CMS initiatives meant to help primary care result in dismay

Populations served by good primary care have – on a risk-adjusted basis – better health outcomes at lower per-capita spending on health.¹  Recognizing the need to better resource the work of good primary care physicians, CMS announced their Comprehensive Primary Care Plus (CPC+) program which will launch January 2017.²

PCPs participating in the more intense of two levels of participation can receive care management fees averaging $28 per beneficiary per month in addition to a four percent performance-based payment incentive and (this is starting to read like a late night advertisement) a Comprehensive Primary Care Payment.  This CPCP replaces some of the fee-for-service with what is essentially an up-front primary care capitation payment.  CMS estimates that this CPCP plus FFS results in 110 percent payment to the practice, even before counting the care management fees and performance incentives.

An essential point is that CMS understands that primary care is important, that it is under-resourced, and that PCPs need up-front payments and can’t go deep into a financial hole speculating on possible shared savings many months down the road.

Expecting relief and praise from my friends in practice, I was taken aback by the intensity of negative reactions.

“After MU and PQRS and MACRA, I doubt anyone in their right minds believes the CPC+ will be anything but a way for mega hospitals to make even more money and finally crush the little guys.”

“Do you know any ophthalmologists who do this crap to get paid?”

“We have spent a lot of money building our capacity to manage populations to better outcomes and have succeeded under MSSP.  CPC+ pulls the rug out from under us – we are excluded from participation and the program makes it harder to get independent PCPs to join with us.”

Some may dismiss these comments as coming from folks who don’t care about outcomes, just as clinicians might write off a patient as “non-compliant.”  That would be a mistake.  So-called non-compliance is most often a signal that we have yet to fully understand the issues that stand between the person and the outcomes we would want for them. 

Each of the folks above (they were speaking off the record so I didn’t use names) are excellent clinicians and administrators and have each spent a decade or more redesigning the ways they work so that their patients get the best care possible. 

Here’s how I interpret these responses:

• The burden of participation is high: CMS is working to reduce the friction through streamlined programs (e.g. MIPS), but has a long way to go.
• Day-to-day practice of primary care is increasingly difficult: Programs aiming to help come with complexity and burdens that are very difficult to manage.
• Technologic solutions in the market fall well short of the goal: The burden of measurement and reporting is too high.  This is due in part to inadequate technology, but also to the mistaken paradigm of measurement. 
• Programs too often focus on the wrong things: Adding process and minute quality detail comes (currently) at a cost of actual care delivery for too many caring clinicians.

Here are some possible solutions:

• Focus more on outcomes and less on process: There are still too many metrics to track in CPC+.
• Allow entities/practices to shift from older into newer programs that better align financing with good care delivery: Allow MSSPs to flip into CPC+ if they can meet the criteria.
• Reduce the friction of participation: Somehow put pressure on the IT vendor community to line up in support of interoperability and other solutions that reduce the friction of work (oh, wait! CPC+ has this built in!  Good going folks.)
• Health plans need to step up their game: CMS is shifting the payment model away from FFS.  Commercial and Medicaid plans should support the shift with more realistic payments to primary care and by bringing to bear innovative solutions to reduce the friction of work.  The commercial plans in particular have a better opportunity to innovate in this space and can demonstrate their continued relevance by moving more quickly.

These problems are not intractable.  We are in the midst of a sea-change in U.S. healthcare financing and have a long way to go to redesign how care is delivered.  The change has been and will continue to be difficult.  We need to keep the pressure on everyone – policy makers, providers, health plans – to focus on what really matters while we shed unhelpful activity.  We should shed not only the unnecessary care delivery, but also the unnecessary aspects of programs that divert attention from people needing care to reporting engines demanding attention in exchange for dollars.

L. Gordon Moore, MD, is senior medical director for Populations and Payment Solutions at 3M Health Information Systems.

¹ Starfield, Barbara, Leiyu Shi, and James Macinko. “Contribution of Primary Care to Health Systems and Health.” The Milbank Quarterly 83, no. 3 (September 2005): 457–502. doi:10.1111/j.1468-0009.2005.00409.x.

² https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-11.html