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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
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That's probably easiest. Health Affairs where health policy advances.
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Marianne Amoss
Welcome to another edition of Health Affairs This Week, the podcast where Health Affairs editors and guests discuss some of the most pressing health policy news of the week. I'm Marianne Amoss.
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Michael Gerber
And I'm Michael Gerber. Marianne, before we dive into this week's topic, we wanted to share that we're proud to announce that the inaugural issue of Health Affairs Scholar is now available online. Health Affairs Scholar is a new open access journal from Health Affairs and our partners at Oxford University Press. In this first issue, you'll find six articles addressing a range of health policy topics, as well as an article by the Health Affairs Scholar editorial team about ten emerging health policy issues for the next decade.
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Michael Gerber
The editors welcome submissions of new research and commentary in these areas, as well as other emerging and global health policy subjects. To learn more, check out the first issue. You can find the link in our show notes.
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Marianne Amoss
Yeah. Thanks, Michael. So this week we are talking about a new primary care model that was just announced by the Centers for Medicare and Medicaid Services, or as we know them, CMS. But first, let's talk a little bit about primary care and why it's so important.
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Michael Gerber
Yeah, I think, you know, primary care is something most of us are pretty familiar with. We all at least should be seeing a primary care clinician. But what we do know in past research is that primary care is associated with decreased spending, improved health outcomes, and overall better quality health care. It's been called the foundation of the health care system.
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Michael Gerber
But what we also know is that it's underfunded. In the United States, only 5 to 7% of total health care spending goes towards primary care. In other high income countries, it's double that, estimated to be around 14%. And this relative low funding has resulted in issues like provider shortages, burnout and a lack of investment in technology and other resources needed to really provide the kind of primary care that we think can help overall health.
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Michael Gerber
Nearly a third of U.S. adults say they don't have access to primary care services, partially due to a shortage of providers in their area, among other reasons. I know around where I live, there's a lot of talk about primary care doctors all going concierge, and so they're seeing fewer patients. So a lot of reasons that it's hard to find access to primary care services.
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Michael Gerber
According to MedPAC, the Medicare Payment Advisory Committee, the fee-for-service schedule, which is, you know, the list of fees that Medicare pays doctors and other providers for health care services undervalues primary care. And I think other research has shown that that's true. Really across a lot of payors beyond Medicare as well. Primary care tends to get reimbursed at lower rates than specialists.
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Michael Gerber
Primary care physicians often come out of training with just as much debt, but get paid a lot less than their colleagues who specialized. And in general, it's believed that fee-for-service is not a great payment mechanism for primary care, which is really more about ongoing care coordination and long term relationships with patients than just individual visits and providing a specific service.
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Marianne Amoss
That's exactly right. And, you know, I think all the for all the reasons you outlined, it's clear that change has been needed. You know, we're not the only ones saying this. The Affordable Care Act recognize this, making primary care a priority. Back in 2010, and since that time, there's been a proliferation of both public and private primary care transformation models.
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Marianne Amoss
Now, these models test out new approaches to primary care delivery and payment reform, and they're overseen by the Center for Medicare and Medicaid Innovation, or CMMI, which was also established as part of the ACA.
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Michael Gerber
A couple of years ago we had a paper in Health Affairs by Deborah Peikes and her colleagues that looked at some of these CMMI models that tried to change how primary care is paid for in the United States. And there were eight models total that they looked at between 2010 and 2020, and they all sort of aimed to focus on things like care management and coordination, increased access and improving quality and making care more patient centered.
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Michael Gerber
And the main finding was that they didn't really improve quality or reduce costs overall, some increased costs in some areas, a little reduce costs in some areas a little. But one thing the authors of this article point out is that some of the lessons learned were, you know, different practices are at different levels of readiness to take on these new models.
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Michael Gerber
And some of them just don't have the infrastructure or the technology or the staff. Some of them it's a culture issue and it takes a while to really redesign how you coordinate care and how that care is paid for. And a lot of these models, if you look you know, this was only ten years after the ACA, so most of them were only piloted for a few years.
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Michael Gerber
Some of the other things that the authors mentioned were that most of the models also still really relied heavily on fee-for-service, with some additional payments for care coordination and maybe some bonuses for savings or quality. But overall, largely more than 90% of revenue was still from fee-for-service and clinicians were still being paid based on a productivity model.
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Michael Gerber
So the authors concluded that considerable progress was made in understanding how to implement and support different approaches to improving primary care delivery. So I think, you know, they saw that while no real outcomes changed in what they looked at, that there was still a lot of promise.
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Marianne Amoss
Yeah, I think that's true. And I'm going to talk now about this new model that CMS recently announced. But I want to point out too for our listeners that this new model really appears to have incorporated some of the feedback that you just went over, Michael. So listeners, keep your ears open for that. So this new model is a voluntary primary care model.
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Marianne Amoss
It's called the Making Care Primary model, or MCP, and CMS announced it on June 8th. So just a few weeks ago. The model, it will be tested in eight states. It will launch on July 1st, 2024, and it will run for about ten and a half years until December 31st or 2034. And it does build on previous primary care models, for example, the comprehensive primary care model and the Maryland primary care program.
