An internists’ view of new payment model
Editor’s note: Robert McLean, MD, FACP, president of the American College of Physicians, says ACP is enthusiastic about the Primary Cares Initiative from CMS, but that the organization is reserving judgment until it can see more details. His comments to Repertoire have been lightly edited for brevity.
Repertoire: In announcing the Primary Cares Initiative, CMS refers to lessons learned from and experiences of the previous models, (presumably, CPC, CPC+). From the American College of Physicians’ perspective, what are some of those “lessons learned?”
Robert McLean
Robert McLean: The first CPC+ comprehensive annual report (based on 2017 performance) came out around the same time the Primary Care First model was announced. According to the report, there were “few” and “small” differences in service use and quality outcomes. The report itself notes that with any model, downstream outcomes and spending changes take time to realize, so it’s not surprising that the results were modest in the very first performance year of the model.
ACP remains supportive of this model and the positive changes that investments in enhanced primary services and other advanced patient care can have on downstream health outcomes and costs. That said, with any alternative payment model, getting the details right – from setting financial benchmarks, to risk adjusting, to attributing patients – is what matters. ACP is still waiting on a lot of those details and we look forward to evaluating them.
Repertoire: In what ways do you expect the Primary Cares Initiative to take ACP members (as well as payers and patients) beyond the Comprehensive Primary Care Plus program?
McLean: The separate track for clinically complex and/or high-risk patients could be an important addition that doesn’t exist in CPC+. As CMS points out, these types of patients absorb a disproportionate proportion of practice resources and finances, so targeting these particularly vulnerable patient populations is really important when we discuss ways to improve value.
From the quality measure side, CMS can stand to improve the validity, accuracy, and clinical relevance of the individual quality and outcomes measures it uses – something ACP has repeatedly called for. CMS notes more generally that the new models will focus on relevant, actionable and outcomes-focused measures. We hope they will, but it’s hard to tell if measures really meet the mark until we actually see them. There is a real risk of patients experiencing poor outcomes and even harm if they are making decisions based on potentially flawed or unclear information. Additionally, patient participation in such programs should be voluntary, and participants should not have financial penalties imposed simply for failing to achieve health goals and outcomes.
ACP has repeatedly argued that if CMS wants clinicians to participate in these models, they need to make a compelling value proposition, particularly when we’re talking about higher risk models. The type of asymmetric reward-to-risk that we see in the Primary Care First model seems like a promising way to go about that, but we need a more complete picture of the payment amounts before we can make that assessment. Harold Miller [president and CEO of the Center for Healthcare Quality and Payment Reform] recently raised some red flags that the level of reimbursement for these models might actually come in below previous models for the vast majority of participants, which is obviously a concern. The 50% sharing rate is only useful if participants are actually achieving it, and that all comes down to the benchmark. It is premature to say whether in fact these models make a compelling value proposition until we have that type of information.
CMS has said it is considering beneficiary incentives for Primary Care First, which were not a piece of CPC+. ACP feels that engaging the patient in his/her own care is critical when talking about value and improving outcomes. Incorporating some type of beneficiary incentives could be another powerful way to make any [alternative payment model] more effective. Of course, with any patient incentives, it is important that patient choice is not restricted. Certainly we hope patients can benefit from positive incentives to align with the model … such as additional services and better care or increased access … that they would not otherwise have through traditional Medicare. But it is important that these models do not swing the pendulum the other way and design payment or coverage structures in a way that restricts patient access to certain clinicians or treatment options.
Repertoire: CMS has said the Primary Cares Initiative will “test out paying for health and outcomes rather than procedures on a much larger scale than ever before.” Do you expect that to be the case? Why or why not?
McLean: Primary Care First has 26 regions versus 18 for CPC+. That alone would hopefully mean wider participation, but of course it will depend on the level of uptake. We will need more information on the payment methodology, attribution, and other core elements of the model before we can have a full sense of how attractive this model will be to potential participants. As with the existing CPC+ model, we’d like to see models generally available on a national scale to promote innovation and better patient care in all areas of the country.
Another important element of this question is control groups. ACP understands the importance of being able to evaluate the effectiveness of a program where Medicare dollars are at stake. However, we urge the Innovation Center to consider options other than the way they approached it for CPC+, which unnecessarily restricts participation by sorting willing participants into a control group and depriving them, and more importantly their patient populations, from participating in and benefiting from the program.
Repertoire: CMS says that Primary Care First “seeks to improve quality of care, specifically patients’ experiences of care and key outcome-based clinical quality measures, which may include controlling high blood pressure, managing diabetes mellitus and screening for colon cancer.” Given all the quality benchmarking programs that already exist, does ACP consider Primary Care First to be a new way to improve quality of care?
McLean: Improving patient outcomes through reporting meaningful quality metrics is not a new concept, but ACP believes it is important to keep in mind that the effectiveness of the model or performance program is only as good as the metrics you are using.
ACP’s Performance Measurement Committee has reviewed internal medicine performance measures for the Merit-Based Incentive Payment System [MIPS] and found half of them to be inappropriate for use. Physicians are also dealing with “noise” from being evaluated on dozens of quality and cost metrics. ACP firmly believes in the importance of aligning syncing metrics across alternative payment models and performance-based programs from all payer types. Intending PCF to be a multi-payer model is a great step in that direction, but it also depends on how many payers actually sign up to participate in PCF first.
Repertoire: CMS says that Primary Care First will reduce administrative expenses or time on the part of the primary care physician. How do you feel about that?
McLean: Through our “Patients Before Paperwork” initiative, ACP has consistently advocated for reducing administrative burden in billing, compliance, documentation, and value-based program reporting, and has noted that alternative payment models in which clinicians are already being held financially accountable for cost and utilization outcomes are a particularly viable vehicle to make this happen.
It’s encouraging to hear that CMS seems to be listening and has at least expressed a desire to leverage these models to streamline billing. That said, they also note that fee-for-service billing will continue, so it remains to be seen how much of an actual burden reduction these models will entail. ACP is certainly hopeful that any model that is already holding clinicians accountable for outcomes, utilization and costs in a substantial way, particularly capitation models, can and should be leveraged as an opportunity to drastically reduce billing, reporting, and other administrative burdens.
It’s also important to keep in mind that Medicare is just one payer. For this to really make a meaningful dent in reducing administrative burden, we’ll need more payers to come to the table and agree to revise their own billing and reporting requirements.
Repertoire: How prepared are ACP members to embrace the concepts behind the Primary Cares Initiative, namely, delivering value-based care using population health management techniques? Will the Primary Cares Initiative help them be more prepared?
McLean: ACP members have expressed a lot of interest and desire in participating in these types of innovative payment models, which reward clinicians for keeping patients healthy. Up until now, one of the main criticisms we’ve heard – and one that we’ve repeatedly relayed to CMS – is that we need more alternative payment models. So, at a high level, we’re certainly excited to see the CMS Innovation Center come out with new models and hope that is just the tip of the iceberg and we have more coming. We’re also encouraged to see alternative payment models, particularly in the primary care space, recognizing the critical role internists play in delivering high-value medicine, and how investing in advanced, comprehensive preventative services can contribute to improved outcomes, reduce the risk of downstream complications, and achieve utilization and cost savings. Additionally, there is a lack of availability of even existing models (like CPC+) in many areas of the country.
That said, with any model, a lot of the devil is in the details, so ACP is looking forward to reviewing all the facts before we can say for certain exactly how much interest there will be in these new models.