By Deborah Peikes, Stacy Dale, et al (Mathematica Policy Research and Center for Medicare and Medicaid Innovation)
Health Affairs, May 23, 2018
The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative’s effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.
From the Introduction
Public and private payers are increasingly experimenting with ways to improve primary care delivery, reduce spending, and improve patient outcomes. Payers are also considering ways to strengthen primary care. New primary care models, such as the patient-centered medical home, have had mixed effects on quality and spending.
The Centers for Medicare and Medicaid Services (CMS) launched the Comprehensive Primary Care Initiative (CPC) in October 2012. CPC tested whether requiring practices to implement a new approach to delivering primary care, and providing financial and technical support to help them do so, reduced spending and improved quality over a four-year period in 502 practices across seven US regions. In addition to CMS, thirty-nine other private and public payers supported CPC practices by implementing an aligned approach to changing care delivery and payment.
This article provides an update to earlier evaluation results of the first two years of CPC.
EFFECTS ON SPENDING AND SERVICE USE
Our estimates showed no significant differences in spending growth during CPC, with or without care management fees.
EFFECTS ON QUALITY OF CARE AND PATIENT EXPERIENCE
Over the course of CPC, we found no significant effects on the claims-based quality-of-care process measures for beneficiaries with diabetes or on the continuity-of-care measure, defined as the percentage of primary care visits that occurred at the practice that the beneficiary was attributed to when CPC began.
EFFECTS ON PHYSICIAN EXPERIENCE
Physicians in CPC practices had largely favorable views of CPC in 2016. However, many indicated that CPC’s administrative reporting was a burden and the transformation work was difficult.
Although CPC required intensive work for practices, we found no meaningful differences on measures of burnout, control over work, alignment of work with training, and job satisfaction between physicians in CPC practices and those in comparison practices in 2013 or 2016.
From the Discussion
Practices participating in the Comprehensive Primary Care Initiative improved some aspects of care delivery, which in turn led to less growth (relative to comparison practices) in numbers of ED visits and thirty-day ED revisits among fee-for-service Medicare attributed patients. However, the four-year initiative did not reduce Medicare hospitalizations or reduce Parts A and B spending enough to cover care management fees. There were no appreciable improvements in patient experience, claims-based quality of care, or physician experience, except that patients reported more follow-up care after hospitalizations and ED visits. Beyond the reduction in ED visits, the additional two years to transform care delivery did not substantively alter the earlier results from midway through the initiative.
Results from CPC illustrate how hard it is to reduce Medicare spending. There are several potential reasons why the findings were not more favorable. First, primary care practices might need stronger value-based financial incentives, accompanied by strong and consistent incentives for other providers (such as specialists and hospitals) that care for the same patients.
Second, some participating practices reported facing barriers to improving care delivery (for example, the burden of reporting, potentially limited actionability of data feedback, insufficient health information technology support for care delivery, and poor health information exchange) that may have made implementation of the initiative less robust than it might have been without such barriers.
Third, general care delivery improvements by comparison practices and other providers—for example, in response to Medicare’s financial penalties for high readmission rates—could have made it challenging for CPC practices to improve their outcomes relative to those of comparison practices.
CPC+ aims to improve on these outcomes by building several new elements on the same foundation of multipayer support and five primary care functions. First, CPC+ introduces a second track that deepens care delivery requirements for practices with more experience in delivering advanced primary care.
Second, CPC+ further moves away from traditional fee-for-service by providing a hybrid payment for practices in the second track (combining a portion of fee-for-service and global payment for evaluation and management services).
Third, CPC+ strengthens incentives. It replaces shared savings with a prepaid bonus that practices must repay if they do not meet practice-level performance targets.
Finally, CMS partners with health information technology vendors to encourage improvement in health information technology functionalities to support practices in meeting the care delivery requirements of CPC+.
Full report from Mathematica Policy Research (over 300 pages):
By Don McCanne, M.D.
CMS is fixated on pushing the health care delivery system into accountable alternative payment models. The Comprehensive Primary Care Initiative is a study that has been going on for four years, and yet the improvements are negligible.
Instead of moving forward with a financing system that really would improve health care spending, CMS is going to expand this experiment with measures such as replacing shared savings with “a prepaid bonus that practices must repay if they do not meet practice-level performance targets.” That’s bizarre since we already know that such policies reduce physician satisfaction and increase burnout. That can’t be their policy goal, or is it?
Enough experimentation with alternative payment models. We definitely need to keep improving primary care, but not with financing policies that don’t work. Let’s go right to the model that does work – a well designed, single payer, improved Medicare for all. Within that system we can refine primary care to make it work well for all of us – patients and health care professionals alike.
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