Former Senior Biden Advisor Unpacks CMS' New Primary Care Model

"One value-based care premise is that better primary care should mean less reliance on specialists. It's too simple a story but the idea is out there." — John Barkett

In June, CMS launched Making Care Primary (MCP). The agency designed the model to "improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients' health needs," including related social needs.

In this exclusive interview with HealthLeaders, former Senior Biden Administration Policy Advisor John Barkett unpacks MCP. Barkett—now a healthcare group managing director at Berkeley Research Group—served as a VBC portfolio advisor on the White House's Domestic Policy Council.

HealthLeaders: MCP applies lessons learned from two prior primary care models and the Centers for Medicare & Medicaid Innovation [CMMI] strategic refresh. What does CMS hope that the new model will accomplish that others haven't?

Barkett: The background here is important: the CMMI strategy refresh and CMS' goal of getting 100% of Medicare beneficiaries into value-based arrangements by 2030. The feedback during the first year of the Biden Administration was that the previous models were not easy to participate in for every provider.

The 10-and-a-half-year length of the MCP model responds to feedback from primary care providers who have said, 'We support value-based primary care, but we need a longer time horizon to realize the benefits of it as we help patients manage their chronic conditions.' You need more time to really bear that out.

HL: Can you unpack why MCP is launching with State Medicaid agencies but also includes Medicare requirements and an invitation for private payers?

Barkett: That ties to the second part of this: the importance of getting the vast majority of Medicaid patients into value-based care as well. MCP starting with Medicaid too helps ensure a multi-payer model. If you start with Medicare only, it's harder to convince practices to participate, especially if they have large Medicaid patient panels.

The Federal government can only control what they can control. With MCP, they're talking to states early on and I suspect that the efforts to bring along commercial payers will also be swift here, because they want as much alignment as possible.

HL: Just how bad is primary care integration and coordination with specialty care?

Barkett: You raise a good point; we should better understand exactly how bad it is. That is something we don't really have yet—a metric that measures how bad or good it is. We know who has insurance and who doesn't. We don't get the same type of data as to who gets value-based care and who doesn't.

With MCP, a question I have is how will practices partner with specialists. One VBC premise is that better primary care should mean less reliance on specialists. It's too simple a story but the idea is out there. This model could go a long way toward providing an initial set of answers to this question as it encourages partnership between primary care and specialty providers. Encouraging primary care practices to engage in coordinated care efforts is something CMS hasn't done much of in previous models.

HL: Given the diverse participants in MCP, who will be in the driver's seat?

Barkett: That's a loaded question. MCP is as public-private partnership-y as it gets.

There's always a tension: payers pushing the practices to transform while making sure the model is attractive enough to make it worth the effort. You've got several people with their hands on the wheel here—maybe two or three with their feet on the gas pedals, others on the brakes. It's almost like a three-legged race with either state or federal governments or payers generally each putting a leg in the sack. The first couple of years, it's, 'Can we walk?' with the goal to be running by year two or three.

HL: It's like we wanted it to happen in dog years—seven years of progress for every one.

Barkett: There was never any question that the administration's Domestic Policy Council would have a subject matter expert tracking value-based care. It really took off under Obama, continued under Trump and now the Biden Administration—the idea that there is an alternative to fee-for-service medicine that gets you better patient health provided at lower costs. But it's not as simple as, 'We can reform the way we pay, and providers will transform their practices.' It's not something you can do overnight.

It takes change management. It takes leadership. It takes learning. It takes sharing best practices. It takes technology. It takes data. Everyone would have hoped that all of these things were slam dunks. Instead, we're probably where we were always going to be, which is having learned a lot and now working on the next generations of these payment models.