The new CMS primary care payment program unveiled this week won tentative buy-in from doctors, hospitals and healthcare players across the political spectrum.
The so-called Primary Cares Initiative set lofty goals, including getting a quarter of providers and beneficiaries to sign up. The program, however, is fully voluntary, and some paths carry significant downside risk. That leaves a key question: Will providers sign up and will they stay in?
Blair Childs, senior vice president at Premier, noted that hospitals and doctors tend to cling to tried-and-true methods, despite inefficiencies. "Getting somebody to leave fee-for-service is really, really hard," he said.
Other details have yet to be released, but it's clear this program will be watched closely as the U.S. healthcare system moves toward leaving fee-for-service behind.
The model garnered bipartisan praise, including from former CMS officials. Andy Slavitt, who ran the agency during President Barack Obama's administration, encouraged physician groups to consider and give feedback.
"There are several watershed moments in the history of the Medicare program like the coverage of prescription drugs and the shift to paying for better care," he said in a statement. "The approach announced today by CMS is another one as it eases the connection of Medicare beneficiaries to a primary care physician and gives doctors the freedom, rewards, and tools to keep people healthy."
Other notable backers include the American Medical Association, the American Academy of Family Physicians and the Physician-Focused Payment Model Technical Advisory Committee.
Myriad organizations seemed on board, including the American Hospital Association, which stated: "We look forward to learning more about these new models and how they can support our collective efforts to improve the health and well-being of our patients and communities."
Atul Gawande, CEO of the Amazon-J.P. Morgan-Berkshire Hathaway joint venture now called Haven, also voiced support. He emphasized its potential to enable "using telehealth, health coaches and other innovations."
HHS Secretary Alex Azar acknowledged his predecessors and the long journey to push the healthcare system toward paying for value instead of volume. "When I announced last year that moving toward a value-based healthcare system would be one of my priorities as secretary, I was well aware that I was at least the fourth HHS secretary to take this issue seriously," he said at the press conference unveiling the new model.
The proposal even got a Twitter shoutout from TV personality and billionaire entrepreneur Mark Cuban.
Built on previous models
PCI has two paths — one for small or individual practices (Primary Care First, with two models) and one for larger practices or health systems (Direct Contracting, with three models). Each model features monthly capitated payments, and they have a range of risk sharing options. Some of the models also have extra incentives for treating patients with chronic conditions. The third model for Direct Contracting is still in development, and CMS is seeking comment on how it would be implemented.
The two paths offered by PCI are closely modeled on existing programs. The small practice path on the Comprehensive Primary Care model and its second iteration, CPC+, and the direct contract path on the Next Generation ACO model.
Participation in Next Generation has seen its ups and downs. Twelve accountable care organizations left or were removed from the model for 2019, leaving 41 now participating. It launched in January 2016, and first-year results showed reduced per-beneficiary spending, fewer inpatient hospital days and increased annual wellness visits.
CPC+, which began in 14 regions in January 2017, has been a popular model. After the first year, only 4% of the nearly 3,000 initial practices stopped participating, according to the program's first annual report, released this month. The first year of the five-year model showed few favorable changes for beneficiaries, but the report concludes "it is too early to determine the ultimate effects of CPC+."
Farzad Mostashari, CEO of Aledade, which works with primary care ACOs, said he hopes CMS makes a change from how CPC+ was initially designed by allowing practices that participate in the Medicare Shared Savings Program to also join the new small practice model. Otherwise, practices are forced to choose and don't get adequate options for wading into value-based care.
While the four models scheduled to roll out in January are fairly fleshed out, a few key details are still outstanding.
The exact benchmarks for payment rates are still unknown, but will be an important factor for practices weighing participation. Mostashari said he hopes CMS looks to Medicare Advantage when figuring out these details. "My advice as much as possible is to stick to what's been honed over a period of 20 years," he said.
There's also the question of how specifically CMS will determine a patient has been kept sufficiently healthy and other quality measures. And it's still not known what waivers CMS may allow for some providers that wish to participate.
One key question for any voluntary payment model is how many organizations will apply — and how many will be left standing through the program's end, said John Feore, associate principle at Avalere. "That's the tradeoff with a voluntary model," he said. "They can volunteer their way out."
The CMS estimation of a quarter of traditional Medicare providers and beneficiaries participating is an aggressive goal, Feore said. "I think that would a huge change to the current system and a certainly a huge change from a few years ago," he said.
But he believes there is an appetite among primary care providers for more opportunities to take on risk. Organizations that have already participated in programs like CPC+ will be well positioned to join PCI, as Avalere research has shown a few years of experience can make a notable difference in performance in value-based models.
CMS innovation center head Adam Boehler said the agency is confident in its estimate based on discussions with providers who say they would prefer to spend less time with their EHRs and paperwork and more time tending directly to patients. "When you pay for quality outcomes instead of volume, you transform a healthcare system that caters to special interests into a market-based system in which providers compete to take care of each patient," he said.