Medicare's Comprehensive Primary Care Initiative - A Two Year Report

After all the buzz (for example) around the coming launch of CMS' Comprehensive Primary Care "Plus" program,  the New England Journal of Medicine (or NEJM) just published a "special article" on the original Comprehensive Primary Care (CPC) initiative.

This is important if you think CMS' approach to supporting primary care is the fix for what ails the U.S. health care system.

Population Health Blog readers may recall that two years ago, CMS launched CPC. This is a still ongoing four-year multi-payer study to determine whether primary care that is "turbocharged" with medical home-style capabilities (see here, here and here - see page 8) would increase quality and lower health care costs. 

The term "multi-payer" is important, because CMS recognized that clinics struggled with providing medical home care to some, but not all, patients on the basis of their insurance.  Better to have one standard of care to all patients.

The NEJM article is an analysis of CPC's results after two years. 

To summarize how CPC was set up, 502 clinics (from 978 applicants) across 8 states participated along with a total of 39 other insurers.  In addition to the usual fee schedules, the Medicare and the other insurers paid a per patient severity-based "care management fee" that, on average, ranged from $8 to $40 per beneficiary per month (PBPM). Practices were also promised an additional bonus if, after two years, they reduced health care costs (i.e., shared savings) and improved various quality measures and performed well in surveys about the patients' experience of care.

These CPC practices' outcomes were compared to a propensity matched group of non-participating practices with a similar electronic health record (EHR) infrastructure that cared for a set of patients with similar levels of disease and baseline costs. 30% of these practices had applied but were not accepted in the initiative. The total number of comparison practices was 908.

Results?  Not good.

Aft the end of two years, there was no statistically (p > .05) significant difference in the growth of health care costs between the CPC and control sites.  This was true whether just claims costs were examined (a negligible difference of $11 per patient per month favoring the CPC sites), or whether claims costs plus the additional fees were examined (a difference of $7 favoring the comparison sites).

When patient costs were examined by the burden of disease, there was no indication that more costly patients achieved any savings. 

CPC sites had a statistically significant reduction in outpatient office visits, but not in hospitalizations.

While the difference in claims expense failed to be statistically significant, the total additional fees collected by the participating sites amounted to a financially significant $389,000. This represented a 15% increase in their income. 

Was quality of care improved?

Patients with diabetes and a high burden of illness were more 3% more (p<.05) likely to receive the recommended follow-up measures to manage their disease. Otherwise, "the initiative did not have significant effects on the processes used as measures of the quality of care for the full sample."

Patient experience of care?

While surveys showed small increases in patient support, "there were no significant effects on other composite measures: ability of patients to obtain timely appointments, care, and information; how well providers communicate with patients; provider’s knowledge of care patient received from other providers; and overall rating of providers by patients."

Yikes. Ouch. Egads.

The authors correctly point out that CPC is a four year program and that it still may be too early to see the impact of the medical home turbocharging.  That was pointed out in the negative one year evaluation.  Maybe something will turn up at three or four years.

In addition, CMS has a lot of other value-based initiatives underway, which may have biased the results.  There may be a "ceiling effect" among the participating sites as well as the control sites, which were already working to reduce (for example) rehospitalizations or pursue the fee schedule modifiers.

It's also important to note that the impact on the other insurers' costs and patient quality was not reported.  It's possible that they saw a benefit.

The PHB's take?

1.  Many care management programs achieve claims reduction with savings (for example) within one to two years.  If CPC hasn't succeeded by now, it probably won't.  And if the just-announced CPC Plus is modelled after this, it's hard to see how that program will turn out any differently.

2. It is possible that, within all the statistical noise, there were some primary care sites with particularly robust approaches to care that did bend the cost curve.  CMS should seek these sites out and find out more about their secret sauce.  More on that in a future post.

2.  If CPC's approach to care is ultimately shown to not bend the curve, what's the problem? 

The PHB continues to believe that one size doesn't fit all and not all patients benefit from care management. Many patients, even those with chronic conditions are quite stable and need minimum attention; some patients are so sick that no intervention will keep them out of emergency rooms and hospitals. As pointed out here, as more and more patients are enrolled in care management, the return on investment can paradoxically go down. Better to focus on patients who are not only at risk, but have "impactable" condition profiles.

