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Payers ink deal to help CMS build primary care initiative for physicians


Forty-five insurers have committed to supporting an innovative payment initiative in seven states. Find out which payers are participating and what tradeoffs 75 practices had to make.

Forty-five commercial, federal, and state insurers have thrown their support recently to the Comprehensive Primary Care Initiative from the Centers for Medicare and Medicaid Services (CMS).

Payers signed agreements with CMS to participate in the 4-year program, which will enroll 75 primary care practices in seven markets, including Arkansas; Colorado; New Jersey; Oregon; New York’s Capital District-Hudson Valley Region; Ohio and Kentucky’s Cincinnati-Dayton Region; and greater Tulsa, Oklahoma.

As part of the program, CMS will pay a care management fee of $20 per beneficiary per month to help support coordinated services. For primary care practices to receive the care management fee, they must agree to provide enhanced services for their patients, including:

• offering longer and more flexible hours;
• using electronic health records;
• delivering preventive care;
• coordinating care with patients’ other healthcare providers;
• engaging patients and caregivers in managing their own care; and
• providing individualized, enhanced care for patients living with multiple chronic diseases and having higher needs.

In addition, insurers are offering enhanced payment to these practices.

The program, spearheaded by the CMS Innovation Center, is attempting to “break through an impasse by inviting payers to join with Medicare in investing in primary care,” a description on the initiative’s Web site explains.

The initiative is attempting to test two models: service delivery and payment.

Five key functions make up the service delivery model, CMS reports:

risk-stratified care management,

access and continuity,

planned care for chronic conditions and preventive care,

patient and caregiver engagement, and

coordination of care across the medical neighborhood.

The payment model includes a monthly care management fee coupled with the potential to share in any savings to the Medicare program. Practices also will receive compensation from other payers participating in the system.

Private payers participating in the program:

In Arkansas: Arkansas Blue Cross and Blue Shield, Arkansas Medicaid, Humana, and QualChoice of Arkansas.

In Colorado: Anthem Blue Cross Blue Shield of Colorado, Cigna, Colorado Access, Colorado Choice Health Plans, Colorado Medicaid, Humana, Rocky Mountain Health Plans, Teamsters Multi-Employer Taft Hartley Funds, and United Healthcare.

In New Jersey: Amerigroup, AmeriHealth New Jersey, Horizon Blue Cross Blue Shield of New Jersey, Teamsters Multi-Employer Taft Hartley Funds, and United Healthcare.

In New York: Aetna, Capital District Physicians’ Health Plan, Empire Blue Cross, Hudson Health Plan, MVP Health Care, and Teamsters Multi-Employer Taft Hartley Funds.

In Ohio: Aetna, Amerigroup, Anthem Blue Cross Blue Shield of Ohio, Humana, UnitedHealthcare, CareSource, HealthSpan, Medical Mutual, Centene Corp., and Ohio Medicaid in the Ohio Department of Job and Family Services.

In Oklahoma: Blue Cross and Blue Shield of Oklahoma, CommunityCare, and Oklahoma Health Care Authority.

In Oregon: CareOregon, ODS Health Plan, Oregon Health Authority, Providence Health Plans, Teamsters Multi-Employer Taft Hartley Funds, and Tuality Health Alliance.

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