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Analysis

Medicare's 'Primary Care First' Program Has Its Skeptics

By MedPage Today  
   May 30, 2019

The initiative is too focused on cutting hospitalizations and doesn't have enough money for doctors, critics say.

This article was published May 29, 2019, by MedPage Today.

By Joyce Frieden, News Editor, MedPage Today

WASHINGTON — Medicare's new "Primary Care First" program for paying primary care doctors who see Medicare patients maintains a fee for office visits while also paying a monthly per-beneficiary amount for care coordination and other "behind the scenes" work that doctors do. So what's not to like?

Plenty, according to Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, in Pittsburgh. "Part of challenge with primary care is that the benefit is going to be in the longer run, not the shorter run. This model is very focused on trying to do something to save money in the short run; it's focused almost exclusively on reducing hospitalizations."

The Primary Care First program, which was announced April 22 by the Centers for Medicare & Medicaid Services (CMS), has two models, both of which would let primary care clinicians move away from fee-for-service and allow them to stop worrying about up-and-down Medicare revenue, according to the CMS. The agency would pay monthly population-based payments along with a simple flat fee for primary care visits. The program is slated to begin in January.

Two-Sided Risk
 

One of the models focuses on a more general population, while the second model is for advanced primary care practices that typically provide hospice or palliative care services and want to take responsibility for high-need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination, according to a CMS fact sheet on the models.

The model involves a potential downside risk of 10%, and an upside risk or bonus of 50%, depending on patients' outcomes, and performance would be measured on "risk-adjusted hospitalizations" or "the ability to keep patients healthy at home," Adam Boehler, director of the Center for Medicare & Medicaid Innovation (CMMI), which developed the models, said at a press briefing. "For example, doctors that earn $200,000 today could earn up to $300,000 if their patients stay healthy." For 2020, the CMS has identified 26 regions where practices can participate.

Related: Medicare Just Invited More Competitors Into Value-Based Primary Care

The CMS says that the model's monthly per-patient payments will help doctors stop worrying about their monthly revenue cycle. However, as Miller noted in an article, "at the same time that Primary Care First eliminates the current E/M [evaluation and management] payments for face-to-face office visits for attributed patients, it creates a brand-new $50 fee for each face-to-face office visit, which is about half as much as the average amount primary care physicians currently receive from Medicare for office visits."

"Based on the current average frequency with which Medicare beneficiaries make primary care office visits, this means that more than 40% of a typical practice's payments would still be tied to face-to-face visits. As a result, if the practice is able to care for patients effectively with fewer office visits, it will lose revenue and it could be unable to cover its operating costs," he wrote.

Lack of Risk Adjustment
 

Another problem with the program is that a primary care practice would receive the exact same monthly payment for a patient regardless of how sick or healthy they are, Miller said. "Since an individual patient who has higher needs will require more time and resources from the practice than other patients, a practice that is caring for that patient will have to reduce the time and resources it devotes to other patients if the payment is the same."

And in addition to those issues, since Medicare payment programs are expected to be revenue-neutral compared with the current budget, "the payment is intended to be the same as what the practice is currently getting," although the practice will be expected to provide more services than before, including 24/7 patient access and integrated behavioral healthcare, Miller said.

Miller is a member of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which advises the CMS on Medicare alternative payment models. "In general, I think there's been a lot of concern for a long time about [the] need to provide better support for primary care, and most payers in the country have been trying to do some kind of medical home programs for quite a while," he said. "Medicare has been fairly slow to the game on that."

In particular, Miller is disappointed that the CMS hasn't shown much interest in pilot-testing the payment models that PTAC has recommended. "With PTAC, two proposals [were submitted] for primary care, and we reviewed them and recommended they be tested and implemented ... It's been a long time since the recommendations were made, and the surprising thing to me was that the [Primary Care First] model that was announced by [the CMS] really didn't look at all like the models recommended by PTAC."

Room for Improvement
 

There are ways that Primary Care First can be improved, Miller said. For starters, "rather than creating a whole new set of office visit payments, what primary care practices have asked for is to get all or most of their payments as a flexible monthly payment so it's not tied to office visits."

In addition, the monthly payments should be higher for patients who require more care. "If you have more diseases and more care challenges, you're going to require more attention from your primary care physician," said Miller. "The way that happens today is more office visits ... but we don't want to pay more only if they come to the office."

When asked during a press briefing about the Primary Care First model, CMS administrator Seema Verma said the agency was trying to give physicians a variety of options. "What we tried to do is recognize that providers are in different places in terms of their ability to take on risk," she told MedPage Today. "What we've tried to do in this model is provide different options ... Some providers may say 'I want to take full risk on,' so we've allowed for that option."

"What we want to do in primary care is have them focus less on revenue cycle ... and actually be able to focus on patients," she continued. "The requirements around 24/7 [availability] — the idea there is that it's based on some work we've already done in primary care and some of [it is] 'lessons learned'; we're looking at what we know works."

Some providers differ with that assessment. "I know it was well intentioned, but [the] CMS seems not to understand the day-to-day mechanisms of [how] primary care practices work," Jean Antonucci, MD, a family physician in rural Maine and the author of one of the alternative payment model proposals that was recommended by PTAC, said in an email. "It is really virtually impossible to figure out how much revenue a practice will receive."

"Supposing that my patients are well taken care of so I am placed in the lowest [payment] category of $24 a month; it's very difficult to [keep patients] out of the hospital for $24 a month, but I might be put in that category because I did a good job. So no good deed will go unpunished," she said.

In her own proposal, she considers the cost of an hour's worth of phone calls — 15 minutes, four times a month — from a practice to a particular patient. "A [medical assistant] is $15/hr. easy, but often the doctor must be involved, or an RN, and that is $40-$150 per hour, plus they need the driver's license form or the forms for oxygen ... We end up with whining by doctors about not being paid, while payers and pundits complain we want to nickel-and-dime them to death."

Other Possible Approaches
 

Primary Care First's early reviews "reveal that longstanding conflicts remain between, on the other hand, budgetary savings and administrative feasibility goals and, on the other hand, more ambitious desires in parts of the medical community redesign care to elevate the role of effective primary care (regardless of the short-term costs)," Tom Miller, JD, resident fellow at the American Enterprise Institute, a right-leaning think tank, said in an email. "Perhaps more medical outcomes per se could be improved by simply paying primary care doctors more, but that assumes away the political food fight it would require to get there."

A more straightforward approach to "subsidize patients more directly to find and receive the care that they could choose to receive would upset providers either benefiting from the current system or imagining that they could be winners in the next round of political reimbursement roulette, labeled 'value-based,'" he added.

Gail Wilensky, PhD, senior fellow at Project HOPE in Bethesda, Maryland, and a former CMS administrator, said in an email that the difficulty with the model "seems to be the amount paid is too small and too unreliable ... That is certainly consistent with the ongoing CMS attempts. It is certainly reason to be skeptical although the results will only become clear after it is tried, assuming [the] CMS goes forward with it ... It has been discouraging how difficult it has proven to be to affect change in this area."


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