Comprehensive Primary Care Initiative a Potentially Worthwhile Gamble

The federal government’s Comprehensive Primary Care Initiative could initially be a boon for physicians who participate, but may prove to be a more difficult proposition for them in the program’s later years, say some participants.

For the first 2 years, the 500 physician practices in seven regions selected for the program – sponsored by the Center for Medicare and Medicaid Innovation – will receive from Medicare a per member, monthly payment averaging $20, in addition to their normal fee-for-service payments.

Doctors are being given the fee in exchange for meeting certain goals and criteria, all with the aim of providing comprehensive primary care. CMS wants practices to better and more intensively manage patients with multiple conditions; ensure better access to care by keeping longer hours and via tools such as e-mail and patient portals; increase preventive care; and better coordinate care with specialists.

A handful of additional payers are participating in each state. Those payers – private insurers and in some states, Medicaid – also will give physicians a per patient/per month fee. The additional payers were selected in April, so that doctors would know how many of their patients might be covered by the added month payments when deciding to apply for the program.

But, by the third and fourth year of the program, the Medicare monthly fee will be reduced to an average of $15, and it’s not clear what private payers will do. Physicians will have an opportunity to share in savings, but it still represents a gamble, say some.

Dr. Stacey Zimmerman, an internist in Clinton, Ark., is looking forward to the revenue stream that will be provided by the primary care initiative, but says she is concerned about how she will manage once the payments drop. With better care coordination, patients will not need as many services, which means practice revenues will drop, she said in an interview. Meanwhile, expenses are not likely to moderate. "So how do we meet our overhead?" she asked.

Courtesy of Foresight Family Physicians

"I think that is a bit of a concern for everyone," agreed Dr. Gregory Reicks, with Foresight Family Physicians in Grand Junction, Colo. Doctors will be building new practice models that are dependent on the per patient/per month fees. The challenge is to find a way to keep funding the new model, he said in an interview.

"Our hope is that the private payers will see the value of it, based on better overall patient satisfaction and lower costs, and that they’ll hopefully want to fund it going forward," he said.

Improving Revenue, Adding Services

Overall, both Dr. Zimmerman and Dr. Reicks said they were very happy to have been chosen for the program.

According to CMS, the practices were selected through a competitive application process. The practices, representing 2,144 providers caring for 313,000 Medicare beneficiaries, are in Arkansas; Colorado; New Jersey; the Capital District/Hudson Valley, N.Y., region; the Cincinnati/Dayton region of Ohio and Kentucky; the greater Tulsa (Okla.) area, and Oregon.

To be selected, practices had to demonstrate that they already had an electronic health record system, that they were already delivering advanced primary care, or that they were engaged in transforming their practices. They also had to have enough patients covered by Medicare and participating private payers to make it worthwhile.

The idea is to provide money to help practices fully transform, said Dr. Robert A. Gluckman, Chair of the American College of Physicians Medical Practice and Quality Committee.

In a traditional model, physicians are only paid for face-to-face encounters. Under this initiative, the monthly fee will help cover services delivered by e-mail, phone, group visits, or by allied health professionals like nutrition and behavioral counselors, said Dr. Gluckman, who also is the chief medical officer for Providence Health Plans. Providence is one of the participating payers in Oregon.

"This is going to be a tremendous opportunity for primary care practices to have the revenue to practice medicine differently," he said.

From a payer point of view, it was worth participating to help "facilitate a more robust primary care network," Dr. Gluckman said. "Payers are increasingly recognizing that we need a more robust primary care delivery system to deliver care more effectively," he said, noting that effective primary care can decrease emergency department visits and curb hospitalizations. "If no one ever tries to deliver care differently, we’re going to keep getting what we’re getting – high cost and some variation in quality."

Dr. Zimmerman said that she has already seen the benefits of creating a better primary care delivery model: happier and somewhat healthier patients. But it was all done without the additional revenue, which meant it was not sustainable, she said.

For the last 2 years, her practice, comprised of herself and two nurse practitioners, participated in a patient-centered medical home pilot program with Arkansas Blue Cross Blue Shield. It is ending in December. No additional payments were given for doing things like creating a patient portal and offering consultations by phone after hours. And not all of her 5,800 patients were covered by the pilot.

The current initiative, with four participating payers in Arkansas – Blue Cross Blue Shield, QualChoice, Humana, and Medicare – will cover 92% of her patients. It’s not clear yet what the monthly payment will be from Medicare or those insurers, but payments are due to start Oct. 1, Dr. Zimmerman said.

