Health Care Delivery Model Designed by CMS Improves Outcomes, Doesn't Reduce Spending

Deborah Peikes, PhD

The Centers for Medicare and Medicaid Services (CMS) recently concluded the Comprehensive Primary Care Initiative (CPC), a health care delivery model, that demonstrated an improvement in care, but fell short in reducing Medicare spending, according to a recent report published in the Health Affairs Journal evaluating the results.

“Patients face a system where care is fragmented across specialists and other providers and information doesn’t flow across providers,” co-author of the report, Deborah Peikes, PhD, Senior Fellow at the Mathmatica Policy Research Institute, told Physician's Money Digest. “It can be hard to get help with an urgent care problem from their primary care provider and patient preferences and goals are not always driving care. And for those with chronic illnesses, too many of them aren’t getting the support they need to learn how to better take care of themselves.”

Health care costs are skyrocketing, growing 4.3 percent to $10,348 per person in 2016, amounting to 17.9 percent of Gross Domestic Product (GDP), according to CMS. Primary care is unique in that its providers are almost always the first point of contact for patients in the health care system and plays an important role in preventative medicine. Unfortunately, a small percentage of medical school graduates choose this area of medicine. Primary Care Progress, a national organization that promotes primary care, reported that about 18,000 people graduate from medical school in the U.S., but only 25 percent practice in primary care. Peikes says that primary care physicians earn less than physicians in other specialties.

“We know from other research that fewer primary care providers is correlated with higher total costs,” said Peikes. “This country’s current fee-for-service payment approach and its reliance on office-based visits with certain types of staff, rewards volume over value. Without improving incentives to enter primary care in terms of better pay and more clinical support, the health care system’s shortage of primary care providers will continue to grow.”

The goal of CPC was to evaluate a new approach in delivering primary care and providing practices with the technology and financial support to implement the changes. The Health Affairs report is an evaluation of the results of the four-year initiative, which took place October 2012 to December 2016 and included 497 practices (plus 908 comparison practices not utilizing CPC) in Arkansas, Colorado, New Jersey, New York State, Ohio, Kentucky, Oklahoma and Oregon. In addition to CMS, 39 other public and private payers implemented CPC practices in care delivery and payment.

CPC required participating practices to implement five comprehensive primary care functions:

• Access and continuity. Practices improve efficiency of care with 24/7 access.
• Planned care for chronic conditions and preventative care. Proactively assessing patient needs and creating a personalized plan of care for high-risk patients.
• Risk-stratified care management. Patients with complicated or multiple medical needs receive extra care.
• Patients and caregiver engagement. When desired, providers include the families of patients in the details of care.
• Coordination of care across medical neighborhood. Providers work closely with other health care providers to coordinate overlapping aspects of care.

Results showed that CPC had a number of benefits, including improved care delivery processes, lower Emergency Department (ED) visits, and lower hospitalizations. However, there were no reductions in both Medicare hospitalizations and Parts A and B spending to cover management fees. Also, while most physicians who reported about their experience with CPC (80 percent) said the quality of care for their patients improved, some added that CPC’s administrative reporting was a burden and the transformation work was difficult.

The next step is evaluating CPC Plus, a five-year advanced primary care medical home model that launched January 2017, to see if it improved outcomes more than CPC did, said Peikes. CPC Plus offers a second track for more advanced practices to undertake deeper transformation, more emphasis on moving away from the fee-for-service model, strengthening incentives, and improving IT functionalities and increasing support for practices.

“We know that primary care is an important part of the solution to improving quality and reducing spending,” said Peikes. “We need to continue to study different approaches to care delivery and payment to see what works.”