APMs Support Better Primary Care, But Value-Based Care Obstacles Remain

Primary care practices in Medicare’s Comprehensive Primary Care (CPC) and CPC+ models made meaningful care delivery changes compared to non-participating practices, making the case for value-based care and reimbursement. However, several lessons learned from the demonstrations could increase participation and inform future healthcare payment reform, CMS’ Innovation Center says.

In a recent JAMA Health Forum Viewpoint article, leaders from the Innovation Center, including Chief Strategy Officer Purva Rawal, shared five major lessons learned from key primary care alternative payment and care delivery models run by the Center. The models included CPC models, which have both ended, and the ongoing Primary Care First (PCF), which launched in 2021.

In addition to organizational changes—which included large changes in risk-stratified care management, access, and continuous data-driven improvement, without evidence of workforce burnout and stress—the Innovation Center leaders learned that shorter performance periods made it difficult to detect changes in quality and cost.

An independent evaluation of CPC, for example, showed no significant difference among participating and control practices on claims-based measures of diabetes care processes or continuity of care among attributed Medicare beneficiaries. There were also improvements for just three of 11 core electronic clinical quality measures (eCQMs) in CPC practices versus practices that formed the benchmark.

“Moving forward, the Innovation Center seeks to harmonize model evaluation measures with quality measures used to determine payment to the greatest extent possible and better capture the impact of care delivery changes on quality and beneficiary experience, including through patient-reported outcome measures,” the article stated.

Innovation Center leaders also noted that CPC+ failed to achieve net savings to CMS after five years because of enhanced payments to practices. This is despite slowed growth in emergency department visits for CPC practices and those that continued to the next iteration of the model.

Leaders said that they “will consider expectations for the period during which savings can develop and the role of primary care clinicians in generating savings, alone or in coordination with other parts of the [healthcare] system.”

The third lesson learned was that health equity must be an explicit goal.

The Innovation Center has refreshed its strategy for achieving cost and quality goals through its alternative payment and care delivery models, making health equity a pillar of the strategy. The Center will include measures of health equity in models to reduce health disparities.

CPC models and PCF did not focus on advancing health equity. Black and Hispanic beneficiaries were also underrepresented in CPC+ and PCF, while White beneficiaries were overrepresented, the article stated. American Indian/Alaska Native beneficiaries were also not well represented in PCF because the Indian Health Service and Tribal clinics that could participate did not.

Making health equity an explicit aim of primary care models will hopefully reach a more representative mix of beneficiaries.

Multipayer alignment was the fourth lesson learned from the three primary care models, according to the article. CPC included multipayer alignment as one of its core features and included state Medicaid agencies and commercial payers.

However, the Innovation Center discovered that multipayer participation does not guarantee meaningful alignment of design features. In CPC+, for example, only 17 percent of payers offered partial capitation payment aligned with CPC+. In PFC, payer participation was also lower compared to CPC+.

“Bringing state Medicaid agencies and commercial payers into the design of models earlier will support multipayer alignment,” the article said.

Finally, Innovation Center leaders found that regional context is key for care transformation, as evident by the primary care models. They stated that effective implementation depends on local and regional factors, such as availability of health information exchange, experience with regional data aggregation, and state population health and equity initiatives.

Effective primary care also hinges on access to and coordination of specialty services and community-based organizations, they added.

CPC models attempted to connect primary care practices with specialty clinicians and provided resources for referral protocols, care transition and management responsibilities, integration of behavioral health care, and screening and referral for social determinants of health. However, Innovation Center leaders noted that the effectiveness of these activities depended on informal and organizational relationships and resources, local referral patterns and practices, and workforce availability.

“The Innovation Center will continue to consider the practice characteristics that contribute to success as well as the regional context necessary for care transformation, including fostering better coordination and integration of primary care with specialty-care and community-based services,” the article stated.

By addressing the five lessons learned, the Innovation Center hopes to increase primary care participation in alternative payment and care delivery models, especially as the Center considers more population-based models.

Currently, only a small portion of total revenue within primary care practices is tied to value-based contracts, new data shows.