Primary care practices are relying on bold payment reform to meet CMS goal
Click Here to Manage Email Alerts
In October, CMS released an Innovation Center Strategy Refresh, describing its proposed destination of the now-common “pathway to value” in our health system.
CMS’s envisioned destination is both powerfully attractive and ambitious: 10 years from now, every Medicare and Medicaid beneficiary will have a care relationship with a provider and can choose who is responsible for the overall quality and total cost of their care. With focused attention to equity, care teams would deliver more comprehensive, person-centered, and affordable care — across public and private sources of health coverage.
Vision for tomorrow meets today’s reality
At the moment, many primary care offices can’t move quickly on that pathway to value. According to regular surveys by the Larry A. Green Center in partnership with the Primary Care Collaborative (PCC) during the COVID-19 pandemic, many primary care teams are simply overwhelmed, making it challenging to innovate in the midst of COVID-19.
Primary care has been the front line in the mental health and substance use epidemics. It works with patients to address the growing rates of heart disease and diabetes, now worsened by delayed or skipped care during the pandemic.
Yet the U.S. health care system has denied primary care teams the resources they needed to succeed in these situations.
This erosion of the primary care sector is not new, but it has been exacerbated by COVID-19. Primary care visits fell by more than 24% from 2008 to 2016, while the proportion of health care spending devoted to primary care continues to shrink, the PCC and others have found. In 2020, Harvard researchers estimated that primary care lost $15 billion in revenue due to COVID-19. Practices downsized and even permanently closed.
How could this happen when many of us needed primary care the most?
It starts with how and how much we pay for primary care.
The fee-for-service (FFS) payment platform, still entrenched across Medicare, Medicaid and private payers, sets discrete, relative fees across clinical work, valuing procedures over diagnosing and managing chronic conditions. This system produces fragmented, inefficient care and underpays for prevention and chronic care management.
This undervaluation and focus on discrete clinical services cannot adequately support the care teams needed for advanced primary care. FFS cannot sufficiently support integrated care for mental health and oral health or connect patients to programs that address social needs like food and housing insecurity.
Under FFS, practices serving patients with generous insurance plans have done relatively better, while practices serving safety net patients with complex needs fall behind. Over time, our health system has diverted resources away from comprehensive primary care for everybody, and particularly for those communities that need it most. Too many members of Black and Brown communities and too many people with lower family incomes lack a regular source of primary care.
As CMS notes, most value-based models to date also fail to reach communities of color and lower-income patients. But this is no surprise. Most new payment models are built on the FFS chassis and generally don’t provide the upfront resources that primary care practices need to transform to meet patient needs, especially in communities facing persistent health inequities.
Primary care and CMS’s strategy refresh
The good news is that CMS’s new roadmap identifies many of the most important signposts. Drawing sound lessons from the CMS Innovation Center’s (CMMI’s) first 10 years, the plan emphasizes extending benefits of delivery transformation to communities facing health inequities and aligning across Medicare, Medicaid and commercial payers. The roadmap even calls for steps to make CMMI’s models more patient-centered and responsive to glaring health inequities, including a shift to patient-centered performance measures and paying for social needs screening and demographic data collection.
But the path CMS has mapped will require more than launching slightly better and slightly more equitable CMMI model tests.
CMS’s clear aim is an accountable care relationship for nearly every beneficiary in Medicare and Medicaid. To actually reach that destination in 10 short years, policymakers must strengthen primary care.
Strengthening primary care means changing how it is paid. Practices in every community need a viable path away from a predominantly FFS system toward one that is predominantly reliant on comprehensive, prospective payments, adjusted for social and clinical risk.
Because primary care is the only health care delivery sector where increased supply is consistently associated with better population health outcomes, it also means increasing how much of each health care dollar goes to primary care, now estimated at between just 5 and 7 cents.
Most importantly, these changes must begin now.
Getting there from here
So how can administrations and Congress work together to reach the destination?
The launch of the Primary Care First model during the previous administration and the current administration’s decision to reopen it to new participants are useful, initial steps. But one size will not fit all the extremely diverse primary care needs in American communities. CMS rightly envisions a new primary care model — to launch in 2023. This new model must provide more options for practices to transition to comprehensive payment.
CMS should find ways to launch more smaller, independent and safety net practices fully on their own journey to better care and value. These practices typically lack the resources of a major multi-specialty group or hospital system. As CMS acknowledges, these practices will need upfront capital and often technical assistance and support to transform.
But a few time-limited model tests, however well-crafted, will not rescue primary care from its challenges. We cannot wait another 7 years for a 5-year model test to be completed, analyzed and expanded.
The more central issue will be whether and how quickly policymakers can apply what they are learning about primary care at CMMI across existing CMS programs. Take the Medicare Shared Savings Program as just one example. CMMI has learned that providing upfront resources to small and underserved accountable care organizations can pay off for them in increased savings and success. CMS could consider making upfront resources available as a permanent option within the Medicare Shared Savings Program for smaller, primary care-focused entrants. Similar consideration is needed across Medicare’s Physician Fee Schedule, the Medicare Advantage program, state Medicaid programs and other federal health care programs.
Congress also has a critical role to play in supporting this ambitious work.
First, Congress must extend the 5% payment bonus for Advanced Alternative Payment Models participation. This provision of the Medicare Access and CHIP Reauthorization Act of 2015 has been central to supporting value-based care, but under current law it will expire after 2024. If it does, more practices will see FFS payment as the only viable option.
Looking beyond Medicare payment, there is more Congress can do. It should require that Medicaid primary care payment levels at least match Medicare rates and increase support for technical assistance and workforce programs that practices need to transform, especially in communities facing health inequities.
Getting to the destination together
Whether we reach CMS’s desired destination in 10 years will depend on the strength of primary care in all American communities, across successive administrations and Congresses. For its part, the PCC will be laying out the evidence, building consensus and identifying the requirements to get us all there. We urge policymakers and stakeholders — clinicians, payers, consumers, purchasers and more — to join us now in strengthening primary care as the foundation of a high-performing health system.
References:
Basu S, et al. Health Affairs. 2020;doi:10.1377/hlthaff.2020.00794.
CMS. Innovation Center Strategy Refresh. https://innovation.cms.gov/strategic-direction-whitepaper. Accessed Dec. 1, 2021.
Ganguli I, et al. Ann Intern Med. 2020;doi:10.7326/M19-1834.
Kaiser Family Foundation. Key facts on health and health care by race and ethnicity. https://www.kff.org/report-section/key-facts-on-health-and-health-care-by-race-and-ethnicity-coverage-access-to-and-use-of-care/. Accessed Dec. 1, 2021.
Larry A. Green Center. Quick COVID-19 survey. https://www.green-center.org/covid-survey. Accessed Dec. 1, 2021.
PCC. Primary care spending: High stakes, low investment. https://www.pcpcc.org/sites/default/files/resources/PCC_Primary_Care_Spending_2020.pdf. Accessed Dec. 1, 2021.
National Academies of Sciences Engineering Medicine. Implementing high-quality primary care: Rebuilding the foundation of health care. https://www.nap.edu/read/25983/chapter/1. Accessed Dec. 1, 2021.