Skip to main content
Subscribe
  • Sign Up Free
  • Login
  • Subscribe
  • News
    • Current News
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Digital Health
    • Transformation
    • ESG
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Blogs
    • AI
    • Deals
    • Layoff Tracker
    • HIMSS 2023
  • Opinion
    • Breaking Bias
    • Commentaries
    • Letters
    • From the Editor
  • Events & Awards
    • Awards
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • Nominate/Eligibility
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Excellence in Governance
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top Innovators
    • Diversity in Healthcare
      • - Luminaries
      • - Top 25 Diversity Leaders
      • - Leaders to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Digital Health Transformation Summit
    • ESG: The Implementation Imperative Summit
    • Leadership Symposium
    • Social Determinants of Health Symposium
    • Women Leaders in Healthcare Conference
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Diversity Leaders Gala
    • Top 25 Women Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Hospital at Home
    • - Workplace of the Future
    • - AI and Digital Health
    • - Future of Staffing
    • - Hospital of the Future (Fall)
  • Multimedia
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Sponsored Video Series - One on One
    • Sponsored Video Series - Checking In with Dan Peres
  • Data & Insights
    • Data & Insights Home
    • Hospital Financials
    • Staffing & Compensation
    • Quality & Safety
    • Mergers & Acquisitions
    • Data Archive
    • Resource Guide: By the Numbers
    • Surveys
    • Data Points
  • Newsletters
  • MORE+
    • Contact Us
    • Advertise
    • Media Kit
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Opinion
April 25, 2019 03:24 PM

Editorial: Yet another voluntary, value-based reimbursement program

Merrill Goozner
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print
    Merrill Goozner

    Merrill Goozner

    To put the CMS’ latest voluntary program promoting primary care in its proper perspective, one should think in biblical terms.

    In the beginning, the 2006 Tax Relief and Health Care Act called on the CMS to set up “medical home” experiments at willing primary-care practices. In 2011, the newborn Center for Medicare and Medicaid Innovation begat the Federally Qualified Health Center Advanced Primary Care Practice demonstration and the Multi-Payer Advanced Primary Care Practice demonstration.

    They begat the 2012 Comprehensive Primary Care initiative, which in turn begat the 2017 Comprehensive Primary Care Plus model.

    And, last week, HHS Secretary Alex Azar announced that starting next January the government will launch a new Primary Care First model—the latest voluntary initiative in a long line of such programs. He claimed this one would eventually reach a quarter of Medicare beneficiaries.

    What have we learned in the decade since the CMS began experimenting with turning primary-care practices into patient-centered medical homes? Have they delivered on their promise of higher salaries for primary-care physicians? Have there been fewer referrals to high-cost specialists, reduced hospitalizations and lower overall spending?

    Most evaluations have concluded: No.

    For instance, an RTI analysis of the use of Medicaid medical home programs in three states found they “did not have a clear pattern of impact on utilization, expenditures or quality.” An evaluation of the CMS’ most recent CPC+ model found “few, very small differences in service use and quality-of-care outcomes or total Medicare expenditures.” In fact, CPC+ practices cost the CMS 2% to 3% more than practices in traditional fee-for-service Medicare.

    But those downbeat assessments are misleading. What the analysts also found was that the practices that achieved program goals have been at it for years. In other words, it takes time, as well as proper incentives, to create a successful medical home program.

    The same has proven true among accountable care organizations. An analysis of physician-led ACOs in the Medicare Shared Savings Program, published last September in the New England Journal of Medicine, showed they collectively saved taxpayers just under $500 per patient even though hospital-led ACOs as a group lost money. The savings at physician-led ACOs grew larger every year they were in the program.

    The organizations that do best in these programs invest heavily in care coordination. They focus on preventing hospitalizations among the 5% of patients with multiple chronic conditions who generate half of all spending.

    They address unmet medical needs like untreated hypertension, pre-diabetes and behavioral health. They deploy social workers and home health aides to help patients address their nonmedical social needs like poor nutrition and inadequate housing. 

    Like previous pilot projects, Primary Care First has tailored its incentives to foster these approaches. It will provide practices with a single monthly payment, which “allows clinicians to focus on caring for patients rather than their revenue cycle.” 

    The two-sided risk model is tilted toward the upside. If practices fail to save the agency money, they can only lose up to 10% of their payments—about what the CMS calculates would be their revenue cycle costs under traditional fee-for-service Medicare. On the other hand, they can collect up to 50% of savings.

    There are dangers here that bear watching. The downside only impacts the primary-care payment. The upside applies to total costs. That could lead to gaming—like stinting on necessary hospital care.

    More significantly, Azar, like all previous secretaries, opted for a voluntary approach. Don’t be surprised when far fewer than projected sign up. Primary-care docs, wildly underpaid compared with specialists, tend to be risk-averse, no matter how small the downside.

    It’s past time for the CMS to adopt mandatory value-based reimbursement, with appropriate ramp-up periods to accommodate the learning curve. Primary-care medical homes would have been a great place to start.

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    capitol hill
    Senate advances bill to temporarily aid hospitals, health centers
    Centene Corporation_i copy_i.png
    Centene to lay off 2,000 workers
    Most Popular
    1
    CMS tries luring providers to revamped Medicare ACOs
    2
    Oregon joins other states in setting ratios for nurse staffing
    3
    Blue Shield CA taps Amazon, Mark Cuban, CVS for new PBM model
    4
    A health innovation hub grows in Lake Nona Medical City
    5
    Hospital-at-home providers push for Medicaid coverage
    Sponsored Content
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Help Center
    • Advertise with Us
    • Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2023. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Digital Health
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • ESG
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Blogs
      • AI
      • Deals
      • Layoff Tracker
      • HIMSS 2023
    • Opinion
      • Breaking Bias
      • Commentaries
      • Letters
      • From the Editor
    • Events & Awards
      • Awards
        • Nominate/Eligibility
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Excellence in Governance
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top Innovators
        • Diversity in Healthcare
          • - Luminaries
          • - Top 25 Diversity Leaders
          • - Leaders to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Conferences
        • Digital Health Transformation Summit
        • ESG: The Implementation Imperative Summit
        • Leadership Symposium
        • Social Determinants of Health Symposium
        • Women Leaders in Healthcare Conference
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Diversity Leaders Gala
        • Top 25 Women Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Hospital at Home
        • - Workplace of the Future
        • - AI and Digital Health
        • - Future of Staffing
        • - Hospital of the Future (Fall)
      • Webinars
    • Multimedia
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Sponsored Video Series - One on One
      • Sponsored Video Series - Checking In with Dan Peres
    • Data & Insights
      • Data & Insights Home
      • Hospital Financials
      • Staffing & Compensation
      • Quality & Safety
      • Mergers & Acquisitions
      • Data Archive
      • Resource Guide: By the Numbers
      • Surveys
      • Data Points
    • Newsletters
    • MORE+
      • Contact Us
      • Advertise
      • Media Kit
      • Jobs
      • People on the Move
      • Reprints & Licensing