Simplifying CMS’s new Comprehensive Primary Cares Innovation Model

 In Healthcare Transformation, Productivity & Management

The Centers for Medicare and Medicaid Services recently launched a new innovation model known as the Comprehensive Primary Cares Initiative (CPCI). The goal of this voluntary multi-payer model is to strengthen the use of and reliance on primary care for all patients, while pushing forward in the progression from fee-for-service to a value-based healthcare system.

The CPCI comprises a new set of payment models designed to transform primary care to deliver higher value for patients throughout the U.S. healthcare system. CMS says the CPCI builds on lessons learned from previous models, and will reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing healthcare costs.

To help understand this complex but important new CMS program, we invited Dr. Andrei Gonzales, Change Healthcare’s AVP of Product Management for Value Based Payments, to talk about the initiative’s potentially transformative effect on payment and clinical models. In addition to helping improve care quality and reducing cost for CMS members, Dr. Gonzales says this new model can also help improve quality scores and expand opportunities for shared savings.

Covered on today’s show:

  • What is the CMS Comprehensive Primary Cares Initiative (7:22)
  • The timeline for the effect on primary care physicians (17:18)
  • What health plans can do now to prepare for the future (20:33)
  • Providers’ reactions to the new initiative (22:35)

Episode Resources

  1. Contact Patrick McGuigan
  2. Dr. Andrei Gonzales’s bio
  3. CMS Comprehensive Primary Care Initiative
  4. Research: Value-Based Care State-by-State
  5. Seminar: How Anthem is Scaling Value-Based Payment
  6. Value-Based Payment Resource Hub

Show Resources

Show Transcript

PATRICK MCGUIGAN: I’m Patrick McGuigan, and I’m back with Dr. Andrei Gonzales who leads the product development efforts for Change Healthcare’s line of value-based payment solutions. Andrei, thank you for joining us today.

ANDREI GONZALES: Thank you. Glad to be here.

Patrick: Andrei, we want to talk with you today to get your thoughts on CMS’s latest announcement called the Primary Care Initiative. This initiative appears to increase the importance of primary care providers and continues CMS’s drive forward in their transition from volume to value. Can you tell our listeners exactly what this initiative is and why it’s generating so much news?


ANDREI: This initiative is a very strong move forward in the progression to value-based care from fee-for-service or fee-for-volume system. Our current system is based on fee-for-service and that fee-for-service really drives the type of behavior that we see in the system. As a result of that fee-for-service system, we really get fee-for-volume. As we look at value-based care, it’s important to really understand how to ensure value-based care, not just from a payment perspective but really from a clinical transformation point-of-view. These models start to put primary care back in the driver’s seat for really the creation of health for all of us as patients.

When we engage with our primary care providers—be they physicians or nurse practitioners or whomever they are—it’s important for us to be able to have a relationship with those providers for those providers to really understand what our health issues are, what are social situations are, and to be able to then work with us in a way that helps to improve our overall health. In a fee-for-service model, those primary care physicians are rewarded and really incented just to see us as we come into the clinic and to focus on what’s happening at that one time. What this model does is start to take the incentive away from those kind of in person visits and really start to focus more on how those primary care providers to help ensure the health of their patients without worrying about having to see them every single time or exactly what the billing, the situation might be.

The way CMS is doing that is by developing five different models. Two of the models are grouped into what are called primary care first. In primary care first, it’s allowing practices to either focus on a population of patients kind of a so called sort of average population of patients or patients who are more chronically ill with more severe illness. Each model simplifies the administrative and billing processes necessary for those providers to bill CMS for their Medicare patients. They put in a flat per member, per beneficiary fee that the practice will be paid as a result of participating in the program. Then there’s a flat in person, inpatient, not inpatient but in person fee of $50 every time the patient comes to see the provider.

The two models are split up because providers who see patients who are more severely ill, more chronically ill have a different set of criteria that they need to work with, some different quality measures, and really a different way of engaging since those members might be in a facility, they might be dually eligible with Medicaid as well as Medicare, and there are some different considerations. But in both models, the basic idea is that providers will be paid on a per monthly basis to manage the care of these patients. The quality measures that they are going to be held to are going to be much simplified.  In the first year, they’re only going to be measured based on inpatient admissions for their patients.

