AAFP Position Paper

Academy Presents Advanced APM for Primary Care

December 21, 2016 10:42 am News Staff

A just-released AAFP position paper introduces an advanced alternative payment model (APM) for primary care.

The paper, "Advanced Primary Care: A Foundational Alternative Payment Model (APM) for Delivering Patient-Centered, Longitudinal and Coordinated Care,"(8 page PDF) covers in substantial detail all the pieces this model must include.

In the paper's introduction, the AAFP notes there is widespread agreement on the need to reorient the U.S. health care system to have a solid primary care foundation.

"Aspirational words such as 'patient-centered' and 'whole person' care have returned to the health policy vernacular," the Academy states, noting that primary care physicians already are shifting their infrastructure and workforce to coordinate patient care and integrate health information from a variety of data sources.

Story Highlights
  • The AAFP released a position paper that presents an advanced alternative payment model (APM) for primary care.
  • The paper defines the primary care medical home as one that is based on the Joint Principles of the Patient-Centered Medical Home.
  • The paper outlines the key components necessary for the success of an advanced APM for primary care including patient attribution, population-based payment and risk stratification.

The paper points out that among the AAFP's clinically active members, 45 percent are providing care in an officially recognized patient-centered medical home (PCMH) that delivers comprehensive, continuous, coordinated and connected care.

Essentially, this is "advanced primary care through the medical home model," says the AAFP, and this kind of care "is foundational to an efficient and effective health care delivery system."

The AAFP defines the primary care medical home as one that is based on the Joint Principles of the PCMH(3 page PDF) and that includes the five key functions of the Comprehensive Primary Care Plus initiative:(innovation.cms.gov) access and continuity, planned care and population health, care management, patient and caregiver engagement, and comprehensiveness and coordination.

"The AAFP considers these five key functions equally important to delivering primary care," says the paper.

Key Components

The position paper hits on all the key components necessary for the success of an advanced APM for primary care.

Patient attribution methodology is critical to payment, quality and cost performance measurement, says the AAFP, as well as to "defining accountability in a primary care medical home." Therefore, the AAFP recommends a four-step attribution process. At the top of the list is the preferred method of attribution: patient selection of his or her primary care physician and team.

Five Principles that Support Patient-Centered APMs

In conjunction with its recently released position paper introducing its advanced alternative payment model (APM) for primary care, the AAFP also made public five principles(2 page PDF) to guide the evaluation of proposed APMs to ensure that all models considered put patients at the center of health care.

According to that document, APMs

  • must provide longitudinal, comprehensive care;
  • must improve quality, access and health outcomes;
  • should coordinate with the primary care team;
  • should promote evidence-based care; and
  • should be designed as a multipayer model.

The AAFP noted in the document that it supports only patient-centered advanced primary care models that promote comprehensive, longitudinal care across settings and hold clinicians appropriately accountable for outcomes and costs. The Comprehensive Primary Care Plus initiative is an example of one such model.

If patient self-selection is not used, however, payers can move on to other selection methods, including, in this order,

  • use of physicals and well visits provided by the patient's primary care physician or practice team,
  • inclusion of all other evaluation and management (E/M) visits to the physician or primary care team, and
  • consideration of claims related to primary care prescription and order events.

Payment changes are summed up this way: "This proposal places a marker in the ground for how primary care should be paid differently and better to deliver an advanced level of care and services to every American."

The paper says the current fee-for-service (FFS) system and its payment levels for primary care "are inadequate on every level" and calls for a dramatic increase in those payment levels. "Extending current payment levels into this new delivery model would be a tragedy and disservice to our health care system and every patient," the AAFP writes.

The Academy says that primary care practices should have the opportunity to select one of two levels of prospective primary care global payment. Level one would cover ambulatory, office-based, face-to-face E/M services; level two would cover all E/M services regardless of site of service.

All other services, including non-E/M services, would continue to be paid according to the FFS model. Notably, primary care global payments under both levels would be risk-stratified based on patient complexity and other factors.

Population-based payment that is risk-stratified and separate from other payment should be paid prospectively on a monthly basis, says the AAFP, and "should be without risk to the physician and free of patient cost-sharing."

Furthermore, risk stratification must be based on patient complexity and include factors such as comorbidities, cognitive impairment and patient demographics. The AAFP recommends use of the Minnesota Complexity Assessment Method to risk-stratify the primary care global payment and the population-based payment on an annual basis.

"The AAFP believes a risk-stratified, two-level option for the primary care global fee would allow medical homes of various capacities to participate and encourage the move to a more robust care provision," says the paper.

Quality measurement should incorporate the performance measures developed by the Core Quality Measures Collaborative, and the AAFP stipulates that the most up-to-date version of the PCMH/ACO/Primary Care Core Measure Set(ahip.org) should be used for this purpose.

Paying for Primary Care

The position paper also discusses financing the AAFP's APM for advanced primary care. The paper points out that presently, primary care represents just 6 percent of total health care spending. "We believe this should be increased to at least 12 percent of total spending. In fact, the AAFP believes increased spending on primary care will lead to a decrease in overall spending on a per-patient basis."

The AAFP notes that most countries that have developed health care systems where primary care is foundational boast per-capita spending that is well below that of the United States.

Notably, in the United States, Rhode Island mandated an increase in primary care spending; the resulting rise from 5.4 percent to 8 percent between 2007 and 2011 led to an 18 percent drop in total spending -- a 15-fold return on investment.

Lastly, the AAFP says that primary care physicians will need financial and technical assistance to keep their practices financially viable in advanced APMs. And they will need time to transform their practices.

"Primary care, by definition, is concerned with delivering patient-centered, longitudinal and coordinated care, and changing such care delivery does not happen quickly," the Academy concludes.

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