The idea of improvement or transformation always begins with the end in mind; a refocus on the broad objective of the system. The Centers for Medicare & Medicaid Services (CMS) recently announced a strategy, “Primary Care Initiatives”, that will refocus our healthcare system on patient-centered services by aligning payment models to outcomes. This is one of the bolder steps our administration has taken to put reality to the vision of value-based care.
General Approach
This strategy targets what has been regarded as the foundation of our health care system: Primary Care. Historically, this setting has received limited attention and recent statistics tells us it only accounts for 2-3% of our health care spend. This is changing. Rather than looking to sub-optimize parts of the system, making an informed decision to focus on what is believed to be the most impactful variable is now the focus. Preliminary information indicates the strategy leverages learnings and successes from other primary care initiatives (CPC+, ACO, DPC) and is aligned to other existing payment models. The Secretary of Health and Human Services, Alex Azar II, notes how Direct Primary Care has caught the attention of the nation by creating service delivery that is convenient, accessible primary care from a provider they know at a predictable and affordable cost.
Having a system composed of the right pieces is important, but one must not forget the interrelationships between the elements that ultimately creates the desired outcome. While the previous paragraph focused on a single system element (the primary care setting), CMS also wants to see improved capability of handling different types of patients. Today, our system largely struggles with providing the right amount of services to the various types of patients that flow through our system. CMS has focused this strategy on the most vulnerable in our nation, the complex and seriously ill population (SIP).
Model Overview
Primary Care Initiatives will focus on patient care access and care continuity, care management, care coordination, patient and caregiver engagement, planned care and population health management (Note: close resemblance to three of for NCQA’s PCMH requirements; see table below). CMS has created multiple paths to meet practices where they are and accelerate transition of the 65% of our Medicare spend that is still fee-for-service. Rather than being paid a fee for each medical service provided, this is a capitation model: providers will receive a sum of money upfront to manage the health of their population, a flat fee-for-service with each visit and significant bonus payments if patients stay out of the hospital. Smaller practices (125+ beneficiaries) will look to the “Primary Care First” tracks to evaluate if transformed care reduces the total cost of care by adopting a risk-sharing agreement. Larger practices (5,000+ beneficiaries) will use the “Direct Contracting” tracks based on the level of risk-sharing with the “Professional” track at 50% and “Global” at 100%.
Reproduced with permission from NCQA PCMH Standards and Guidelines (2017 Edition) by the National Committee for Quality Assurance (NCQA). To obtain a copy of this publication, visit www.ncqa.org/publications or contact NCQA Customer Support at 888-275-7585.
“Change is possible, change is necessary, and change is coming” –Alex Azar II
CMS has set the stage of mutuality by creating the opportunity to not only partner with, but financially incentivize those practices that are looking to help in the effort of moving our nation toward customer-defined health care systems. In addition, here are five added benefits:
Participation Benefits
- Connect to purpose by being able to focus on the ones that need you the most
- Reduced burden through reporting a limited set of quality metrics
- Leverage existing improvement work by knowing requirements align with existing programs
- You decide what level of risk-sharing is right for you
- Give your patients the best care through benefit enhancements
It is important to identify and manage risk with capitated payment models. We have been pioneers in the Direct Primary Care space by supporting practices in managing their risk through population health management. Through our partnerships, practices have witnessed improved clinical outcomes, access, utilization and cost savings. This is an evolving area with more information to come. Regardless, we feel well-suited to support practices who want to explore this risk-sharing agreement based not only on our past experience and success in this area, but also, because it directly aligns with our road map of seeking PCMH pre-validation status and more.
The Direct Care model prides itself on offering more ways for patients to access their primary care provider. In the fee-for-service world, most people need to schedule an appointment (often weeks in advance), visit an urgent care clinic, go to the emergency room, or utilize telemedicine to immediately access care, the latter three often being with different providers who don’t have an established relationship with a patient or don’t have access to a patient’s history. Direct Care providers, however, often utilize some form of virtual communications technology that allows patients to text, email, or directly call a practice representative at any time of the day, making it quick and simple for patients subscribing to a Direct Care plan to access their provider.
