Primary Care Model Did Not Reduce Healthcare Spending or Improve Care

The CMS Comprehensive Primary Care Plus (CPC+) model was not associated with reduced healthcare expenditures or care quality improvements, a study published in JAMA found.

CMS launched the five-year model in 2017, building upon the CPC Classic model. The CPC+ model provided practice-level over regional financial incentives, required practices to provide more comprehensive care, and furthered the shift to value-based care.

The 2-track model provided care management fees, as in the CPC Classic model, and offered alternative fee-for-service payments in track 2 and practice-level performance-based incentive payments in both tracks. Primary care practices could also participate in both CPC+ and the Medicare Shared Savings Program (MSSP).

The CPC+ model’s framework requires participating primary care practices to improve care delivery across five areas: access and continuity, care management, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health. CMS provided enhanced payments to support practices through these requirements.

Researchers used Medicare claims files from the Virtual Research Data Center to assess how the CPC+ model impacted healthcare spending, utilization, and quality of care.

The study sample included 1,373 track 1 and 1,515 track 2 primary care practices. Researchers also assessed 5,243 comparison practices in track 1 and 3,783 comparison practices in track 2.

When excluding the enhanced payments from CMS, the CPC+ model was not associated with lower Medicare expenditures, the study findings indicated. After including the enhanced payments, the model was associated with increased spending of $13 per beneficiary per month in track 1 and $24 per beneficiary per month in track 2, relative to comparison practices.

However, the model was associated with a reduction in emergency department visits. Across the five performance years, there was almost a 2 percent greater mean annual reduction in both tracks relative to comparison practices. These results were driven by fewer primary care substitutable and preventable emergency department visits.

The model was tied to fewer acute hospitalizations starting in the third year, leading to a greater mean annual reduction of 1 percent for CPC+ participants in both tracks. The model was also associated with a decrease in acute inpatient expenditures.

The CPC+ track 2 reduced ambulatory primary care visits by 1 percent and 0.6 percent fewer specialist visits.

These associations were more common among practices participating in both CPC+ and MSSP, suggesting that aligning primary care supports with global incentives leads to better outcomes.

Among 27 care quality measures examined, the CPC+ model was not associated with any significant changes in readmissions, unplanned acute care, use of low-value services, appropriate use of recommended medications, continuity, or comprehensiveness of primary care.

However, the model was associated with improvements in certain measures of planned care and population health and patient and caregiver engagement. For example, the receipt of recommended services for diabetes and breast cancer screening among females both increased by one percentage point in both tracks over the five years. Hospice use also increased by 0.1 percentage points in both tracks relative to comparison practices.

Several reasons may be behind the varying levels of success in improving care delivery. Some claims-based quality measures were not directly incentivized in the CPC+ model, and some were already high before practices joined the model.

In addition, the aspects of comprehensiveness that CPC+ emphasized may not have been enough to impact the care the quality measures assessed.

Although healthcare expenditures could have declined if the model had spanned over a longer period, the researchers noted that the positive changes the practices accomplished may not have been sufficient to reduce total spending. Primary care practices rarely influence specialist and hospital expenditures, making it difficult for these practices to decrease total costs on their own.

Aligning models and their incentives across specialties would likely lead to more spending reductions and better care quality, researchers concluded.