In addition, CPC is based on a 5 year-old model of care. Things have changed since then: modern population health brings many more resources to the table.  That not only includes in-depth analytics support (for example, to define those patients who are at greatest risk) but mHealth. For example, there is one innovative company (the PHB's Shameless Commerce Dept. over on the right side of your screen) that provides recently discharged patients with an app-enabled handheld configured to provide close follow-up.  And so on.

3. It may be that care management works best in a managed care setting.  CPC is a study of classic fee-fore-service Medicare beneficiaries with access to any participating Medicare provider. In Medicare managed care, the insurers and their providers have an even larger incentive to maximize quality and lower cost.  If that's the case, CMS - despite their commitment to innovation - may want to get out of the care management business, because they just don't know how to do it.

The Patient Centered Medical Home, Medicare's Comprehensive Primary Care Intiative and Cost Neutrality

Like this, but with snow

Oh my, he was really angry.

Back when the teenage Population Health Blog was living in New York, our family had a small garden tractor that was outfitted with a snowplow. After a particularly heavy snowfall, the PHB's father assigned the son the task of clearing the driveway. When the obliging PHB ran out of space to push the snow, its solution was to eschew use of a shovel and ram piles of snow outward by repeatedly backing up and accelerating forward in 4th gear. Teenage cries of "ramming speed!" seemed like a good idea at the time, but it really mangled the metal struts that held the plow to the front end of the tractor.

In economic terms, any savings the father achieved in outsourcing the snow removal was chewed up by hours of do-it-yourself blacksmithing that weekend. The driveway may have been cleared, but to the PHB father, the entire transaction ultimately ended up being a cost neutral bust.

Which brings CMS' Comprehensive Primary Care ("CPC") Initiative to mind. Thanks to the just-concluded Medical Home Summit, the PHB got to hear one of the authors of a CPC deep-dive analysis speak to the initiative's first-year findings.

 The entire report can be found here.

Very briefly, by October of 2012, CMS got Medicaid and 29 commercial health insurers to agree to ALL align and have everyone - including Medicare - to pay participating primary care sites a fee for Patient Centered Medical Home (PCMH) style care management.

 The rationale for this arrangement was to spare the clinics from having to offer the PCMH to only some of their patients. By imposing a "critical mass of payers" all patients had equal access to the same benefit.  That meant that practices wouldn't have to deal with the variations of different payer-dependent work flows and payment structures.

More than 500 practices (with an average of 4.4 providers) serving more than 2.5 million patients in 7 Medicare regions agreed to participate. In order to do that, the practices had to demonstrate that they had met meaningful-use criteria for their electronic health records (EHRs), had been officially recognized as a PCMH and had experience in quality improvement.

Once they were in the CPC, they were not only paid additional care management fees by CMS, but received quarterly feedback reports and technical assistance in achieving CMS mandated "milestones" (they can be found on page 84)  Over the course of the first year, practices received a median of $226,000 in care management fees.

At the end of one year, compared to propensity-matched non-CPC practices, CMS averaged $20 per beneficiary per month in care management fees.  They saved $14 per beneficiary per month in claims expense.  Compared to the non-participating sites, that $6 in additional cost did not achieve statistical significance.  Because the confidence intervals crossed $0, the conclusion was that CPC was cost neutral (the results can be found on page 120).  Some of the regions had statistically significant savings, while other regions had statistically significant losses.

The PHB's take:

Good thing the PHB father isn't in charge. 

This isn't the transformative PCMH break-through, and if CMS is looking to bend the cost curve, these one year results suggest Ms. Burwell et al are going to have to look elsewhere.

That being said, it's possible that years 2, 3 and 4 will show savings.  Even if that's true, the PHB wishes CMS and the health system "good luck" in being able to execute anything outside of fiscal year blocks of time.  We'll see.

The good news? The PHB suspects that the participating primary care sites ended up in the black.  They had already absorbed the costs of their EHRs and becoming PCMHs prior to the start of the initiative, so most of their $226,000 probably flowed right to their bottom lines.

As an aside, some of the $14 PBPM savings were attributed to a reduction in 30-day readmissions.  As the PHB understands it, CMS already has a methodology to claw that cost back from the health care system.  If that's true, the PCMH readmission savings are being double counted.

Image from Wikipedia