Value Based Payment

Will a quarter of primary care physicians join the new Medicare payment models?

May 9, 2019 3:45 pm

April 23—The Trump administration envisions the five coming primary care models that were unveiled this week to include one-quarter of such clinicians. But Medicare advisers and others are split on whether many providers can succeed in the models.

The administration unveiled CMS Primary Cares, a group of five models for Medicare fee-for-service (FFS) primary care practices. The models either pay flat, risk-adjusted monthly fees to manage care or implement direct-contracting arrangements for providers to take on two-sided risk for large groups of the sickest patients.

Alex Azar, secretary of the U.S. Department of Health and Human Services (HHS), said the models will enroll at least a quarter of both traditional Medicare beneficiaries and providers.

“Moving in this direction, toward value-based care, has been largely just a vision for so long,” Azar said at a press conference to introduce the models. “Now, value-based care is a reality for a quarter of traditional-Medicare beneficiaries in primary care and a significant and growing number of patients in other settings as well.”

But some Medicare advisers are doubtful.

“When you think about organizations that are set up to do that, there aren’t that many,” said Kavita Patel, MD, a member of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which recommends physician payment models to HHS.

“Because if you’re a primary care group, you’re probably going to say, ‘I’m sitting out this first year and I’m just going to see what’s happening, and then I’ll go in if I think it actually works,’” Patel said in an interview.

Ann Greiner, president and CEO of the Patient-Centered Primary Care Collaborative, said the potential upside for small practices in the first two model options, collectively known as Primary Care First, was potentially “a very attractive boost.” However, the real challenge involves the readiness of the practices.

“It’s a very different way to practice,” Greiner said in an interview. “They want to practice in a different way. They want to take care of their patients in a more holistic way. But what they’ve had experience with for decades is a very different kind of care.”

She warned that the transitions required by the new models likely will take time, and she cited the experience of patient-centered medical home models. It commonly takes four years for desired results, like quality improvement and reductions in emergency department (ED) use, to occur.

Broader appeal seems realistic

Other analysts were more optimistic about the new models.

Sheila Fusé, senior vice president of policy and payment models at Navvis Healthcare, said the models are “going to have broad appeal” because they build on the experience of a growing number of practices that have been managing care through accountable care organizations (ACOs) and managing populations through Comprehensive Primary Care Plus (CPC+). And practices that wanted to take on two-sided risk but lacked the minimum 5,000-Medicare-beneficiary patient panel could not qualify to operate ACOs.

The new models have “moved to [requiring only] 125 members; that really allows an independent practice to be able to participate in some of these models,” Fusé said in an interview.

Harold Miller, another PTAC member, said the models have the potential to “affect primary care across a broad swath of the country because that has been a real gap in Medicare payment programs.”

Previous models for primary care were available only in a small number of regions and did not include the range of options in the new models, Miller said in an interview.

“It’s clear that what can work for a large primary care practice or multispecialty group is not the same thing that can work for a small primary care practice,” Miller said. “They are recognizing that those practices need more flexible payment to help patients.”

The new models also are consistent with some recommended PTAC models, such as one from the American Academy of Family Physicians that proposed risk-stratified monthly payments.

Early challenges anticipated

Many details that will be key to determining providers’ chances to succeed with the models have not yet been released by the Centers for Medicare and Medicaid Services (CMS), said a range of policy advisers.

For instance, it is unclear whether primary care practices employed by hospitals will qualify to participate. Chad Mulvany, a director of healthcare financial practices at HFMA, assumes they would be eligible. If they don’t qualify, the many regions where CPC+ operates — and will continue until 2021 — will struggle to find providers.

Another major challenge is the open-network approach, which allows Medicare FFS beneficiaries treated by these primary care providers to go to any physician they want.

“Anyone who’s taking full or partial capitation for this population better have a pretty good system in place to track and correct network leakage,” Mulvany wrote in an email. “If I’m taking full risk, my tolerance for an open network just got a heck of a lot lower unless CMS is paying me a premium to take that risk, which doesn’t sound like they are.”

Another key unknown is whether the models will offer floors or ceilings on risk adjustment.

“If they put a ceiling on it, as they did in Pathways to Success, over a five-year contract that’s pretty limiting,” said Fusé, referring to the recent overhaul of the Medicare Shared Savings Program.


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