AMA Pres Talks CMS' Latest Alternate Primary-Care Model

Earlier this week, CMS announced a new multi-payer initiative aimed at improving primary care. It's a sequel that AMA President Steven J. Stack, an emergency physician, says he hopes is better than the original.

Building off 2012's Comprehensive Primary Care initiative, the Comprehensive Primary Care Plus (CPC+) will be implemented in up to 20 regions, accommodate up to 5,000 practices, and have an effect on more than 20,000 primary-care doctors in January of next year. If your primary-care practice is affiliated with a payer that is selected in your region, this could have an effect on you.

The model will give practices an upfront care management fee that they'll get to keep if they meet various performance-based quality and utilization performance thresholds. For the model, there are two tracks for practices to take: One that pays a care management fee in addition to fee-for-service payments and one that will pay greater incentive payments in exchange for less reliance on fee for service care. The models will include five key components: 24/7 access to care through telephone or electronic means; proactive care for patients with the highest medical risk; preventive and coordinated care with specialists; engagement of patients and families; and measurement of quality and utilization.

What should primary-care physicians know about this model? Physicians Practice spoke with Stack to get the AMA's thoughts on what it means for docs, why this may be better than CMS' first primary-care model, and much more, in a two-part interview series. Below is part one of the interview. Here is part two of the interview.

What were your initial thoughts on CMS' new primary-care plus model?

On first glance, we see this is a good sign and are grateful that CMS has taken to heart some of the suggestions that we've made. It's one of the first initiatives they've created that doesn't rely on a shared savings methodology and doesn't base the performance calculations on the total cost of care. This heads closer to our recommendations, focusing on specific types of utilization that particular physicians can influence, rather than just penalizing them based on things beyond their control. These sorts of incentives hopefully positively transform healthcare, but also support physicians by giving them the resources to do things that patients need done. It holds physicians accountable for things within their control, not things outside their control.

It also appears there will be flexibility and the population-based payment, as I understand it, can provide support and flexibility for the more advanced primary-care practices to manage the health of their patient populations and provide additional services, such as care management and consultations with physician specialists, which are not covered in the traditional payment system. We believe to be successful, these population-based payments should be designed in a way that allows practices to plan and budget ahead of time, without adding unduly to the physicians' burden.

We see this as a positive first step, but we are cautious and the details really matter. We are hopeful this is a sign that CMS, with who we have been dialoguing, can work together with us to advance a high-quality delivery system that increases value to patients, enhances quality, but also advances the quadruple aim. We want better health, better care, and lower cost, but we also want to have healthier physicians and clinicians providing that care. We've too long failed to attend to the adverse consequences on the physician workforce, who are feeling progressively demoralized and burned out by an overwhelming crush of administrative and regulatory burdens that are often unobtainable and conflicting.

Why is this an improvement over the current primary-care model, as you said?

We see it as an improvement because previous models held physicians accountable for total costs of care, which at times, many aspects of which were outside their realm. As we understand it, this more closely tailors to the things the physician can directly influence or control. Therefore, it aligns accountability with their true ability to impact.

One sure-fire way to set anyone up, especially high-performing professionals, for failure and frustration is to say you are responsible for this, even if you can't control it. This approach … is not constructive. This model, as we understand it, heads to the direction that physicians can directly influence.

One good thing about [these new models], we've observed in the past a number of the early iterations of alternative payment models failed to give physicians the upfront resources they needed to invest in new delivery systems. If we want to coordinate care for a patient, offer extended services, make investments in technology tools to facilitate new payment models, this all costs money. Primary-care offices don't have abundance of money in today's world. Having CMS invest upfront and give the practices the resources they need to make those delivery and process redesigns, it's a step forward. We're grateful to see them do it.

This plan calls for upfront incentive payments that physicians either keep or give back depending on how well they perform on "quality and utilization metrics." Does concern you?

All of us would rather have the gift on the front end without nothing on the back end. If I had my druthers, I'd have the incentive on the front, [but] I don't think that's realistic. The government isn't going that way and there is nothing to suggest they were going that way. Congress … requires these alternative payment models have some of the risks shared with physicians. Now, how we share that risk is an important detail and what is reasonable to discuss. Is it shared risk between CMS and physician or is it fully borne by the physician? As we look at the details of the proposal, and others that are coming, we are going to have to look very carefully. The upfront investments are essential if people and professionals will have to update the system. Accountability for use of the resources is unavoidable.

Part two will be coming on Friday, April 15^th.