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Invited Commentary
Health Policy
September 28, 2018

Payment and Care Delivery Improvements Could Benefit All Patients

JAMA Netw Open. 2018;1(5):e182883. doi:10.1001/jamanetworkopen.2018.2883

“The times they are a-changin’.”1 The mantra of the health care system, moving “from volume to value,”2 now is heard in boardrooms and medical practices from policy makers, payers, and health care practitioners. Yet the question Fraze et al3 have asked in their study is whether all patients or just the most advantaged are benefiting from the changes.

Fraze and colleagues analyzed medical practices that voluntarily joined the Centers for Medicare & Medicaid Services (CMS) Comprehensive Primary Care Plus (CPC+) model—America’s largest initiative to transform primary care payment and care delivery. They found that participating practices within the 14 geographical regions that started CPC+ in 2017 were in more advantaged areas compared with nonparticipating practices and were more likely to include nonphysician health care practitioners and have lower inpatient utilization.

As the insurer of one-third of the US population,4 CMS has a substantial impact on the payment for and delivery of health care in the United States. That effect is magnified when CMS partners with other payers, as CMS has done in CPC+. What can CMS and other payers do to ensure that models developed through its Innovation Center to test improvements in the delivery of and payment for care, such as CPC+, are available to and benefit all Americans, including those who are most vulnerable and at highest need?

Models developed by the CMS Innovation Center “succeed” and may expand more broadly only if they either reduce the cost of care without reducing the quality of care, or improve the quality of care without increasing its cost.5 It is often a race against time for participants to join a model, learn its requirements, adjust to payment changes, implement care delivery changes while providing ongoing patient care, refine their implementation when time-lagged outcome data become available, and obtain improvements in the cost and quality of care before the model ends in 4 to 5 years. Because it is critical to the model’s success to have participants able to quickly do the hard work of the model, CPC+ targeted medical practices with some prior experience with payment and care delivery transformation. This might have resulted in the exclusion of practices in less well-resourced areas caring for less advantaged populations.

Regardless of any past experience with transformation, primary care practices that are Federally Qualified Health Centers (FQHCs) (and, depending on their billing processes, Rural Health Clinics [RHCs]) were not eligible for CPC+. The Medicare payment structure for FQHCs and RHCs is both complex and quite different from traditional fee for service (FFS), making the payment transformation aspects of CPC+ (and some other Innovation Center models) not only inapplicable but also potentially detrimental to them financially.

The FQHCs and many RHCs are paid amounts in excess of usual Medicare FFS based on the proposition that their unique circumstances and patient populations are costlier. This preexisting additional payment creates quite a conundrum for Innovation Center models that are designed to save money and are focused on the individual practice. However, the finding by Fraze and colleagues that the majority of areas without a CPC+ practice had an FQHC, as well as significantly higher inpatient utilization and potentially avoidable discharges, provides a noteworthy foundation for cost savings and quality improvement for FQHCs in future, similar models. However, to include FQHCs and RHCs in these Innovation Center models will require substantial effort across CMS to understand and address the barriers to, and opportunities for, payment redesign in these unique settings.

Medical practice eligibility for CPC+ also hinged on the percentage of the practice population covered by CMS and other payers—including Medicaid—who partnered with CMS in the model. Practices needed approximately half of their practice population to be covered by CMS and payer partners to be eligible for CPC+. Medicaid’s partnership with CMS in CPC+ was likely important for participation by practices that care for less advantaged populations. Practices with a larger percentage of Medicaid-enrolled patients had difficulty meeting the eligibility criteria either if state Medicaid agencies in Medicaid FFS states chose not to partner with CMS in CPC+ or if commercial partners chose not to include (or were not authorized to include) their Medicaid managed care lines of business in the model. State Medicaid agencies partnered with CMS in approximately half of the 14 regions, and at least 1 Medicaid Managed Care Organization partnered in an additional 4 regions. As a result, a few regions have no Medicaid involvement and other regions have only limited involvement.

Even for the most motivated of Medicaid agencies, determining and obtaining the necessary authority to align their payment, quality measurement, and other requirements with the model as well as navigating budgetary constraints and state-level political changes affecting their funding can be daunting. Some Managed Care Organizations are limited in their ability to join such an initiative by their state Medicaid agency. Providing Medicaid with flexibility and encouragement to align with Innovation Center models quickly and with relative ease would reduce their administrative burden and would facilitate the payer alignment that allows medical practices to focus their limited transformation time and resources on the goals of the model. Such encouragement, however, would necessitate CMS commitment, and the flexibility would likely require congressional action.

While the CPC+ practices were, as a whole, located in more advantaged areas compared with non-CPC+ practices, some individual CPC+ practices are serving highly vulnerable and less advantaged patient populations. Effects on the quality of care across various subpopulations within such practices and across practices in the model as a whole could be determined from the practices’ reporting on quality measures. The CPC+ practices report electronic clinical quality measures that include all patients in their practice population who meet the measure specifications, regardless of payer. If and when those measures are reported using the 2015 Edition Health Information Technology (Health IT) Certification Criteria (c)(4) filter,6 it will be possible to stratify the results by race, ethnicity, and other criteria, allowing for critical examination of the effects of CPC+ practices’ quality of care overall compared with subpopulations. With the information from this evaluation, it could be possible to know whether CPC+ practices need to adjust their care delivery changes to ensure that individual subpopulations of patients benefit from overall improvements in care.

The times are indeed changing. As we transform primary care payment and care delivery, policy makers, payers, practices, and patients must be vigilant to ensure that improvements in care benefit all patients and not just those who are already advantaged.

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Article Information

Published: September 28, 2018. doi:10.1001/jamanetworkopen.2018.2883

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Sessums LL. JAMA Network Open.

Corresponding Author: Laura L. Sessums, JD, MD, 5081 Lowell St NW, Washington, DC 20016 (sessula@gmail.com).

Conflict of Interest Disclosures: Dr Sessums reported previous employment with the Centers for Medicare & Medicaid Services Innovation Center.

References
1.
Dylan  B. The times they are a-changin’. On: The Times They Are a-Changin’ [album]. New York, NY: Columbia; 1964.
2.
Miller  HD.  From volume to value: better ways to pay for health care.  Health Aff (Millwood). 2009;28(5):1418-1428. doi:10.1377/hlthaff.28.5.1418PubMedGoogle ScholarCrossref
3.
Fraze  TK, Fisher  ES, Tomaino  MR, Peck  KA, Meara  E.  Comparison of populations served in hospital service areas with and without comprehensive primary care plus medical homes.  JAMA Netw Open. 2018;1(5):e182169. doi:10.1001/jamanetworkopen.2018.2169Google ScholarCrossref
4.
Kaiser Family Foundation. Health insurance coverage of the total population. https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed August 10, 2018.
5.
Centers for Medicare & Medicaid Services. About the CMS Innovation Center. https://innovation.cms.gov/About/index.html. Accessed August 10, 2018.
6.
Office of the National Coordinator for Health Information Technology. 2015 Edition certification companion guide. https://www.healthit.gov/sites/default/files/2015Ed_CCG_c4-CQM-filter.pdf. Accessed August 10, 2018.
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