The additional funds will let her invest in areas that she couldn’t before, like diabetes education, and to perhaps hire a care coordinator. It also eill help her maintain her EHR and improve her patient portal. Only about a third of patients are using it – to make appointments, request prescription refills, and access lab results or e-mail Dr. Zimmerman. She uses it to send patients a visit summary and lab results and to share educational materials.

The portal makes her work a lot easier, she said. For instance, the system tracks whether a patient has accessed those educational materials or lab results and notifies the physician that the materials have been – or have not been – read. It also allows relatives – say a daughter of an elderly patient – to see medical records and communicate directly with her. That’s especially important if the daughter lives elsewhere.

She also uses her website and a clinic Facebook page to stay in touch with patients. In rural Arkansas, a large number of people have smartphones because so many use Facebook as entertainment, said Dr. Zimmerman. "I would rather them get on my Facebook page and read about something I posted from the Mayo Clinic than surf the web and look up something that’s not good educational information," she said.

Dr. Reicks also says that his patients have been enthusiastic about his patient portal, though only about a third have signed up for access. Initially, the practice’s providers – three physicians, a nurse practitioner, and a physician assistant – were worried that inviting patients to e-mail would open up a flood that would take away from actual practice time.

But uptake has been slow, and "we’ve found it to be convenient and effective," saving time, money on postage, and miscommunications, Dr. Reicks said.

His practice has had an EHR since 2007, and it participated in the Colorado Beacon Consortium, a CMS-funded practice-improvement program in western Colorado. Though the practice underwent a huge transformation, it was looking to move to the next level, said Dr. Reicks.

The per patient/per month fee under the primary care initiative will help the practice "pull in additional human resources," he said. That would include case managers, health coaches, and behavioral health specialists. The idea is to offer truly comprehensive care, Dr. Reicks said.

About 4,500 of the practice’s 10,000 patients will be covered under the initiative, including some 3,000 Medicare patients and 800 Medicaid patients. The practice anticipates an average $10 per patient monthly fee, but it could be more after Medicare payment is risk-adjusted. Like Dr. Zimmerman, Dr. Reicks is waiting on getting word from the private payers – which include Rocky Mountain Health Plans, Anthem Blue Cross Blue Shield, UnitedHealthcare and Cigna – on their monthly payment. But at least one payer – Rocky Mountain Health Plans – has suggested that it will offer in-kind resources such as health coaches instead of an actual payment, Dr. Reicks said.

The uncertainty over the revenue stream is a familiar, but vexing problem, he said. CMS is requiring the participating practices to submit a plan detailing how the monthly fees will be spent. "And we don’t know how much will be coming in," Dr. Reicks said.

It begs the question of why a practice would seek out participation in this initiative.

Besides improving patient satisfaction and health outcomes, "we’re hoping this will somehow restore the joy of practicing medicine again," he said.

The federal government’s Comprehensive Primary Care Initiative could initially be a boon for physicians who participate, but may prove to be a more difficult proposition for them in the program’s later years, say some participants.

For the first 2 years, the 500 physician practices in seven regions selected for the program – sponsored by the Center for Medicare and Medicaid Innovation – will receive from Medicare a per member, monthly payment averaging $20, in addition to their normal fee-for-service payments.

Doctors are being given the fee in exchange for meeting certain goals and criteria, all with the aim of providing comprehensive primary care. CMS wants practices to better and more intensively manage patients with multiple conditions; ensure better access to care by keeping longer hours and via tools such as e-mail and patient portals; increase preventive care; and better coordinate care with specialists.

A handful of additional payers are participating in each state. Those payers – private insurers and in some states, Medicaid – also will give physicians a per patient/per month fee. The additional payers were selected in April, so that doctors would know how many of their patients might be covered by the added month payments when deciding to apply for the program.

But, by the third and fourth year of the program, the Medicare monthly fee will be reduced to an average of $15, and it’s not clear what private payers will do. Physicians will have an opportunity to share in savings, but it still represents a gamble, say some.

Dr. Stacey Zimmerman, an internist in Clinton, Ark., is looking forward to the revenue stream that will be provided by the primary care initiative, but says she is concerned about how she will manage once the payments drop. With better care coordination, patients will not need as many services, which means practice revenues will drop, she said in an interview. Meanwhile, expenses are not likely to moderate. "So how do we meet our overhead?" she asked.

