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September 18, 2017

It's time for more multi-payer Medicare models, some providers argue

Daily Briefing

    Citing success under CMS' Comprehensive Primary Care (CPC) initiative, providers are urging the agency to pursue more multi-payer reimbursement models, arguing such models will better spur an industry shift toward value-based care than single-payer options, Virgil Dickson writes for Modern Healthcare.

    Exclusive Medicare Market Explorer tool: View Medicare share across services, patients, and physicians

    CPC details

    CMS in October 2012 launched CPC, under which participating health care providers receive payments from both commercial and government payers to provide care for more than 300,000 Medicare beneficiaries. Under the four-year program, which ended in 2016, CMS paid primary care practices participating in the program a monthly "management fee" that averaged $20 per beneficiary for the first two program years. The fee then declined to an average of $15 per month in 2015 and 2016.

    CPC by the conclusion of the third year generated a total of $57.7 million in savings just for Medicare expenditures alone, according to CMS.

    Providers report success

    Individual practices also reported success under the program, Dickson reports.

    For instance, after Kettering Physician Network's Integrated Medical Group in Ohio shifted from a fee-for-service to value-based care under the CPC initiative, the medical practice cut average monthly patient costs by 40 percent, from more than $1,200 per month to $725 in 2016; lowered ED use; curbed the hospitalization rate for patients with chronic illnesses; and cut costs associated with congestive heart failure by almost 50 percent.

    According to Katherine Clark, a family medicine doctor at Integrated Medical Group, said the practice was "able to use the revenue that came in through the program as seed money to begin to change our whole system's model of primary care." For instance, the practice used the payments it received in the program to hire a care coordinator, a health care coach focused on fostering patient engagement, and an RN. The practice was also able to sort patients by their medical needs and track patients' adherence to care instructions for chronic conditions.

    And Matthew Callaway, a family medicine specialist at SAMA Healthcare in Arkansas, said participating in CPC enabled his practice to prioritize preventive screenings and follow up on referrals.  In fact, with payments distributed under the program, SAMA was able to create care teams consisting of a care manager, doctor, and nurse. As Callaway put it, the payments under the program "gave us a little bit of teeth to track the patient better."

    Separately, Kevin Sears, executive director of Cleveland Clinic's market and network services, said the program also boosted data-sharing among providers and payers to help track and assist patients who used a lot of health care services. For example, he said the shared data enabled providers participating in CPC to quickly spot gaps in care, track when patients received care from other providers, and alerted them when a patient made an ED visit.

    Perhaps the greatest signal of providers' support for the program is that a majority of CPC participants—96 percent—have opted to participate in the next iteration of the program, CPC+, which began on Jan. 1, 2017, CMS said.

    The best way forward

    Providers say multi-payer models like CPC are the best way forward to shift toward value-based care, Dickson writes.  For instance, Richard Shonk, CMO at Health Collaborative, a not-for-profit that trained practices to participate in CPC, said, "It really doesn't work if there is a single-payer approach, simply because there isn't enough volume of any one payer in a primary-care practice to create the critical mass necessary to transform care."

    And Sears voiced similar support for multi-payer models over single-payer ones, saying, "It's much harder to [shift from fee-for-service to value-based care] when the expectations are fragmented among different payers" (Dickson, Modern Healthcare, 9/13).

    Market Scan: Review 4 primary care models for geriatric patients

    For providers with value-based reimbursement, "geriatricizing" primary care is an opportunity to help manage complex care needs and increase access to care for the elderly population.

    This market scan reviews four models for fixed or mobile primary care, including geriatrics clinics, providing primary care in assisted living facilities, forming house call programs, and an overview of strategies to geriatricize existing primary care practices.

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