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The Roger C. Lipitz Center for Integrated Health Care

Posted Date: January 2, 2014

Accelerating Adoption of Advanced Primary Care Practice
Karen Davis

Richard Baron, M.D., president of the American Board of Internal Medicine, and I propose that Medicare establish a new provider category – Advanced Primary Care Practices (APCP) – to accelerate the adoption of a patient-centered, coordinated care model of practice in a recent New England Journal of Medicine article. While enhanced payment for individual primary care services can help improve the availability of primary care, the provision of high-value patient-centered care requires a team approach and investment in infrastructure needed to ensure accessibility, quality, and efficiency. Tying payment to transformed high-value models of advanced primary care would accelerate adoption of these cutting-edge forms of care delivery.

This proposal builds on two Center for Medicare and Medicaid Innovation (CMMI) multi-payer pilots of primary care payment.  In the Multi-Payer Advanced Primary Care Initiative, Medicare joined with private insurers and state Medicaid programs in eight states to reward primary care practices meeting the standards of patient-centered medical homes through a blended payment model of fee-for-service, care management, and shared savings or performance bonuses. States played a key role in creating a safe harbor for private payers to collaborate in defining and determining how to pay for care.

In the Comprehensive Primary Care Initiative (CPCI), 44 private payers and state Medicaid agencies joined with Medicare in seven market areas engaging 500 high-performing practices with more than 2000 providers. The clinical model of care and clinical milestones were established upfront. The payment model includes fee-for-service payment, a $20 monthly per patient care management fee in years one and two (a 40 percent increase over current Medicare rates), and the opportunity for shared savings starting in year two. These two demonstrations and their evaluation are on-going, but they already demonstrate the feasibility and attractiveness of the model to patients, providers, and payers.

Provision of high-value care can be accelerated by focusing first on a promising delivery model and then designing a payment model to reward its spread. For several years health systems, private insurers, and state Medicaid programs have been experimenting with this new form of advanced primary care. Evaluation to date shows that this form of care delivery improves provision of preventive care, improves satisfaction with practice of physicians and staff, and reduces use of high-cost care such as emergency department visits.

Creation of a new provider category in Medicare, Advanced Primary Care Practices (APCP), has a number of advantages. It would be open to practices meeting eligibility requirements, performance standards, and assumption of accountability for achieving better outcomes for patients, better care, and lower cost. It would have its own payment method, building on the methods used in CMMI demonstrations.  In addition, we recommend that Medicare beneficiaries enrolling in APCPs would receive primary care services without facing a deductible. 

Establishing APCPs as a provider entity would accelerate adoption of a team-approach to care and investment in the necessary infrastructure such as practice redesign, a system of ensuring accessible off-hours care, and information systems that ensure patients receive timely, coordinated, and proactive care management. While ongoing support for CMMI pilots and demonstrations can help inform implementation of high-value primary care models, rapid spread will require commitment to a payment model that will reward this form of care.