Featured in Electronic Healthcare Reporter Aug 2019
By Chris Jaeger, Advisor for ACO and Health System Strategy
In April 2019, CMS announced the Primary Cares Initiative which is expected to reduce administrative burdens and increase patient care while decreasing healthcare costs. Learn more about the payment models of the Primary Cares Initiatives, and how eConsults directly support this new initiative.
While the healthcare landscape has never been static, rarely has it seen such radical changes as within recent decades. The United States’ population continues to age, and the prevalence of chronic conditions such as obesity, diabetes, heart disease, and anxiety/depression contribute to a substantially increased demand for care. These factors are pushing a shift from a provider-centric model toward more efficient, outcomes-based models that put the patient at the center and heavily rely on primary care as the steward of patient care.
Primary care is a vital resource in dealing with the many factors altering the healthcare landscape. A 2019 study published in JAMA Internal Medicine corroborates this, finding that for every 10 additional primary care physicians per 100,000 people, patients saw a 51.5-day increased life expectancy—more than 2.5 times the increase associated with additional nonprimary care physicians. For years, primary care delivery has shifted along with changes in the healthcare landscape. Innovations in primary care and aligned incentive models reward more continuous and comprehensive healthcare, as opposed to care delivery and reimbursement models for discrete moments or episodes of care highlighted by numerous appointments and separate visits to different providers. These innovations strive to put patients at the center of care above all else.
To promote further adoption of primary-care based models, the U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) recently announced a set of payment models meant to further transform primary care through value-based options under the new Primary Cares Initiative. This voluntary initiative will test financial risk and payments for primary care physicians (PCPs) based on performance and efficiency, including five new payment models under two paths: Primary Care First (PCF) and Direct Contracting (DC). These models, slated to hit 20 states in the year 2020, seek to address the many difficulties in paying for, and incentivizing, valuable primary care within current payment models.
Primary Cares Initiative payment models aimed to PCPs
All five of the payment models described in the Primary Cares Initiative are aimed at PCPs in the hopes of improving services at these linchpins within the healthcare system. However, these models can be grouped into two distinct categories–Primary Care First and Direct Contracting–and there are variations within these groups.
Primary Care First
The models categorized under PCF are aimed squarely at relieving strained hospital resources and improving health outcomes through primary care. These models aim to more adequately reward primary care providers through performance-based payment adjustments, in the hopes that this will be an effective way to reduce the overuse of hospitals for healthcare needs. These two models are:
- Primary Care First (PCF): The general PCF model will test whether risk- and performance-based payments for primary care practitioners will reduce Medicare expenditures while preserving or improving quality of care. Under this option, payment will be provided to an advanced primary care site based on the size of its patient population (on top of a flat primary care visit fee), and adjusted based on performance within “easily understood, actionable outcomes,” according to CMS. The performance-based adjustment represents a potential quarterly upside of up to 50 percent of revenue as well as a potential small downside (10 percent of revenue).
- Primary Care First – High Need Populations: In addition to the general PCF model, the Primary Cares Initiative includes a payment model specifically geared toward practices specializing in care for high-need patient populations. This includes patients with chronic care needs and a group the model refers to as seriously ill populations (SIP). This payment model creates an option for high-need patients without a primary care physician to receive care from a participating practice if the patient indicates interest.
The Direct Contracting path includes a pair of risk-sharing payment models, both voluntary, along with a third payment model for which CMS is seeking public input. Like the PCF models, these models aim to reward those providing more efficient, high-quality care. However, these models are geared toward organizations with experience serving broader patient populations rather than individual primary care practices. The three models are:
- Direct Contracting – Global Population-Based Payment (PBP): Participants in the Global model will take on the full share of risk, but also be eligible for 100 percent of any savings achieved on the total cost of care for aligned beneficiaries.
- Direct Contracting – Professional PBP: Under the Professional model, participants will retain both savings and losses accrued on the total cost of care for aligned beneficiaries, but at a rate of 50 percent.
- Direct Contracting – Geographic PBP: The Geographic model is similar to the Global model, but with an important caveat: Participants would accrue 100 percent of savings or losses on the total cost of care, but only for aligned beneficiaries within a target region. The stated aim for this model is to drive accountability to a local level so that communities can develop strategies tailored to more individualized needs. CMS is still seeking input on this model, however.
Additional healthcare initiatives strengthening primary care
As mentioned above, primary care is a crucial avenue for fostering improved health outcomes for a wide range of patients and populations. In addition to increased life expectancy, some motivations for focusing on improved primary care include the following:
- Adults in the U.S. who have a primary care provider have 19 percent lower odds of premature death than those who only see specialists for their care.
- People who have a primary care provider save 33 percent on healthcare over their peers who only see specialists.