So really looking at what is considered a very negative outcome for us as patients, and also very costly to the healthcare system. So those providers will be rewarded for keeping their patients healthy and keeping them out of the hospital. That’s the first year quality measure. In future years, a handful more quality measures will be added such as colorectal cancer screening and hemoglobin A1C measurements. So there will be some of those measures that are current now or present now in the MIP system but they will be much simplified over what primary care doctors have had to deal with in terms of quality measurement in the past. Those are the first two models that fall under the primary care first model.

The second model is a direct contracting model. This model looks more like an ACO sort of model. And there are three different models there. One is the professional-population-based payment option. The second is a global-population-based payment option. And the third is a regional. We have some information about the professional and the global options right now that are focused on capitating primary care in the professional model. In the global model there are two options. The participants can either choose to capitate just primary care or total cost of care. The regional model still has more details to be worked out.

It’s a very interesting model that looks like health systems will have the option to take ownership of and responsibility for care of all the Medicare members in the region. Again, we’ll have to wait and see some of the details there. In this model, it’s allowing healthcare systems that are maybe bigger than would be interested in the primary care first model who already have experience with some level of risk and want to take on more risk. The level of risk in the direct contracting model is greater and the potential for shared savings is also greater.

So by introducing these five new models, CMS and Medicare specifically have given their healthcare providers the option to focus more on the overall care of a patient instead of looking at how to increase the volume of care that they provide to those patients. They’ve started to alleviate and introduce waivers over certain types of care and certain restrictions on care to give providers more flexibility to use their resources in their local communities and at their disposal to take care of patients. They’ve really encouraged providers to start looking more at social determinants of health, the aspects of care that are really difficult for providers to manage in the office and require more of an engagement with patients to understand their living situation and how their living situation and their economic status might actually be impacting their health in a very significant way.

Such as if a patient doesn’t have adequate air conditioning and lives in a very hot climate that can really have an impact on for instance their congestive heart failure. For a patient with significant allergies or COPD if they don’t have the ability to clean their carpets and really remove allergens from their home, that can exacerbate their COPD. So really starting to allow us as healthcare providers to look at the overall health of a patient and all of the determinants that really come into play for them.

This payment model is set up to reduce the focus on really making sure that a specific medical claim is exactly right. You’ve got all the diagnosis codes that your ENM coding is supported by every single diagnosis. And for instance, in the primary care first initiative, it completely removes any requirement for those sorts of a diagnoses and allows the clinician to focus on documenting for clinical care instead of using the EMR as a revenue cycle management tool. That’s really one of the revolutionary, I think, parts of this model when it comes to the transition from fee-for-service to value-based care. It really starts to say okay, we’re not going to rely on the fee-for-service claim and infrastructure to pay our primary care providers. We’re going to start to move away from that, remove some of those administrative restrictions that really add a lot of cost to a provider’s practice, and simplify those requirements.

The last point I’ll make on this is that CMS is looking to make this a multi-payer model. They are encouraging private commercial payers to engage in these models with them so that health systems and primary care providers specifically can really transition their whole practice to this sort of a very patient-focused model to really ensure they’re managing the care of their patients, they’re coordinating the care of their patients, not just for their Medicare patients but hopefully also for their commercial patients. So this model if CMS is successful, especially in engaging commercial payers to make it a multi-payer model can really start to move the overall industry towards value-based care even quicker than it has been progressing on its own to now.


PATRICK: Wow. So pretty far reaching model. Andrei, do you have any thoughts on when this would impact primary care physicians and how they practice? What stage is CMS in?

ANDREI: Well, they’ve rolled out the program. They’ve held some very helpful webinars to introduce some of the details of these programs. The programs begin in 2020. There are some restrictions in terms of where the programs will be implemented. And they’re expecting to use this as a pilot. They are clear that this is the first model of its kind. They want to roll it out and see what kind of impact it has. Of course if there’s a negative impact, then they’ll end the program and fix anything that might have gone wrong with it. If it’s got a positive impact, they’ll make any enhancements or improvements they need to but their plan is definitely to expand the program. So the program starts in 2020 and they’re expecting this whole model to cover about 25% of Medicare beneficiaries pretty quickly in the program.