Courtesy of Foresight Family Physicians

"I think that is a bit of a concern for everyone," agreed Dr. Gregory Reicks, with Foresight Family Physicians in Grand Junction, Colo. Doctors will be building new practice models that are dependent on the per patient/per month fees. The challenge is to find a way to keep funding the new model, he said in an interview.

"Our hope is that the private payers will see the value of it, based on better overall patient satisfaction and lower costs, and that they’ll hopefully want to fund it going forward," he said.

Improving Revenue, Adding Services

Overall, both Dr. Zimmerman and Dr. Reicks said they were very happy to have been chosen for the program.

According to CMS, the practices were selected through a competitive application process. The practices, representing 2,144 providers caring for 313,000 Medicare beneficiaries, are in Arkansas; Colorado; New Jersey; the Capital District/Hudson Valley, N.Y., region; the Cincinnati/Dayton region of Ohio and Kentucky; the greater Tulsa (Okla.) area, and Oregon.

To be selected, practices had to demonstrate that they already had an electronic health record system, that they were already delivering advanced primary care, or that they were engaged in transforming their practices. They also had to have enough patients covered by Medicare and participating private payers to make it worthwhile.

The idea is to provide money to help practices fully transform, said Dr. Robert A. Gluckman, Chair of the American College of Physicians Medical Practice and Quality Committee.

In a traditional model, physicians are only paid for face-to-face encounters. Under this initiative, the monthly fee will help cover services delivered by e-mail, phone, group visits, or by allied health professionals like nutrition and behavioral counselors, said Dr. Gluckman, who also is the chief medical officer for Providence Health Plans. Providence is one of the participating payers in Oregon.

"This is going to be a tremendous opportunity for primary care practices to have the revenue to practice medicine differently," he said.

From a payer point of view, it was worth participating to help "facilitate a more robust primary care network," Dr. Gluckman said. "Payers are increasingly recognizing that we need a more robust primary care delivery system to deliver care more effectively," he said, noting that effective primary care can decrease emergency department visits and curb hospitalizations. "If no one ever tries to deliver care differently, we’re going to keep getting what we’re getting – high cost and some variation in quality."

Dr. Zimmerman said that she has already seen the benefits of creating a better primary care delivery model: happier and somewhat healthier patients. But it was all done without the additional revenue, which meant it was not sustainable, she said.

For the last 2 years, her practice, comprised of herself and two nurse practitioners, participated in a patient-centered medical home pilot program with Arkansas Blue Cross Blue Shield. It is ending in December. No additional payments were given for doing things like creating a patient portal and offering consultations by phone after hours. And not all of her 5,800 patients were covered by the pilot.

The current initiative, with four participating payers in Arkansas – Blue Cross Blue Shield, QualChoice, Humana, and Medicare – will cover 92% of her patients. It’s not clear yet what the monthly payment will be from Medicare or those insurers, but payments are due to start Oct. 1, Dr. Zimmerman said.

The additional funds will let her invest in areas that she couldn’t before, like diabetes education, and to perhaps hire a care coordinator. It also eill help her maintain her EHR and improve her patient portal. Only about a third of patients are using it – to make appointments, request prescription refills, and access lab results or e-mail Dr. Zimmerman. She uses it to send patients a visit summary and lab results and to share educational materials.

The portal makes her work a lot easier, she said. For instance, the system tracks whether a patient has accessed those educational materials or lab results and notifies the physician that the materials have been – or have not been – read. It also allows relatives – say a daughter of an elderly patient – to see medical records and communicate directly with her. That’s especially important if the daughter lives elsewhere.

She also uses her website and a clinic Facebook page to stay in touch with patients. In rural Arkansas, a large number of people have smartphones because so many use Facebook as entertainment, said Dr. Zimmerman. "I would rather them get on my Facebook page and read about something I posted from the Mayo Clinic than surf the web and look up something that’s not good educational information," she said.

Dr. Reicks also says that his patients have been enthusiastic about his patient portal, though only about a third have signed up for access. Initially, the practice’s providers – three physicians, a nurse practitioner, and a physician assistant – were worried that inviting patients to e-mail would open up a flood that would take away from actual practice time.

But uptake has been slow, and "we’ve found it to be convenient and effective," saving time, money on postage, and miscommunications, Dr. Reicks said.

