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Imagine a world in which patient visits with primary
care providers consistently last more than 10 minutes, patients are engaged in their
care, and clinical staff believe they are making a sustainable difference in
their patients’ health.
For some practices, this world has become a reality
under new models designed to significantly change how primary care is
Essentially focused on population health management, these
models place primary care at the center of efforts to improve quality and reduce
costs. Reductions in utilization, admissions, and specialist and emergency
department (ED) visits are targeted through approaches such as team-based care,
chronic care management, and transitional care.
This year, the Centers for Medicare & Medicaid
Services (CMS) implemented its latest model: Comprehensive Primary Care Plus (CPC+),
the successor to the Comprehensive Primary Care (CPC) initiative, which ran
from October 2012 through December 2016.
CPC+ charges participating practices with five key
functions: care access and continuity, care management, care comprehensiveness
and coordination, patient and caregiver engagement, and planned care and
population health. Like its CPC predecessor, CPC+ includes both government and
commercial payers who, in addition to traditional payments, pay a monthly care
management fee to support the additional care services. Unlike CPC, which used
a shared-savings approach, the new model includes incentive payments linked to
quality and utilization and, under a second track, a hybrid of fee-for-service
and CPC payments, the latter of which apply to in-office and out-of-office
evaluation and management services.
As is true for other models seeking to advance care
delivery, CPC+ is challenging. Such models rely heavily on staffing, data, and
collaboration among clinicians. But when these models work, their benefits can
be substantial for both patients and providers.
Lynn Barr, CEO of Kansas City, Mo.-based Caravan
Health, a provider of population health management services to mainly rural
practices, says new care delivery models have had such a dramatic effect on
providers that many of her clients have said they would never return to their
“old” way of delivering patient care.
“Their patients are healthier and happier and more
engaged,” she says. “The patients are using less services overall, but they’re
using local services more, which has been a real boon to our rural hospitals.
It makes sense. They make money on mammograms and colonoscopies. Having a
robust wellness program generates lots of population health revenue.”
Many of Caravan’s client practices are in the Medicare
Shared Savings Program (MSSP), with the majority in the Accountable Care
Organization Investment Model, in which practices receive loans from the Center
for Medicare & Medicaid Innovation (CMMI) to fund population health
management programs. The loans are recovered from savings generated by participation
in the model.
Although Caravan did not work specifically with practices
in the CPC initiative, Barr says, the firm did assist about 250 practices
through the application process for CPC+.
Barr says providers believed their practices had
become more like urgent care centers—focused on treating conditions rather than
preventing them. Population health management is “reenergizing them as
community health systems,” she says.
Feedback on CPC from physicians and care
managers has been extremely positive, says Richard Shonk, MD, chief medical
officer of The Health Collaborative, a Cincinnati-based nonprofit organization
that contracted with CMS to help participants coordinate efforts and reach
Shonk says one care manager reported that the
CPC model enabled clinicians to focus more on patients, which has had several benefits.
“The patients felt better cared for, and that made them feel more engaged in
their care,” he says. “That created a sense of satisfaction and gratification within
the staff that helped their morale.”
Perhaps the most significant obstacle in achieving
success in any clinical transformation is gaining the buy-in of physicians. Primary
care providers and specialists must work in conjunction to reduce utilization
and coordinate the care of their patients.
National insurer Anthem, Inc., which has
initiated its own value-based payment models, participated in the CPC model and
is participating in CPC+. Gaining the trust of physicians has been an issue for
some practices. “Some have really committed to it, and the physician leadership
in place truly believe in it and are championing it among their peer
physicians, while others may have less experience or just less buy-in,” says
Veeneta Lakhani, vice president of provider enablement for Anthem.
Anthem addresses the trust issue through data,
education, and physician engagement, delivered
through vehicles such as webinars and practice group get-togethers, to help practices
better understand the benefit of value-based payment models and to demonstrate how
some practices have succeeded.
