The CMS' newest experiment to change the way primary care is delivered and reimbursed may have a tough time getting off the ground and reaching its goals, experts say.
The new model involves Medicare working with commercial payers and state Medicaid programs to tweak the way they pay providers for care management in an effort to find better and less expensive ways to improve health outcomes.
But regulatory hurdles and bad experiences with an earlier pilot program could lead to poor participation. Experts say the model also could steer providers away from alternate payment models like accountable care organizations, which federal officials hope will account for half of Medicare spending by 2018.
Under the Comprehensive Primary Care Plus initiative unveiled Monday, the CMS and other payers will pay providers a monthly fee for patients' primary-care visits. The model will be implemented in up to 20 regions and could include up to 5,000 practices with 20,000 doctors and clinicians. As many as 25 million patients could be involved.
A pilot program launched in 2012 ends later this year. The initiative was found to have reduced total monthly expenditures by 2% per beneficiary in Medicare Parts A and B. The savings would offset the new monthly fees paid by the CMS.
Providers can participate in CPC Plus in two ways. In Track 1, the CMS will pay a monthly fee for specific services in addition to the fee-for-service Medicare payments.
In Track 2, practices will also receive a monthly care-management fee, but instead of full Medicare fee-for-service payments for primary care they will receive reduced Medicare fee-for-service payments and up-front payments. This hybrid model allows practices to provide care outside of the traditional face-to-face encounter, the agency said.
For example, practices might offer telemedicine visits or simply provide longer office visits for patients with complex needs.
The CMS hopes there is more interest in Track 2, which the agency estimates will save about $2 billion over the course of the five-year program. Track 1 was tagged as budget-neutral.
But the project will launch only in regions where there is “a critical mass of interested payers,” and experts say not many plans can participate in Track 2 because of state insurance regulations.
In response to reports of poor quality of care provided by physician practices receiving risk-based payments in the late 1980s and early '90s, many states passed laws restricting the arrangements to tightly regulated health maintenance organizations, according to Peter Kongstvedt, a senior health policy faculty member at George Mason University.
But relatively few consumers are now enrolled in commercial HMO plans, and state laws may prohibit other types of plans from participating in the CPC Plus program's risk-based track.
Regulatory concerns aside, some private plans may be leery of the program because of negative experiences with the similar pilot. For example, last year, Cigna wrote to the CMS asking that the program not be expanded.
“After three years of participation, we have not seen evidence of savings generated by the program,” the plan said.
“Continuing (the program) would be a crutch for providers, and would reduce incentives for them to join more innovative and better-run provider groups who are contracting with payers for more advanced patient-centered medical homes and accountable care arrangements,” it added.
The Blue Cross and Blue Shield Association, the parent organization of 36 plans, many of which dominate the markets in their states, said its members struggled under the demonstration.
“The unique nature of CMS working with private payers ... has created tension at times as well as a feeling that the (program) is not a true 'partnership',” the association said in its own letter last year. It pointed to situations where "payers received critical program updates secondhand from other regions or provider partners."
However, unlike Cigna, the Blue Cross and Blue Shield Association supported expanding the pilot because it felt that the CMS could improve communication.
The program's reliance on interest from providers and commercial payers means it may not reach many patients in the Southeast and mid-Atlantic regions of the U.S.
Those regions are consistently underrepresented in the CMS Innovation Center's initiatives, according to Dr. Kavita Patel, a senior fellow at the Brookings Institute and a former policy director for the Obama administration. A 2014 Northwestern University study found that Southern states have more unfavorable views of ACOs.
Another pitfall is that many providers could be attracted to Track 1 of CPC Plus, which doesn't require them, and siphon attention from more robust alternative payment models such as the Medicare Shared Savings Program for accountable care organizations.
Alternative payment models aim to address criticism that CMS has long provided economic incentives for providers to offer a greater volume of care regardless of outcomes.
Dr. Bob Kocher, a healthcare sector venture capitalist with the firm Venrock, said CPC Plus, and especially Track 1, might allow doctors to avoid taking responsibility for lowering their total cost of care and improving their performance on quality metrics.
A CMS spokesman did not return a request for comment.
Starting April 15, the agency will begin seeking payer partners. Once it gets a sense of which insurers are interested and in which regions, the CMS will solicit nearby practices for participation. That process will take place between July 15 and Sept. 1.