His practice has had an EHR since 2007, and it participated in the Colorado Beacon Consortium, a CMS-funded practice-improvement program in western Colorado. Though the practice underwent a huge transformation, it was looking to move to the next level, said Dr. Reicks.

The per patient/per month fee under the primary care initiative will help the practice "pull in additional human resources," he said. That would include case managers, health coaches, and behavioral health specialists. The idea is to offer truly comprehensive care, Dr. Reicks said.

About 4,500 of the practice’s 10,000 patients will be covered under the initiative, including some 3,000 Medicare patients and 800 Medicaid patients. The practice anticipates an average $10 per patient monthly fee, but it could be more after Medicare payment is risk-adjusted. Like Dr. Zimmerman, Dr. Reicks is waiting on getting word from the private payers – which include Rocky Mountain Health Plans, Anthem Blue Cross Blue Shield, UnitedHealthcare and Cigna – on their monthly payment. But at least one payer – Rocky Mountain Health Plans – has suggested that it will offer in-kind resources such as health coaches instead of an actual payment, Dr. Reicks said.

The uncertainty over the revenue stream is a familiar, but vexing problem, he said. CMS is requiring the participating practices to submit a plan detailing how the monthly fees will be spent. "And we don’t know how much will be coming in," Dr. Reicks said.

It begs the question of why a practice would seek out participation in this initiative.

Besides improving patient satisfaction and health outcomes, "we’re hoping this will somehow restore the joy of practicing medicine again," he said.

The federal government’s Comprehensive Primary Care Initiative could initially be a boon for physicians who participate, but may prove to be a more difficult proposition for them in the program’s later years, say some participants.

For the first 2 years, the 500 physician practices in seven regions selected for the program – sponsored by the Center for Medicare and Medicaid Innovation – will receive from Medicare a per member, monthly payment averaging $20, in addition to their normal fee-for-service payments.

Doctors are being given the fee in exchange for meeting certain goals and criteria, all with the aim of providing comprehensive primary care. CMS wants practices to better and more intensively manage patients with multiple conditions; ensure better access to care by keeping longer hours and via tools such as e-mail and patient portals; increase preventive care; and better coordinate care with specialists.

A handful of additional payers are participating in each state. Those payers – private insurers and in some states, Medicaid – also will give physicians a per patient/per month fee. The additional payers were selected in April, so that doctors would know how many of their patients might be covered by the added month payments when deciding to apply for the program.

But, by the third and fourth year of the program, the Medicare monthly fee will be reduced to an average of $15, and it’s not clear what private payers will do. Physicians will have an opportunity to share in savings, but it still represents a gamble, say some.

Dr. Stacey Zimmerman, an internist in Clinton, Ark., is looking forward to the revenue stream that will be provided by the primary care initiative, but says she is concerned about how she will manage once the payments drop. With better care coordination, patients will not need as many services, which means practice revenues will drop, she said in an interview. Meanwhile, expenses are not likely to moderate. "So how do we meet our overhead?" she asked.

Courtesy of Foresight Family Physicians

"I think that is a bit of a concern for everyone," agreed Dr. Gregory Reicks, with Foresight Family Physicians in Grand Junction, Colo. Doctors will be building new practice models that are dependent on the per patient/per month fees. The challenge is to find a way to keep funding the new model, he said in an interview.

"Our hope is that the private payers will see the value of it, based on better overall patient satisfaction and lower costs, and that they’ll hopefully want to fund it going forward," he said.

Improving Revenue, Adding Services

Overall, both Dr. Zimmerman and Dr. Reicks said they were very happy to have been chosen for the program.

According to CMS, the practices were selected through a competitive application process. The practices, representing 2,144 providers caring for 313,000 Medicare beneficiaries, are in Arkansas; Colorado; New Jersey; the Capital District/Hudson Valley, N.Y., region; the Cincinnati/Dayton region of Ohio and Kentucky; the greater Tulsa (Okla.) area, and Oregon.

To be selected, practices had to demonstrate that they already had an electronic health record system, that they were already delivering advanced primary care, or that they were engaged in transforming their practices. They also had to have enough patients covered by Medicare and participating private payers to make it worthwhile.

The idea is to provide money to help practices fully transform, said Dr. Robert A. Gluckman, Chair of the American College of Physicians Medical Practice and Quality Committee.