“We had to walk the talk—continue to bring
data, continue to bring resources,” says Julie Schilz, Anthem’s staff vice
president for care delivery transformation, who spearheaded the health plan’s CPC
Webinars have featured national speakers who
are well-respected in primary care, such as Pauline Lapin from CMMI. Physician practice
representatives have offered best practices, such as for reducing ED
In addition to accepting value-based models, physicians
must also become adjusted to the concept of team-based care. For physicians who
are accustomed to one style of care practice, working with a care manager is
very different, says David Cho, MD, FACP, co-chair of the division of primary
care at Health Quest Medical Practice, a LaGrangeville, N.Y.-based health
system that includes four hospitals, 13 primary care clinics, and multiple specialty clinics. Five of
Health Quest’s primary care practices participated in the CPC model and 10
are enrolled in CPC+.
Even more challenging has been getting
specialists onboard with a coordinated, team-based care management model, Cho says.
“We realized that as primary care providers, we
could control the cost of certain services in terms of utilization as well as
decreased visits to the ED and hospital,” Cho says. At the same time, the
imaging and other tests that specialists often order affect the total cost of
caring for a patient, which is used to evaluate the performance of primary care
practices in the model. “Our utilization we found out is very dependent on the
specialists’ costs,” Cho says.
Cho says two approaches can help win buy-in
from specialists. A specialist champion can persuade colleagues to recognize the
need to coordinate care and to comply with new care practices as they are
instituted. “The issue really is about trying to identify a leader from the
specialty side and having them understand that the overall health of the patient
depends on active integration with the patient and with the patient’s primary
care provider,” he says.
There should also be a direct line of
communication between the primary care physician and specialist to ensure the
specialist knows who to contact for questions about prior care. The primary
care physician and specialist should also establish a clear set of expectations,
which can be established in a document outlining what services are expected from
the specialist and what follow-up the primary care physician should provide.
Once a patient’s issue with chest pain has been resolved, for example, the next
step may include follow-up primary care visits for ongoing treatment of related
conditions, such as hypertension. “Even something as simple as that can really
be enlightening,” Cho says.
The primary care physician and specialist
should also have secure forms of communication, such as texting or messaging,
to transmit documentation and images in real time, Cho says.
Another challenge that turned up in the CPC model was
data aggregation from disparate systems of non-CMS payers.
Along with 75 practices that included 250
physicians, CMS and nine commercial health plans participated in the CPC model
in southwestern Ohio and northern Kentucky in which The Health Collaborative
was involved, Shonk says.
Physicians quickly realized that receiving data
sets from multiple commercial insurers and CMS would be overwhelming. The
physicians wanted to know how process improvement could be possible when their
performance—measured through utilization rates, quality outcomes, and cost data—varied
by payer, Shonk says. Consequently, the physicians wanted the data to be
managed, analyzed, and presented in a transparent and actionable format.
Fortunately, the health plans also recognized
the need for high-quality, usable data “and were willing to go down this route
with us to do that,” he says.
Participating physician practices and health
plans agreed to split the cost of developing a tool that would generate and
aggregate the data into an actionable form. “That created a somewhat
unanticipated large benefit in that it made the practices co-owners of the data
Shonk says. “They were involved in what
we called our data work group, where they had input into risk adjustment and
other methodologies,” Shonk says. “So when the
data actually came out, they were less likely to question it and argue over it
and were much more willing to accept and work on the results.”
The reports took
about 18 months to develop, including establishing agreements to satisfy data
security requirements and comply with the legal policies of each health plan,
Shonk says. “That was a major accomplishment of this approach.”
The CPC model included a shared-savings component
designed to split cost savings from improved care practices between payers and
practices. Four of the seven participating regions shared in CMS savings, which
were calculated at the regional level; three had net losses.
In terms of overall performance, the indicators show
practices are progressing.
“We’re certainly seeing that the needle is
being moved,” Anthem’s Lakhani says. “Across our value-based
programs, we have seen consistent improvement in inpatient utilization as well
as gaps-in-care closure and year-over-year improvement in quality measures.”
