On September 28, 2011, the Centers for Medicare & Medicaid Services announced its Comprehensive Primary Care (CPC) initiative, a new CMS-led, multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care for all Americans.
Primary care is critical to promoting health, improving care, and reducing overall system costs, but it has been historically under-funded and under-valued in the United States. Without a significant enough investment across multiple payers, independent health plans– covering only their own members and offering support only for their segment of the total practice population– cannot provide enough resources to transform entire primary care practices and make expanded services available to all patients served by those practices.
The CPC initiative offers a way to break through this historical impasse by inviting payers to join with Medicare in investing in primary care in 5-7 selected localities across the country. The CPC initiative will test two models simultaneously: a service delivery model and a payment model. The service delivery model will test comprehensive primary care, which is characterized as having the following five functions:
- Risk-stratified Care Management;
- Access and Continuity;
- Planned Care for Chronic Conditions and Preventative Care;
- Patient and Caregiver Engagement;
- Coordination of Care Across the Medical Neighborhood.
The payment model includes a monthly care management fee paid to the selected primary care practices on behalf of their fee-for-service Medicare beneficiaries and, in years 2-4 of the initiative, the potential to share in any savings to the Medicare program. Practices will also receive compensation from other payers participating in the initiative, including private insurance companies and other health plans, which will allow them to integrate multi-payer funding streams to strengthen their capacity to implement practice-wide quality improvement.
The Innovation Center is now accepting letters of intent from public and private health care payers for the Comprehensive Primary Care initiative. The first step is for public and private payers (including states) to indicate their interest to CMS, including the level and type of support for primary care practices being offered. Interested payers must submit a nonbinding letter of intent and a completed Geographic Service Area Worksheet by November 15, 2011.
Final applications, to be completed only after the letter of intent has been submitted, must be received on or before January 17, 2012. Once CMS evaluates these proposals and selects the markets, a second solicitation will be issued for primary care practices in those markets.
Ignatius Bau 
I was very interested in this proposed demonstration and hoped that it would be a substantial improvement on the abortive Medicare medical home program developed for CMS in 2009/2010. While I am sure that the average extra $20 per Medicare beneficiary per month as part of other pm/pms from other payors will do a great deal to make primary care viable once more, I don’t think this demonstration can succeed. For an average physician who has 200 Medicare beneficiaries in his or her practice, this will add up to an extra $48,000 annually. Unfortunately, for this program to be viable, CMS has to get the money back from savings elsewhere. So there is an interesting mathematical function at work, CMS has to pay enough that the practice owner can both take home some extra and cover new “medical home” services/costs (e.g., a registry nurse, patient navigator, or transition coach). Those services must be effective enough to reduce utilization elsewhere in the system (i.e., hospitalizations) to make the program cost neutral and quality positive. I’m not sure what practices can do for their 50 sickest Medicare beneficiaries with $48,000 that will make a difference in outcomes and costs. Bottom line they have to prevent 6 hospitalizations in each year.
In this case, I am afraid that mixing the issues of the multiply chronically ill Medicare beneficiaries with those of commercially insured younger patients is unlikely to work well for those who need really intense case management and intervention. I suspect that this program will just subsidize the care of commercially insured younger people and do little for the public programs and beneficiaries.
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