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Preliminary Results for Primary Care Transformations

On February 23, 2015, the Centers for Medicare & Medicaid Services (CMS) announced the promising findings from two large-scale tests of advanced primary care: the Comprehensive Primary Care (CPC) initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration. These two programs are part of Primary Care transformation efforts to deliver better care, spend dollars more wisely, and have healthier people and communities.

Comprehensive Primary Care initiative

With authority from the Affordable Care Act, the CPC initiative is a unique multi-payer partnership between Medicare, Medicaid private health care payers, and primary care practices. The CPC initiative integrates a defined payment model with a specific practice redesign model to support improved care, better health for populations, and lower health costs. This initiative includes providing care management for those at greatest risk; improving health care access; tracking patient experience; coordinating care with hospitals and specialists; and using health information technology to support population health. Practices receive non-visit based care management fees from the participating payers, and the opportunity to share in savings.

In the first year, 492 practices participated, serving about 345,000 Medicare beneficiaries and more than 2.5 million patients overall. The CPC initiative, resulted in decreased hospital admissions by 2% and emergency department visits by 3%, contributing to the reduction of expenditures nearly enough to offset care management fees paid by CMS. Savings were seen in the reduced rates of hospital admissions and emergency department visits. Most of the savings were generated by patients in the highest-risk category, but good results were seen in other patients. About 90 percent of practices successfully met all first-year transformation requirements. The effects of the CPC program will probably be larger in subsequent years, these early results are consistent with the possibility that the model will eventually break-even or generate savings.

Multi-payer Advanced Primary Care Practice Demonstration

The MAPCP Demonstration is multi-payer initiative in which Medicare is participating with Medicaid and private health care payers through advanced primary care initiatives. Under this demonstration, participating practices and other auxiliary supports receive monthly care management fees from the participating payers and additional supporters. Unlike CPC, the states convene the participants and administer the initiatives rather than CMS

In the first year, more than 3,800 providers, 700 practices, and 400,000 Medicare beneficiaries participated. During the first year, the demonstration produced an estimated $4.2 million in savings. The MAPCP payments provided needed support to help practices transform the way they deliver and coordinate care, including use of nurse care managers or care coordinators, restructuring of staff, improvements in patient flow, adoption of health information technology, and more frequent staff meetings. Medicare was able to integrate seamlessly with the structure and organization in the initiatives. Medicare’s participation sent a strong signal about the importance of primary care and the potential of these programs, helping to affirm payer and provider commitments. CMS anticipates continued improvements as the participating practices deepen and refine their methods of delivering advanced primary care so that patients can continue to receive improved quality and coordination of care.

Based on first year results, CMS says its two advanced primary care initiatives show promise for saving money and improving health-care quality. Results from this first year suggest that CPC initiative has generated nearly enough savings in Medicare health care expenditures to offset care management fees paid by CMS. MAPCP Demonstration illustrates the potential for steady improvements in the participating practices’ advanced primary care capabilities. Results should be interpreted cautiously as effects are emerging earlier than anticipated and additional research is needed to assess how the initiative will affects cost and quality of care in the long run.

While these efforts primarily focus on the Medicaid and Medicare fee-for-service environments, CMS is also pushing Medicaid managed care and Medicare Advantage plans to put a priority on establishing medical homes and ensuring primary care physicians engage with health plans to improve quality and participate in care management. New Special Needs Plans regulations and guidance, along with audit findings, have forced Medicaid and Medicare plans to take seriously their Models of Care and show outcomes.

It is hoped that the various initiatives of CMS and state Medicaid agencies will finally emphasize primary care and prevention, a notable weak spot for America compared with other developed countries with mature health systems.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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