthcare system as a whole. Larger reforms won’t be effective unless primary care functions well, Gordon says.