500 practices selected for primary care management fee demo

Washington More than 2,000 physicians and health professionals will care for Medicare, Medicaid and private plan beneficiaries under the same new payment model aimed at coordinating care and keeping patients healthy to avoid costly admissions for inpatient care.

Roughly 500 physician practices in seven regions spread out over eight states successfully applied to participate in the Centers for Medicare & Medicaid Services-led comprehensive primary care initiative. Doctors will receive as much as $40 per high-risk patient per month to support care coordination and wellness programs. Practices that keep health spending below expenditure targets will share in the savings, but those that do not meet expectations might be asked to leave the project.

In June, CMS announced that dozens of private insurers also would pay physicians using the same shared savings model. The program will begin in November and last four years.

The American Medical Association applauded the inclusion of nearly 500 physician practices in the initiative, said AMA President Jeremy A. Lazarus, MD. “This innovative model will not only enhance primary care delivery for patients but will also bring private insurers to the table to support physicians’ efforts.”

Hunterdon Healthcare will have 11 out of its 24 employed and affiliated practice sites participating in the project in New Jersey, said George Roksvaag, MD, the system’s chief medical officer. The typical primary care practice under the fee-for-service payment model does not earn enough revenue to support care coordination activities for patients at high risk for serious illness.

“If you’re going to transform care, you have to transform the payment methodology,” Dr. Roksvaag said.

The initiative will pay practices an average of $20 per patient per month for the first two years. The average management fee then drops to $15 per patient during the third and fourth years of the demonstration. Some insurers, such as Horizon Blue Cross Blue Shield of New Jersey, will extend the care management fee option to sites that were not selected for the official demo, Dr. Roksvaag said.

St. Elizabeth Physicians, with offices in Kentucky and Ohio, had evaluated the Medicare accountable care organization program, which rewards physicians who help generate savings from coordinated care and assesses penalties for not containing health spending. The ACO model was not the right fit, but the primary care initiative seemed to make more sense, said Glenn Loomis, MD, president and CEO of St. Elizabeth Physicians.

CMS picked 14 St. Elizabeth practices for the demo, representing about half of the offices in the group. Up to 80% of a selected physician’s patient panel will have insurance coverage from a payer participating in the primary care initiative. However, all patients in the practices will receive the same medical home services regardless of their coverage, Dr. Loomis said.

“Having a large percentage of patients in the initiative is going to make it successful,” he said. All primary care physicians are aligned around the concept of a patient-centered medical home and ensuring that necessary infrastructure, such as an electronic health record system, is in place to support the initiative. However, he said patient management fees will allow physicians to use better patient registries, operate call centers for patients, and support disease management staff to improve care and prevent hospital readmissions.

“We have the chance to change not just the model of practice, but maybe change outcomes and the health of millions of patients,” Dr. Loomis said. “I have not seen anything as exciting as this in my career.”

The insurer Humana is participating in Arkansas, Colorado, Kentucky and Ohio. Patients with coverage through Humana will have access to 75 practices participating in the initiative in three regions. The partnership with CMS will allow primary care practices to operate within a framework to coordinate care, said Renee Buckingham, Humana’s vice president of provider engagement, in a statement. “By collecting data that pertains to cost, quality and member satisfaction, the comprehensive primary care initiative enables Humana to identify and drive greater efficiencies while delivering quality, affordable health care to our members in their quest to achieve well-being.”

The primary care demonstration needs to show it can improve or maintain quality and decrease expenditures before it can be expanded nationwide, said Richard Gilfillan, MD, acting director of the CMS Center for Medicare and Medicaid Innovation. “We think we will be able to convince actuaries that it is making a difference.”