Primary care is the bedrock of a robust healthcare system, acting as the first point of contact for individuals seeking medical assistance. In the United States, recognizing the critical role of primary care, various initiatives have been launched to bolster its effectiveness and accessibility. Among these, the Comprehensive Primary Care (CPC) initiative stands out as a significant endeavor. This article delves into the details of a Primary Care Initiative Program, using the CPC as a prime example, to understand how such programs aim to revolutionize healthcare delivery, improve patient outcomes, and manage costs effectively.
The Comprehensive Primary Care Initiative: A Model Program
The Comprehensive Primary Care (CPC) initiative was a four-year, multi-payer program designed to strengthen primary care practices across the United States. Launched in October 2012, the Centers for Medicare & Medicaid Services (CMS) collaborated with commercial and state health insurance plans across seven designated U.S. regions to implement this initiative. The core objective of this primary care initiative program was to empower primary care practices by providing them with population-based care management fees and shared savings opportunities. This financial support was intended to facilitate the delivery of five core functions of comprehensive primary care:
- Risk-Stratified Care Management: Identifying and managing patients based on their risk levels to ensure tailored care.
- Access and Continuity: Ensuring patients have consistent access to care and a continuous relationship with their primary care provider.
- Planned Care for Chronic Conditions and Preventive Care: Proactively managing chronic conditions and delivering preventive services to maintain patient health.
- Patient and Caregiver Engagement: Actively involving patients and their caregivers in care decisions and self-management.
- Coordination of Care Across the Medical Neighborhood: Enhancing communication and coordination among various healthcare providers involved in a patient’s care.
This primary care initiative program aimed to assess whether supporting these five core functions, coupled with multi-payer payment reforms, data-driven improvement strategies, and the effective use of health information technology, could lead to improved care quality, healthier populations, and reduced healthcare costs. The findings were intended to inform future Medicare and Medicaid policies related to primary care.
Participating Practices and Reach
By October 2016, the CPC initiative had expanded to include 442 practice sites across the seven participating regions. This extensive network involved 2,188 healthcare providers serving approximately 2,700,000 patients. Of these patients, around 410,177 were Medicare & Medicaid beneficiaries, highlighting the program’s significant reach within vulnerable populations. The collaborative nature of this primary care initiative program is further underscored by the participation of 38 public and private payers.
Addressing the Need for Primary Care Investment
Historically, primary care in the United States has faced underfunding, hindering its ability to transform and meet the evolving healthcare needs of the population. Individual payer investments, addressing only segments of a practice’s patient base, proved insufficient to drive the comprehensive changes required for effective primary care transformation. The CPC initiative was specifically designed to overcome this obstacle through multi-payer collaboration.
The selection of the seven CPC regions was a strategic process. Payers nationwide were invited to express their interest, and regions demonstrating the highest collective commitment to aligning payment models in support of the five CPC functions were chosen. Eligible practices within these selected markets were then invited to apply and begin delivering enhanced healthcare services. Practices were chosen based on a competitive application process that considered their use of health information technology, recognition by accreditation bodies for advanced primary care delivery, service to patients covered by participating payers, engagement in practice transformation activities, and diversity in geography, size, and ownership structure. The CPC initiative concluded in December 2016, paving the way for future advancements in primary care models.
Initiative Mechanics: Payment and Practice Redesign
This primary care initiative program operated on a dual approach, integrating a specific payment model with a practice redesign model to drive improvements in care, population health, and healthcare costs.
Payment Model:
Participating primary care practices received financial support for their fee-for-service (FFS) Medicare beneficiaries through two main avenues:
- Monthly Care Management Fee: A consistent monthly payment, independent of patient visits, to support care management activities.
- Shared Savings Opportunity: An opportunity to share in any net savings generated for the Medicare program through improved care delivery.
The monthly care management fee from Medicare averaged $20 per beneficiary per month during the initial two years (2013-14) and subsequently adjusted to $15 per beneficiary per month for years three and four (2015-16). Practices also received comparable monthly fees from other participating CPC payers. These combined revenues were intended to empower practices to develop and implement comprehensive, practice-wide transformation strategies. Furthermore, the shared savings component provided a performance-based incentive. Savings to the Medicare program were calculated regionally and distributed to practices based on their performance on predetermined quality metrics. Similar shared savings opportunities were also available with other CPC payers within their respective regions. The payer landscape within the CPC regions was diverse, encompassing commercial insurers, Medicare Advantage plans, Medicaid managed care organizations, and Third Party Administrators, along with state fee-for-service Medicaid agencies in Arkansas, Colorado, Ohio, and Oregon, with CMS funding the enhanced payment models for these state Medicaid agencies.
Practice Redesign Model:
The CPC initiative provided resources and guidance to help practices implement the five core comprehensive primary care functions. These functions represented a roadmap for transforming primary care delivery:
- Access and Continuity: Practices were encouraged to provide timely, 24/7 access to care, leveraging medical records to ensure continuity, and tracking continuity of care by provider or panel.
- Planned Care for Chronic Conditions and Preventive Care: Practices were expected to proactively assess patient needs, deliver timely chronic and preventive care, including medication management, develop personalized care plans for high-risk patients, and integrate team-based approaches, such as behavioral health services.
- Risk-Stratified Care Management: Practices were tasked with identifying and risk-stratifying their patient populations and implementing targeted care management programs for high-need patients.
- Patient and Caregiver Engagement: Engaging patients and their families in shared decision-making across all aspects of care, promoting culturally competent self-management support, and utilizing decision aids for preference-sensitive conditions were key components.
- Coordination of Care Across the Medical Neighborhood: As the central point of contact for many patients, primary care practices were to lead care coordination efforts, managing care transitions, referrals, and information exchange with other healthcare providers.
CMS facilitated the implementation of these five functions through a framework of “Milestones,” with participating practices regularly reporting their progress via a web portal. Support mechanisms included national and regional learning networks, online collaboration platforms, and access to local academic and clinical faculty contracted by CMS to provide hands-on assistance. To foster learning across payers, CMS convened regional and national forums for CPC payers to review data, discuss trends, and share improvement strategies.
Practice Spotlight: Brunswick Family Practice
The CPC initiative also highlighted success stories from participating practices. For instance, Brunswick Family Practice in Troy, NY, utilized data analysis to identify areas for improvement. By analyzing top diagnosis codes, they focused on radiological screening options for patients with low back pain. This led to the development of a video decision aid for patients, accessible through the patient portal, to promote shared decision-making and reduce unnecessary radiation exposure. Data from May 2014 showed that 79% of eligible patients had viewed the decision aid, and radiology studies among eligible patients decreased by over 4 percentage points, demonstrating both cost savings and improved patient care.
Evaluations and Further Information
The CPC initiative underwent rigorous evaluations to assess its impact. Evaluation reports are available to provide detailed insights into the program’s effectiveness and outcomes. For further inquiries, individuals were encouraged to contact [email protected].
In conclusion, the Comprehensive Primary Care initiative program serves as a valuable model for strengthening primary care in the United States. By integrating multi-payer collaboration, innovative payment models, and a focus on comprehensive practice redesign, such initiatives hold the potential to significantly improve healthcare quality, enhance population health, and achieve cost efficiencies within the healthcare system.