Still, individual performance varied
significantly. “You definitely find that all providers are not made equal, and
some are really doing very well, earning savings, and winning in these programs
while others are struggling,” she says.
Lakhani attributes this variation to differences in readiness
for value-based care in terms of mindset, resources, and data utilization. “Enablement
is all about how people, process, technology, and culture come together to
deliver a result, and that’s where we see the differences across providers.”
From Anthem’s perspective, the CPC model was
lacking in efforts to help practices understand cost and how to achieve savings
through reduced utilization, Schilz says.
“We tend in our model to look at both quality
and cost as the total package on value,” she says. “CPC, in the learning
curriculum, initially focused a lot on quality and a lot on care delivery
organization and a little less on things like utilization, such as ED visits or
inpatient utilization or perhaps cost of care related to pharmaceuticals, which
we feel is a critical component to add.”
Schilz says CPC+ addresses this issue in part
by replacing the shared savings approach with an incentive system that measures
performance at the practice level rather than the regional level, thereby helping
to foster accountability for the cost of care at each practice site.
CPC practices affiliated with The Health Collaborative
saw improvements in quality and utilization for members across Medicare
(including Medicare Advantage), Medicaid, and commercial payers, Shonk says.
Comparing data from the first quarter of 2013
to the first quarter of 2016, the number of specialty visits and primary care
visits declined by 10 percent and 9 percent, respectively, and the number of ED
visits declined by 5 to 7 percent, Shonk says. Inpatient admissions declined by
about 18 percent, including a 25 percent reduction among ambulatory sensitive
conditions, a group of about 15 chronic-disease diagnoses. This decrease included
reductions of 28 percent in admissions for congestive heart failure and 13
percent in admissions for chronic obstructive pulmonary disease.
“The reduction in
admissions for chronic conditions is
probably our most significant outcome because it is exactly where you would
expect to see the impact of a methodology that paid practices to manage care,” Shonk
Despite the mixed results from CPC, the outlook for
CPC+ is encouraging. For the first round, which began in January, CMS expanded
the program from 500 to 2,983 practices. The number of payers grew from 31 to
54 and the number of regions increased from seven to 14. Round 2 of CPC+ will
begin in January 2018 with as many as 2,000 additional practices and up to 10 additional
Caravan’s Barr says the care management requirements for
CPC+ are intimidating—roughly twice the amount of work as is required in an
ACO. In addition to wellness and chronic care management, she says, CPC+ requirements
include the integration of behavioral health services and the use of data for
risk stratification and disease-specific panels.
basically the roadmap to how you would manage population health in a primary
practice if you did it all,” Barr says.
Barr says she has high hopes for CPC+ even though she believes
some practices will leave the program because of the heavy demands. “But the
ones that stick with the work are going to do a great job for their patients,”
she says. “It’s a great time to be in primary care.”
Health Quest’s Cho is also encouraged by CPC+, specifically
noting the use of psycho-social factors to identify a patient’s barriers to effective
care. He acknowledges that there are many compliance and documentation
requirements—a lot of “clicking of boxes”—that may frustrate clinicians.
“I really don’t think that advances the
delivery of health care, frankly,” he says. “I think that ensures compliance.” With
these increased requirements, he says, CPC+ will be challenging, “but I think
this is definitely the way forward.”
is a freelance healthcare writer based in Forest Lake, Ill., and a frequent
contributor to HFMA publications.
for this article: Lynn Barr,
CEO, Caravan Health, Kansas City, MO.; Richard Shonk,
MD, chief medical officer, The Health Collaborative, Cincinnati; David Cho,
MD, FACP, co-chair, division of primary care, Health Quest Medical Practice,
LaGrangeville, N.Y.; Veeneta
Lakhani, vice president, provider enablement, Anthem, Inc.,
Schilz, staff vice president, care delivery transformation, Anthem, Inc.,
David Cho photo: Courtesy of Health Quest Medical Practice.
Julie Schilz photo: Courtesy of Anthem.
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