- A study in a North Carolina ER found that nearly 60 percent of the patients’ problems could have been addressed in a primary care clinic for a savings of 320 percent to 720 percent–that’s a value of a 3 to 7 times reduction in healthcare spend.
For many, primary care serves as the entry point to the healthcare system, as individuals and families alike head first to their primary care physician for treatment. Primary care emphasizes population health and managing chronic illness. As such, primary care is an ideal means for improving our healthcare system on many fronts including access, cost of care, and quality of healthcare services. Given the benefits listed above, it’s no surprise that so much attention has been paid to improve primary care, and the Primary Cares Initiative is not the first such effort. Programs such as the Patient-Centered Medical Home (PCMH), the Comprehensive Primary Care (CPC+) program, and Medicare Advantage Value-based Insurance Design (VBID) test model give healthcare stakeholders the means to promote triple and quadruple goals of allocating resources more efficiently, improving health outcomes, and improving the experience of all individuals involved–including both physicians and patients.
As its name implies, the PCMH is focused on putting patients at the center of healthcare. It recognizes the value of team-based primary care, and five core attributes are included in this model:
- Committed to quality and safety
Beyond PCMH is the CPC+ program, an initiative aimed squarely at care sites that have demonstrated significant improvement and transformation in pursuit of value-based goals. Payers are invited by CMS to participate in the program if they provide, or aim to provide, care practices that go beyond fee-for-service payments based solely on visits and episodic appointments. Through this program, CMS aims to work with payers representing 5 to 7 markets and accounting for roughly 525 practices (around 75 practices in each market). Some 330,750 patients would be reached by this initiative, which focuses on several functions for practices to achieve greater healthcare successes including:
- Access and continuity
- Care management
- Comprehensiveness and coordination
- Patient and caregiver engagement
- Planned care and population health
By their nature, Medicare Advantage (MA) plans seek to optimize the delivery of healthcare for their members. Receiving capitated payments to provide all Medicare-covered services to plan participants, plan objectives are the perfect setting to test models of care delivery that may reduce cost while being able to offer beneficiaries improved access, options, and quality of care–versus traditional Medicare plans. MA plans have proven to be more efficient in reducing expenditures than both Accountable Care Organizations (ACOs) and traditional Medicare. The Medicare Advantage Value-Based Insurance Design (VBID) model was introduced in 2017 by CMS to allow MA plans the opportunity to offer supplemental benefits or reduced cost-sharing for enrollees with certain chronic conditions who engage with services/providers that are of highest clinical value to them. CMS released major changes to the VBID model in January 2019, and plans to test new additions 2020 to 2024. The updates are intended to lower costs while increasing the quality and coverage of care for Medicare beneficiaries and include:
- Allowing customization of cost-sharing based on chronic condition, socioeconomic status, or both, including some non-health related benefits, such as transportation.
- Expanding eligibility to include chronic condition special needs plans (SNPs), dual eligible SNPs, institutional SNPs, and regional preferred provider organizations.
- Bolstering the rewards and incentives programs that plans can offer beneficiaries to take steps to improving their health.
- Increasing access to telehealth services.
Thus, the Primary Cares Initiative represents not just a single push to improve the healthcare system as a whole through primary care, but an overarching drive to do so via many initiatives and programs. Bringing more practices on board with initiatives such as the PCMH, CPC+, innovation within Medicare Advantage, and the Primary Cares Initiative will undoubtedly solidify the success of these and future programs, as stakeholders and policymakers come to a greater understanding of how to incentivize and create a path toward improved healthcare outcomes.
eConsults directly support Primary Cares Initiatives by maximizing primary care’s value in healthcare delivery
A continuing challenge in maximizing the efficiency and effectiveness of primary care is that of managing specialist referrals. Electronic consultations (eConsults) have gained favor in meeting this challenge. eConsults help in reducing variations in referrals, increasing access to specialist care and consultations among broader populations, and reducing wait times for specialist visits.
With the new CMS Primary Cares Initiative targeting advanced primary care practices for these payment models, eConsults are becoming increasingly valuable. Advanced primary care practices are defined as those that demonstrate an aim toward implementing fundamental strategies that focus on patient needs, with primary care as the foundation for maximizing value in healthcare delivery. These practices focus squarely on improving primary care in terms of health outcomes and lower costs. A key component of such advanced primary care practices is shepherding resources to improve efficiency and effectiveness in order to achieve their goals.
eConsults–which directly support improved health outcomes, reduced costs, and increased provider and patient satisfaction–are one such resource. As more health systems look toward creating PCMH models and consider adopting new value-based payment models under the Primary Cares Initiative to better manage the health of their patient population, eConsult systems will be instrumental in improving team-based care coordination and communication.