By Lisa Dulsky Watkins, Monica Ng, and Greg Poorman

April 4, 2018

Established in 2010 through the authority of the Affordable Care Act, the Centers for Medicare and Medicaid Services’ Innovation Center (CMMI) provides a mechanism for Medicare and Medicaid to test new payment and service delivery models that have the potential to increase the “value” of health care by improving quality, lowering utilization and costs, and improving the experience of both delivering and receiving care. The Comprehensive Primary Care Plus (CPC+)¹ program is the largest-scale endeavor focused on patient-centered primary care through aligned regional multi-payer payment reform and care delivery transformation. The Milbank Memorial Fund collaborates with the regional leaders and implementers of the CPC+ in an effort to accelerate achievement of the program’s goals.

In September 2017, CMMI released a request for information (RFI)², eliciting ideas for and comments on future directions for CMMI, which triggered over 1000 responses. Many physician groups, insurers, state government agencies, and special interest groups submitted letters or comments.

In the past, RFI responses were shared with the public, but were not in this case. Since RFI comments are often informative, and potentially instructive for others engaged in similar work, we believed that there was much to be learned about stakeholders’ concerns and priorities through an examination of their RFI responses. We collected and analyzed 69 RFI comments and letters from a diverse group of stakeholders (Table 1). Of those, 57 were publicly available online and 12 were shared by Comprehensive Primary Care Plus (CPC+) regional participants via email.

Table 1.

Organizations represented in RFI collection     Number of RFI responses

Commercial payers                                                               10
State agencies (including state Medicaid)                         10
Physician specialty groups                                                   23
Medical technology organizations                                      11
Health policy-focused organizations                                  14

Several common themes emerged from our analysis of this response sample.

1.  There is nearly unanimous support for CMMI and Advanced Alternative Payment Models (APMs) among RFI respondents. 

Several common themes emerged from our analysis of this response sample. CMMI has tested models that support a departure from fee-for-service payment systems, which by definition pays per service rendered and rewards volume in the form of the number of billable encounters. Ninety-six percent of respondents to the RFI agreed that the way forward is through development and expansion of APMs, payment structures which reward value and quality rather than volume.

Respondents suggested several features for future alternative payment models (APMs) that could help to make them successful. The Arizona Health Care Cost Containment System and others emphasized that models must be put into an easy-to-evaluate form to encourage uptake. They emphasized that the clarity with which quality, cost, and outcome changes are measurable is paramount. The Colorado State Innovation Model Team petitioned for strong CMMI leadership, positing that private payers will follow Medicare’s lead towards enhanced payment for primary care.

2. There is broad support for continuation of current CMMI models.

The majority (78%) of respondents appealed for continuation or expansion of current CMMI models such as the CPC+ and accountable care organizations (ACO). Concern was expressed that any new directions CMMI takes should not preclude current models from continuing and therefore seeing long-term results. The Health Care Transformation Task Force wrote, “A critical focus of CMMI going forward should be using the lessons learned….to make improvements to the existing models that are showing genuine, long-term promise. CMS should carefully evaluate the current models, many of which have required significant stakeholder investment and don’t necessarily lend themselves to overnight success.”

3. There is support for multi-payer payment reform.

 CPC+ and other advanced primary care initiatives’ success and sustainability hinge on multi-payer payment reform.³ Sixty-one percent of our sample of RFI responses advocated for alignment across payers, which can include coordination on payment policies and methodologies, data-sharing practices, quality measurement protocols, and administrative protocols. Respondents such as the Medical Group Management Association and American Academy of Family Physicians noted that increased payer alignment allows for standardized outcome measures, decreases administrative burdens, and enables more clinical entities to participate in APMs.

Twenty-five of the collected RFI responses explicitly highlighted the advanced medical home. The Patient-Centered Primary Care Collaborative wrote, “CPC+ offers the potential of greatly strengthening the ability of internists, family physicians, pediatricians, nurse practitioners, and other primary care clinicians, in thousands of practices nationwide, to deliver high value, high performing, effective, and accessible primary care to millions of their patients. While it is too early to expect results, we believe that the success of this program will depend on Medicare and other payers providing physicians and their practices with the sustained financial support needed to transform their practices and achieve the quadruple aim.” In other RFI responses, the Oregon Health Authority, the Ohio Governor’s Office of Health Transformation, and the Tennessee Health Care Innovation Initiative reported that hundreds of thousands of patients in their states are being routed to improved primary care services via CPC+ programs.

4. Participation in advanced APMs should be available to more types of clinical practices.

RFI respondents discussed the need for more types of practices to be considered eligible for participation in APMs. Many organizations representing small and rural health clinics, federally qualified health centers (FQHCs), and pediatric practices advocated for eligibility to participate in CMMI models. AmeriHealth Caritas highlighted the difficulty encountered by practitioners: “We have found that many [FQHCs] in our provider networks are equally or more ready for value-based payment. In fact, we have an increasing number of FQHCs participating in our shared-savings programs, and these providers are actively using data to monitor and improve performance and quality outcomes.”

5. Cost and quality data need to be reformed and aligned for transparent information exchange.

Sixty-five percent of respondents emphasized the need for continued innovative support for data transparency and alignment. The Ohio Governor’s Office of Health Transformation described success with data aggregation, where providers are using claims data in their episode-based payment model. “We are seeing proactive examples of value-seeking behavior, for example many primary care providers have started to have weekly conversations with local emergency departments based on the reports they receive on specific episodes of care with a goal of preventing similar, unnecessary episodes from occurring in the future.” The Oregon Health Authority explained that alignment of performance metrics can promote coordinated care, improve health outcomes, and reduce cost. The Oregon Health Authority also specifically requested Innovation Center support for certain technology features including real-time claim adjudication and follow-up, end-to-end data analytics, data visualization, and “big data” architecture management.

6. Behavioral health needs greater resource investment.

Sixty-two percent of responses emphasized the need to integrate behavioral and medical health. The national Blue Cross Blue Shield Association wrote that patients with both mental and physical illnesses are currently treated and financed in separate systems and are therefore forced to interact with myriad agencies and providers. This leads to significant fragmentation of care. United Health Care’s statement underscored this premise. “Integrating behavioral health care with medical care will: improve health outcomes; enhance patient engagement and activation; increase adherence to appropriate behavioral health services; improve patient satisfaction; and reduce costs.”

In summary, our review of a modest sample of RFI responses demonstrates support for continued and potentially expanded testing of new models of payment for primary care.

References

1. Centers for Medicare and Medicaid Services.  Comprehensive Primary Care Plus. Centers for Medicare and Medicaid Services- Innovation Center website. https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus. Accessed March 15, 2018.

2. Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services: Innovation Center New Direction. Centers for Medicare and Medicaid Services Innovation Center website. https://innovation.cms.gov/initiatives/direction/.  Accessed March 15,2018.

3. The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization. The Patient-Centered Primary Care Collaborative. The Patient-Centered Primary Care Collaborative website. https://www.pcpcc.org/sites/default/files/resources/pcmh_evidence_report_08-1-17%20FINAL.pdf. 2017. Accessed March 15, 2018.