Center for Medicare and Medicaid Innovation

AAFP Challenges Payment Inequities in Primary Care, Oncology Initiatives

April 07, 2015 03:34 pm News Staff

The AAFP recently took CMS to task for introducing serious payment inequities between two payment model initiatives with similar practice requirements.

[Calendar with stethoscope laying on top]

In an April 2 letter(2 page PDF) to CMS Acting Administrator Andy Slavitt, the AAFP questioned CMS' rationale in offering a $160 per-beneficiary, per-month (PBPM) payment to practices that participate in a new Oncology Care Model (OCM)(innovation.cms.gov) when primary care practices receive PBPM payments that range from $8 to $40 ($20 on average) for their work in the Comprehensive Primary Care (CPC) initiative.(innovation.cms.gov)

What's more, the oncology PBPM amount will remain constant for the duration of the five-year program, while PBPM payments to primary care practices in the CPC initiative are set to decrease to an average of $15 in the program's third and fourth years.

"The significant, glaring discrepancy between the two programs' PBPM payments is of great concern to the AAFP," said AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn.

The AAFP realizes that patients with cancer require significant resources, but is nonetheless "alarmed" at the differences in payment given that both initiatives require significant practice transformation, said Blackwelder.

Story Highlights
  • AAFP Board Chair Reid Blackwelder, M.D., recently challenged CMS on its decision to introduce serious payment inequities into two payment model initiatives with similar practice requirements.
  • Practices participating in the Comprehensive Primary Care (CPC) initiative earn per-beneficiary, per-month (PBPM) payments that are one-fourth of those set for practices that join the new Oncology Care Model.
  • The AAFP urged CMS to raise the PBPM payments for the CPC initiative and said that doing so would match the agency's verbal commitment to primary care with a financial commitment.

He pointed out some of the overlapping requirements in the two care models. For instance, practices in both initiatives must

  • provide around-the-clock access to a health care professional with real-time availability to the practice's medical records,
  • use data to drive continuous quality improvement,
  • work with patients to develop care plans and
  • provide care coordination to ensure continuity of care.

The AAFP supports both programs, but is "compelled to remind CMS" that practices participating in each are required to provide enhanced services, said Blackwelder.

"We are concerned that PBPM (payments) in the CPC program are one-fourth of those provided in the OCM," he said.

"If CMS implements this model, it will further drive a delta between payments for services provided by primary care and (sub)specialty care," said Blackwelder. "We believe the OCM continues the current pay disparity that undervalues primary care," a situation that steers students into subspecialty careers and perpetuates the country's primary care shortage, he added.

Blackwelder called on CMS to increase the CPC initiative's PBPM to a level that is equal -- or at least closer -- to the PBPM planned for the Oncology Care Model.

He reminded CMS that first-year CPC initiative results showed a 2 percent reduction in hospitalizations, a 3 percent reduction in emergency department visits and a 2 percent decline in patient visits to subspecialists.

"The CPC initiative reduced total monthly Medicare expenditures without care management fees during the first program year by $14 per beneficiary," said Blackwelder.

Pointing to that first-year success, Blackwelder urged CMS to expand the CPC initiative nationally and to "eliminate or radically decrease the payment gap" between the primary care and the oncology care models.

Instituting this change would allow CMS to "make a financial commitment to primary care commensurate with its verbal commitment," concluded Blackwelder.

Both the CPC initiative and the OCM are products of the Center for Medicare and Medicaid Innovation. The center is tasked with testing innovative payment and delivery models with an overarching goal of reducing the cost of health care while maintaining or enhancing the quality of care provided to patients enrolled in Medicare, Medicaid and the Children's Health Insurance Program.

A request for applications for the Oncology Care Model was published in the Feb. 17 Federal Register.(www.gpo.gov)

Related AAFP News Coverage
Year One Updates
First-year Primary Care Project Findings Note Slow, Steady Progress

2/4/2015

Update: Comprehensive Primary Care Initiative
Practices Making Good Progress on Achieving Care Management Milestones

(1/14/2014)

More From AAFP
Comprehensive Primary Care Initiative