In a traditional model, physicians are only paid for face-to-face encounters. Under this initiative, the monthly fee will help cover services delivered by e-mail, phone, group visits, or by allied health professionals like nutrition and behavioral counselors, said Dr. Gluckman, who also is the chief medical officer for Providence Health Plans. Providence is one of the participating payers in Oregon.

"This is going to be a tremendous opportunity for primary care practices to have the revenue to practice medicine differently," he said.

From a payer point of view, it was worth participating to help "facilitate a more robust primary care network," Dr. Gluckman said. "Payers are increasingly recognizing that we need a more robust primary care delivery system to deliver care more effectively," he said, noting that effective primary care can decrease emergency department visits and curb hospitalizations. "If no one ever tries to deliver care differently, we’re going to keep getting what we’re getting – high cost and some variation in quality."

Dr. Zimmerman said that she has already seen the benefits of creating a better primary care delivery model: happier and somewhat healthier patients. But it was all done without the additional revenue, which meant it was not sustainable, she said.

For the last 2 years, her practice, comprised of herself and two nurse practitioners, participated in a patient-centered medical home pilot program with Arkansas Blue Cross Blue Shield. It is ending in December. No additional payments were given for doing things like creating a patient portal and offering consultations by phone after hours. And not all of her 5,800 patients were covered by the pilot.

The current initiative, with four participating payers in Arkansas – Blue Cross Blue Shield, QualChoice, Humana, and Medicare – will cover 92% of her patients. It’s not clear yet what the monthly payment will be from Medicare or those insurers, but payments are due to start Oct. 1, Dr. Zimmerman said.

The additional funds will let her invest in areas that she couldn’t before, like diabetes education, and to perhaps hire a care coordinator. It also eill help her maintain her EHR and improve her patient portal. Only about a third of patients are using it – to make appointments, request prescription refills, and access lab results or e-mail Dr. Zimmerman. She uses it to send patients a visit summary and lab results and to share educational materials.

The portal makes her work a lot easier, she said. For instance, the system tracks whether a patient has accessed those educational materials or lab results and notifies the physician that the materials have been – or have not been – read. It also allows relatives – say a daughter of an elderly patient – to see medical records and communicate directly with her. That’s especially important if the daughter lives elsewhere.

She also uses her website and a clinic Facebook page to stay in touch with patients. In rural Arkansas, a large number of people have smartphones because so many use Facebook as entertainment, said Dr. Zimmerman. "I would rather them get on my Facebook page and read about something I posted from the Mayo Clinic than surf the web and look up something that’s not good educational information," she said.

Dr. Reicks also says that his patients have been enthusiastic about his patient portal, though only about a third have signed up for access. Initially, the practice’s providers – three physicians, a nurse practitioner, and a physician assistant – were worried that inviting patients to e-mail would open up a flood that would take away from actual practice time.

But uptake has been slow, and "we’ve found it to be convenient and effective," saving time, money on postage, and miscommunications, Dr. Reicks said.

His practice has had an EHR since 2007, and it participated in the Colorado Beacon Consortium, a CMS-funded practice-improvement program in western Colorado. Though the practice underwent a huge transformation, it was looking to move to the next level, said Dr. Reicks.

The per patient/per month fee under the primary care initiative will help the practice "pull in additional human resources," he said. That would include case managers, health coaches, and behavioral health specialists. The idea is to offer truly comprehensive care, Dr. Reicks said.

About 4,500 of the practice’s 10,000 patients will be covered under the initiative, including some 3,000 Medicare patients and 800 Medicaid patients. The practice anticipates an average $10 per patient monthly fee, but it could be more after Medicare payment is risk-adjusted. Like Dr. Zimmerman, Dr. Reicks is waiting on getting word from the private payers – which include Rocky Mountain Health Plans, Anthem Blue Cross Blue Shield, UnitedHealthcare and Cigna – on their monthly payment. But at least one payer – Rocky Mountain Health Plans – has suggested that it will offer in-kind resources such as health coaches instead of an actual payment, Dr. Reicks said.

The uncertainty over the revenue stream is a familiar, but vexing problem, he said. CMS is requiring the participating practices to submit a plan detailing how the monthly fees will be spent. "And we don’t know how much will be coming in," Dr. Reicks said.

It begs the question of why a practice would seek out participation in this initiative.

Besides improving patient satisfaction and health outcomes, "we’re hoping this will somehow restore the joy of practicing medicine again," he said.