This spring, CMS thrust primary care into the spotlight. The same day CMS announced its new Primary Cares Initiative, a third-party research institution it hired to evaluate the Comprehensive Primary Care Plus (CPC+) initiative released its First Annual Report of the ongoing primary care transformation program. Before we start drawing comparisons between the two programs, here are four things we learned from the first year of CPC+:
1. Data is inconclusive on change in utilization, cost, and quality outcomes
Analysis revealed that ED service use and growth in the primary care visit rate both slowed among CPC+ practices as compared with non-CPC+ practices (by 1.2/1.6% and 1.6/1.8% for tracks 1/2, respectively), per-member-per-month costs increased (by $18/$27), and quality results were mixed and mostly insignificant.
While these outcomes may seem like a strike against CPC+, they are consistent with other studies evaluating primary care transformation, especially in early stages. The literature evaluating the Patient-Centered Medical Home (PCMH) model, for example, demonstrates stronger impacts over time. And for CPC+, the researchers stipulated that having only one year of data prevented them from drawing any conclusions. So, if your practices aren't showing quantitative returns after one year, don't assume your model isn't working.
2. Even with funding aside, CMS guidance drives primary care transformation
One of the things holding organizations back from transforming primary care is not knowing where to start. Which investments will realize meaningful change? Which will see an ROI? The data show that simply having CMS lay out a roadmap to transformation is enough to inspire some organizations to make the necessary investments.
Track 2 of the CPC+ program carries heavier requirements for transformation, backed by stronger financial support. But the data reveal that even track 1 practices are investing in some track 2 requirements that contribute to holistic, patient-centered care. For example, practices participating in track 2 are required to use data to risk stratify their patients, screen for unmet social needs, and integrate behavioral health. However, researchers found that, for each of these imperatives, 79%, 71%, and 85% of track 1 practices, respectively, were investing in or offering these services—despite the fact that those services aren't required or financially supported in track 1.
3. Providers are incorporating social needs into care—but not systematically
Providers are showing greater interest in addressing social determinants of health, but they struggle to actionably incorporate social factors into care infrastructures. The majority of CPC+ practices (71%/85%) provide universal or targeted (e.g., for high-risk only) social needs screening. But practices say it's difficult to track social needs over time—even when screening tools are integrated into EHRs. Additionally, social needs are typically omitted from algorithms providers use to risk stratify patients. Instead, social needs are the most common factors informally incorporated into risk stratification as part of "clinical intuition." Finally, while most individual practices report having access to a reservoir of available community resources, these reservoirs aren't typically shared. This means that staff are duplicating efforts across practices, which may undercut productivity and lead to avoidable service gaps.
To efficiently use the information they're already collecting, organizations should standardize internal practices around storing social needs information. This approach could mean training all staff to enter patients' social needs-related information in a certain place in the EHR or creating a living resource reservoir shared among multiple practices. IT capabilities around social determinants may catch up to practice needs eventually, but, in the meantime, organizations need to take matters into their own hands.
4. Integrated behavioral health is already the norm (among transformation practices)
With access to specialty behavioral health care limited across the country, there is widespread uptake of the integrated behavioral health model in most CPC+ practices. Overall, 97% of track 2 practices and 85% of track 1 practices are currently integrating or have plans to integrate behavioral health. The most common way organizations do this is by including a specialist, such as a psychologist or social worker, on the care team (13%/36%). However, while practices are increasingly trying to collocate these team members in the office, the provider shortage makes it difficult to achieve. The other common integration approaches include having PCPs deliver behavioral health care (36%/32%), and referring patients to specialists (24%/16%).
Follow these 4 strategies to overcome the behavioral health access challenge
Though it may be too early for researchers to predict the long-term impacts of CPC+, it’s not too early to isolate the factors that differentiate struggling practices from those that are readily transforming. Based on these factors, we'll identify in an upcoming post three areas that are imperative for organizations looking to succeed in primary care transformation. Stay tuned.
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