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Weak Payment Reform Limits Impact of ACA Primary Care Initiatives

By Christopher Cheney  
   March 02, 2020

A tentative shift from fee-for-service to value-based payment models has constrained primary care initiatives under the Affordable Care Act, new research suggests.

In its first decade, the Affordable Care Act (ACA) sparked significant innovations to boost primary care but new payment models lacked sufficient incentives to drive change, new research suggests.

President Barack Obama signed the ACA into law on March 23, 2010. One of the top goals of the healthcare reform law is to improve primary care. A body of research indicates that robust primary care capabilities are linked to lower healthcare spending, better clinical outcomes, and lower mortality rates for several conditions.

The new research, which was published today by Health Affairs, examines the impact of primary care reform initiatives launched under the ACA through the Center for Medicare & Medicaid Innovation (CMMI). The initiatives generated mixed results, the study co-authors wrote.

"Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade, though evaluations showed little progress in spending or quality outcomes. This may be because none of the models was able to test substantial increases in primary care payment or strong incentives for other providers to coordinate with primary care to reduce costs and improve quality."

Research data

The Health Affairs study includes data showing the largely limited impact of seven CMMI primary care reform initiatives on healthcare spending, utilization, and quality for Medicare fee-for-service beneficiaries.

1. Comprehensive Primary Care (CPC)

Spending: No effect

Hospitalizations: Reduced by 2%

Quality: No significant effect

2. Comprehensive Primary Care Plus (CPC+)

Spending: Increased by 2% to 3% in first year

Hospitalizations: No effect

Quality: Small quality-of-care measure improvements

3. Federally Qualified Health Center Advanced Primary Care Practice Demonstration

Spending: Small increases

Hospitalizations: Small increases

Quality: Mixed patient experience impacts

4. Independence at Home Demonstration

Spending: No effect

Hospitalizations: No effect

Quality: Reduced preventable hospitalizations by 6.7%, but there was no effect on hospital readmissions

5. Health Care Innovation Awards: Primary Care Redesign programs

Spending: One awardee (hospital) achieved a 31% reduction in Medicare spending

Hospitalizations: Two awardees reduced combined hospitalizations and emergency department visits by 6% and 15%

Quality: Awardees improved quality-of-care measures by 2% to 10%

6. Multi-Payer Advanced Primary Care Practice Demonstration

Spending: No states achieved savings and two states increased spending

Hospitalizations: Decreased in one state but increased in two states

Quality: Three states improved process-of-care measures, but three states had unfavorable results in process-of-care measures

7. State Innovation Models initiative, round one

Spending: Increased in one of three states by 12.3%

Hospitalizations: Inpatient admission rates were reduced by 34.6% in one state but increased by 15.5% in another state

Quality: Two states achieved small improvements in quality-of-care measures

"Model results show how hard it is for primary care delivery—in the context of modestly reformed payment that still rests firmly on a fee-for-service chassis—to improve cost and quality outcomes," the study co-authors wrote.

ACA primary care model keys to success

The lead author of the study, who has experience as an evaluator of the CPC and CPC+ initiatives, told HealthLeaders that primary care practices can have their greatest effect on overall healthcare spending by reducing hospitalizations.

"Many of the models encouraged practices to work with hospitals to alert the practice when a patient was admitted or discharged from the hospital or the emergency room, so they could work with patients to prevent future admissions when clinically appropriate," said Deborah Peikes, PhD, MPA, a senior fellow at Princeton, New Jersey-based Mathematica.

She said there are three other main ways primary care practices could reduce hospitalizations through the CMMI initiatives or other programs.

First, primary care practices in the CMMI models were encouraged to enhance care management for patients with complex needs, including teaching patients self-care for chronic conditions. "The goal of enhanced care management and self-care is to improve patients' quality of life and to prevent patients' conditions from worsening, thereby avoiding preventable hospitalizations," Peikes said.

Second, some CMMI models also attempt to improve the coordination of care with specialists, she said.

Third, Peikes said data feedback to help clinicians understand which patients and diagnoses are driving costs can also be helpful.

She also provided advice for primary care practices seeking to make gains through CMMI initiatives.

Practices should be prepared to make substantial changes in how care is delivered, Peikes said. "To succeed in such efforts, it is important to build buy-in among the practitioners and staff at the practice. A healthy learning culture where everyone has a voice and feels empowered to try new things and see what worked well and what did not will help practices redesign multi-step work processes and avoid team burnout."

Patients are an important piece of the puzzle, she said. "Primary care practices that engage their patients, encourage them to set goals and take better care of themselves, and solicit their feedback on how to improve their experience are more likely to be successful. Promising approaches include shifting from dictating recommendations to exploring the patient's readiness to change and using motivational interviewing."

Primary care practices should consider the impact of participating in a CMMI model carefully, Peikes said. "Practices should make sure they understand the incentives baked into the new payment approaches tested in the ACA models, which patients are covered, and the standards that need to be met to earn any bonuses or shared savings. They should weigh the benefits versus costs of model participation and investment in care delivery changes, such as new staff, technology, and time spent on different aspects of care."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Seven primary care initiatives under the Affordable Care Act generated disappointing or mixed results for healthcare spending, hospitalizations, and quality.

For most of the initiatives, there was either no effect on spending or relatively small increases in spending.

For participants in ACA primary care initiatives, keys to success include buy-in among clinicians and other staff at practices.

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