So their plans are pretty aggressive. They are, I guess, optimistic that they’re going to get pretty significant participation early on. These are voluntary programs at this point. CMS has come out and said they do see a role for mandatory programs. Their goal is to at least try out voluntary programs and show benefit, show that the programs are working before they move to mandatory programs. But at this point, I think it’s a great idea for any primary care practice to look at these models and consider whether or not they think they can be successful in these models. And if they don’t think they can be successful, to start to think about how they could be successful in these models. It’s clear that there is strong momentum in the CMS administration to move forward with value-based care models.

There’s clear optimism and push from commercial plans to move forward with value-based care. So this is a model that starts to address some of the most frustrating aspects of healthcare for providers. Those aspects are the need to document so extensively just for billing purposes, not necessarily for clinical communication and clinical documentation. This removes that requirement. And it really allows primary care doctors and practices to focus on what they got into medicine for and that we’ve got the right resources that we need to make good choices and contribute to our own health.


PATRICK: So, Andrei, certainly a significant impact on the provider community. What about health plans?  What does this mean for health plans? What should they be doing now to prepare for this future?

ANDREI: Right. Well as I said, one of the goals that CMS has for the primary care’s initiative is for it to become a multi-payer model. I think for every health plan and I’m sure they’re looking at these models very closely, would be for them to look at their own initiatives and their provider networks and especially consider working with their primary care practices to understand how they could implement this model. I’m sure that CMS will be very glad to work directly with them to share even more detail about how they’re planning to roll this out. The goal would be that as I said, practices would be able to operate under the same payment models and quality measures for all of their patients instead of having one program for their Medicare patients, another program for their different commercial patients.

So as a commercial plan, I think there’s a lot of benefit to be gained from this model just as CMS thinks that Medicare can benefit a lot from this model both in terms of improving the quality of care for their members and also reducing the cost of care. Commercial plans have those same goals. So I think it would be great for commercial plans to kind of take up the invitation that CMS has extended to engage in multi-payer programs here and really start to understand how the payer could adjust their processes and administrative requirements to meet these models, especially in the states where these models are going to be active and for the health systems who are engaging.


PATRICK: And what about the providers? How are they reacting? I think especially the primary care physicians? Do they see this as a positive or a hindrance to their efforts?

ANDREI: Yeah. At this point the program has gotten I’d say cautious enthusiasm from the association of AFP, the Family Practitioners Association, from the American Medical Association. So these organizations are looking at the programs and recognizing some of the significant changes that Medicare is making in terms of how they are paid for care and some of the administrative requirements that have led to what they consider to be excessive costs in just ensuring that they’re paid for the work that they do. So just that alone should reduce the overall cost of care for Medicare patients. When you start to carve out such significant chunk of cost in the model, if you’re looking at it from like a lean six sigma perspective you’ve just reduced a whole bunch of waste that doesn’t really add any value to your customer who’s the patient and which in this case is Medicare.

So by reducing those administrative costs, they’ve done something that hasn’t really been done in any value-based care program to date which is to take cost out of the program up front. And then now what’s left is if the incentives to coordinate and manage care will result in overall lower utilization of care through improved quality. So if patients aren’t getting sick enough to have to go to the hospital, of course that’s going to reduce the overall cost of care and produce a very good outcome and benefit for patients in that they didn’t have to get that sick in the first place. So the practices who are looking at this, I think need to look at how their systems and administrative capabilities and really their care management and care coordination capabilities through nurse care coordinators can be enhanced to ensure that they’re keeping track and tabs of their patients who are really accountable to them, or who they’re accountable to and start to ensure that they’re keeping track of those patients outside of when those patients visit the clinic.

That for the patients who they know are prone to exacerbations of chronic illnesses or who maybe have higher risk because of their social situations, maybe work a little more closely with those patients even when the patients aren’t reaching out to them to make sure that those patients are staying healthy and staying on the right course. That will lead to better outcomes for those patients, but in this model, it’ll also lead to higher quality scores and greater opportunities for shared savings for those practices.

PATRICK: Well, Andrei, as always a great summary of another complex CMS initiative. Thank you so much for sharing that with us. We hope you’ll update us once CMS finalizes their plans and this initiative moves forward.

ANDREI:  Thank you.

PATRICK: That’s it for this show. But be on the lookout for our next episode in which Rob Capobianco will be talking with Aparna Higgins, founder and CEO Ananya Health Innovations and former guiding committee member of the Healthcare Payment Learning and Action Network. Aparna will be sharing her insights on the recently released roadmap for driving high performance in alternative payment models. Thanks for listening and tune in again.

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