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Marianne Amoss
So the primary goal of the MCP model is really to support the delivery of advanced primary care. And when I say advanced primary care, I mean a more holistic and patient centric approach to primary care. At a high level, MCP’s goals are to, one, ensure the delivery of integrated, coordinated, accountable and person centered primary care. Two, to establish a pathway by which primary care providers can enter into value based care arrangements.
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Marianne Amoss
And they point out that they're really trying to establish these pathways for small, rural, independent and safety net providers. And third, to improve patients quality of care and health outcomes while reducing costs. So MCP will support primary care physicians with a range of experience and value based care, and it'll help them gradually adopt perspective population based payments, which are an advanced value based payment approach.
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Marianne Amoss
And it'll also support participants in building the infrastructure to improve behavioral health and specialty integration, as well as facilitate more equitable access to health care. And on that point, in terms of health equity, as I already mentioned, there is this attention to small rural safety net providers that that I think is important in terms of health equity.
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Marianne Amoss
And there are a few other components in the model that are designed specifically to improve health equity. So, for example, participants will have to create a strategic plan for how they'll identify and reduce health disparities.
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Michael Gerber
Great. So that all sounds really good, but how do they really propose making that happen?
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Marianne Amoss
Yeah, that's always a good question. Right. The devil's in the details, I think. So this model is really focused on three things: care management, care integration and community connection. So some of the examples given about what specifically participants will receive support on is strengthening support services around chronic conditions like diabetes and hypertension, building connections with specialty care clinicians, identifying and addressing health related social needs and connecting patients to supports and services in the community.
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Michael Gerber
Got it. You know, one thing you also mentioned is that one of the lessons learned in some of the previous research and something that they're trying to address with this MCP model is to really, as they say it, to meet providers where they are in this transition to value based care. There are some primary care practices that are really far along in already coordinating care, hiring the kind of staff needed to do so.
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Michael Gerber
And there's some that really aren't, and that will face some difficulties in acquiring the resources they need. So they've created three tracks in this model that it seems from first glance that some participants will start maybe at track one, two or three, while others will move along and progress as there are in the model over the decade it's piloted.
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Michael Gerber
So track one is really for those participants with no experience in value based care. And it's really also going to be focused on supporting their ability to gather data, to hire the right staff, to evaluate the outcomes. And the pay for them will remain largely fee-for-service. Track two and three are a little further along.
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Michael Gerber
Track to participants will focus on those partnerships with specialists that you mentioned and with social services providers, implementing care management and systematically screening for behavioral health conditions. And their payment will be more of a 5050 blend of fee-for-service and population based payments. And then track three is the most advanced, you might say, with a focus on quality improvement efforts and improving workflows and care coordination and deepening those partnerships and connections to community resources and payment and track three will be fully population based, but it is important to note that all three tracks will include some rewards for improving patient health outcomes.
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Michael Gerber
One other thing to note is, you know, if you're a provider or a primary care clinician, obviously you have some Medicare patients, but also some Medicaid patients and probably some commercial payor patients and others. So this CMMI, this model specifically are hoping to use a multi payor alignment strategy, which will mean working with the state Medicaid agencies and the eight states that are participating, and then also even working with commercial payors to try to align some of their payments to make it more consistent and hopefully improve outcomes and reduce costs across payors.
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Marianne Amoss
Yeah, that's right. So I was trying to find out a little bit about how this model has been received by the community. And so I found an article on Fierce Healthcare and it said that many provider groups have cheered this new model. So that's pretty positive reception. One of the reasons for that, or at least one of the groups that has been excited about this model is the American Medical Association.
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Marianne Amoss
And that's because the model includes several specific recommendations that the AMA made, including this longer model test period of ten plus years. And the fact that the model's voluntary, that it has this progressive track system that really provides practices with ways to advance on the prospective payment journey and also this meaningful alignment with Medicaid. One group that wasn't so pleased was the National Association of ACOs, because providers who are already in ACOs are not eligible to participate in this model.
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Michael Gerber
Yeah, I guess. I guess you can't please everyone, although maybe it's a good sign that they were upset because they can't be part of it and it at least shows that maybe everyone thinks it's a good idea and eventually when it when it's shown, if it is shown to work, then then more can get into the model.
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Michael Gerber
It'll be interesting to see how things go, obviously. I think we all like to do three month pilot programs and then figure out things work and get started, but probably taking ten years and really looking at longer term outcomes as is the way to go. But it's a long time to wait and things will kick off later this summer when applications open and the CMS website, which we'll link to in our show notes, has more details about the program and eligibility as well.
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Michael Gerber
And with that, I think we'll have to leave it there. Thank you for listening to this episode of Health Affairs This Week. If you liked it, please leave us a review and tell a friend. And don't forget to subscribe wherever you get your podcasts so you don't miss an episode. Thanks, Marianne.
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Marianne Amoss
Thanks, Michael.