Investing in primary care can save significant costs for the U.S. health care system, and yet it has been historically underfunded. A new experimental payment model in the Medicare program may finally change that trend by paying primary care providers in advance to examine patients holistically. Under the Innovation Center at CMS, funding will be available to organizations that are looking to prevent unnecessary and expensive acute care episodes through preventive services, directing patients to the follow-up services they need – whether that be from specialists or social service organizations. In this article, we explain how the model will work, how long it will last, and why it is different from past failed experiments in funding primary care models.
Is Primary Care the Future of Health Care?
In recent years, innovators have begun to recognize the value of primary care in health care transformation. To make a difference on health care spending and outcomes, patients’ health must be treated holistically — which begins with primary care and prevention of serious, costlier health issues.
Private Sector Investments In Primary Care
Evidence of the serious funding of primary care initiatives over the past few years include:
• Amazon acquiring membership-based primary care service One Medical in a $3.9B deal “to make it easier for people to get and stay healthier.”
• Walgreens’ investment in VillageMD, to help accelerate the opening of at least 600 Village Medical at Walgreens primary care centers by 2025– making Walgreens the first pharmacy chain to offer full-service primary care practices.
• Aledade, a network of independent primary care practices and platform that helps them transition to value-based models, raised $260 million in a 2023 Series F funding.
Federal Government Investments In Primary Care
The Innovation Center at CMS, also known as CMMI, is a sub-agency of CMS that tests different ways to pay for health care in federal programs through “alternative payment models.” CMMI set a lofty goal – to get all Medicare and Medicaid beneficiaries in an accountable care arrangement by 2030. The Center has identified advanced primary care as a key to achieving this goal. One new payment model is called “Making Care Primary.”
Making Care Primary: Promoting Preventive Care through Care Coordination
Making Care Primary is CMMI’s most recent attempt to strengthen primary care financing, advance equity, and support sustainable primary care transformation through strengthening community-based infrastructure and multi-payer alignment.
The model will provide primary care providers with value-based payments so they can access tools and resources to improve the health outcomes of their patients. These payments are designed to allow for better integration so that primary care providers can streamline coordination with specialists, behavioral health providers, and community-based organizations when needed.
Making Care Primary will last for 10 years, from 2024 to 2034 in eight states: Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina, and Washington. Participants will initially be Medicare-enrolled primary care organizations that can apply for the model as soon as Summer 2023. CMMI is hoping to include Medicaid managed care organizations later.
CMMI identified three domains participants will focus on as they expand their value-based primary care infrastructure and delivery:
• Care Management – Participants build care and chronic disease management, focusing on diabetes and hypertension. They will work to reduce unnecessary emergency department use and total cost of care.
• Care Integration – Participants will focus on coordinating care with specialists by using evidence-based screenings and evaluations.
• Community Connection – Participants will work to address health related social needs and connect patients with community services.
What is the goal of the CMMI Making Care Primary? To improve health care costs and achieve financial savings by advancing preventative care that manages chronic conditions, meets patients’ social needs, and reduces repeat hospitalizations.
CMS Builds on Lessons Learned in Past Models for Easier Participation
Past CMMI primary care models were unsuccessful. Provider practices struggled to reach diverse patients, were not financially able to sustain the programs, or did not serve enough Medicare patients to participate. The Making Care Primary model addresses these issues by:
• Focusing on Federally Qualified Health Centers (FQHCs) and Rural Health Centers;
• Making it voluntary to participate in, and setting the length for ten years for stability; and
• Offering a phased-in, three-track process providers can enter into based on their advancement in infrastructure.
The three tracks of value-based payments are a progressive staging process, to allow organizations to move from fee-for-service payments to prospective, population-based payments over the course of ten years. Each track targets a different goal, starting first with building the infrastructure needed to achieve population health management:
• Track 1 – Building Infrastructure: Participants would first risk-stratify their population, review data, conduct health-related social needs screening and referrals. CMS will offer financial support in pre-payments to help build infrastructure to participate in more advanced value-based models. Participants can begin earning financial rewards for improving health outcomes.
• Track 2 – Implementing Advanced Primary Care: Participants will build off Track 1, while beginning to partner with social service and specialist providers. Payments will shift to a 50/50 blend of population-based and FFS, with some financial support from CMS. Participants can earn increased financial rewards in this track.
• Track 3 – Optimizing Care and Partnerships: Participants will continue to partner with social service providers and specialists and implement care management services and use quality improvement frameworks to strengthen all of those tools and relationships. Payments will shift to a full value-based care payment model.
• Advanced primary care is a critical component to managing health care outcomes and costs. Recent industry and policymaker attention highlight the focus on making primary care coordination streamlined to actually achieve this goal.
• CMMI’s newest payment model presents an opportunity for primary care organizations – and eventually some managed care organizations—to promote preventive care and invest in infrastructure to support value-based payment models.
• By building infrastructure, implementing care coordination, and optimizing workflows and relationships, primary care organizations can better participate in value-based payment models to improve health outcomes and reduce costs.
We extend our thanks to Maverick Health Policy’s Julie Barnes and Eric Schiavone. Their expertise and insight have been critical in our effort to turn complex federal policy into practical, innovative solutions, helping Medecision’s customers confidently navigate the ever-changing healthcare landscape.