Medicare project promotes coordinated care

One promising approach to improving health care is the largely untapped potential of primary care practices to coordinate treatment, especially for patients with chronic conditions. Maintaining continuity of care and appropriately avoiding the very costly end of the treatment spectrum -- unnecessary hospital admissions or trips to the emergency department -- makes sense.

What, to a large degree, is still missing is practical support from public and private payers for these efforts, which in their fullest form are typically referred to as medical homes. If anything, there is a payer wariness about paying for "something extra" for patients. Now, a new Medicare demonstration project, in concert with private insurers, is being launched to support and assess the delivery of this type of enhanced primary care.

The Comprehensive Primary Care Initiative, announced in September, will offer patient management fees to physicians while sharing savings under an alternative primary care payment model.

The effort is being led by the Centers for Medicare & Medicaid Services, which will be joined in 2012 by private payers. Physician practices can apply once the payer side of the initiative is in place.

The patient management fee alone is expected to average $20 a month for each patient who is covered by participating payers. This is in addition to traditional fee-for-service payments. The shared portion of the payment will be based on what Medicare saves during the initiative.

This demonstration has a lot going for it. The physician, appropriately, is in the driver's seat. There is a guaranteed per-patient payment that addresses the fact that participation places demands on practice resources. All this is paired with providing the practice with quality and utilization data.

All told, CMS will select up to seven areas of the country for the project. About 75 practices will be included in each market and serve more than 300,000 Medicare and Medicaid beneficiaries.

At present, relatively few private payers support medical home models, and a physician may find that in a given market, one plan that the practice contracts with will pay, and others won't. What's needed is greater understanding by the payer community -- both public and private -- of the effectiveness of the medical home. This must be paired with a recognition that the work must be paid for if it ever is to become a standard part of patient care.

Already, initiatives based on such coordinated care have shown to be successful at keeping patients healthier and lowering health care costs. For example, the Community Care of North Carolina program, which was started as a Medicaid medical home project, has reduced preventable hospitalizations for patients with chronic conditions.

The Comprehensive Primary Care Initiative is supported by the American Medical Association. The AMA has called on CMS to transform health care delivery and payment in ways that improve care and save money. In the case of this initiative, the AMA made recommendations that were reflected in the final design of the demonstration project, such as the monthly payments to doctors for care coordination and the flexibility to design programs that work best at the local level.

No doubt, many primary care physicians have provided what amounted to medical home services -- unfairly, unpaid and unsupported -- as a matter of concern for their patients. That's admirable, but even paired with what payer support is out there, it is not transformational. If the medical home is to provide large-scale benefits to the health care system, this approach requires much broader application.