Moving away from fee-for-service (FFS) into value-based payment is a priority for many family physicians, as well as for public and private insurers, and CMS is seeking to accelerate the transition through demonstration projects led by the Center for Medicare and Medicaid Innovation.
The center supervises projects that pay for care in new ways while allowing participating practices more flexibility in care delivery. To help expand successful programs and launch new ones, CMS asked for public input on how initiatives could be improved to promote patient-centered care, better outcomes, lower costs and greater physician participation in alternative payment models.
In response, the AAFP provided detailed feedback to CMS Administrator Seema Verma, M.P.H., in a 12-page letter dated Nov. 15 that emphasized the importance of primary care.
"While some of the alternative payment models and physician-focused payment models may deliver comprehensive, longitudinal care, many run the risk of perpetuating (or even exacerbating) the fragmented care many patients receive under the current FFS system," stated the letter, which was signed by Board Chair John Meigs, M.D., of Centreville, Ala. "Evidence shows that health systems built with primary care as the foundation have positive impacts on quality, access and costs."
- In response to CMS's request for ideas to improve alternative payment models, the AAFP recently gave the agency detailed feedback in a 12-page letter.
- The letter highlighted the important role of primary care in increasing quality and access while reducing costs.
- The AAFP noted that its recommendations were based on a set of guiding principles that emphasize quality and outcomes while supporting longitudinal, comprehensive patient-centered care.
Among the AAFP's recommendations was that CMS continue the Comprehensive Primary Care Plus (CPC+) program and begin testing the AAFP's Advanced Primary Care Alternative Payment Model (APC-APM)(38 page PDF), which builds on CPC+.
The APC-APM program, which would be voluntary for physicians, would pay for evaluation and management visits on a prospective, risk-adjusted monthly basis so physicians would not have to file claims for payment, and would use a single set of core measures. The AAFP noted this program could help smaller practices remain independent.
In response to a request for ideas to allow Medicare beneficiaries to contract with physicians directly, the AAFP pointed out that the direct primary care (DPC) model is effective in increasing price transparency and reducing administrative burden.
"DPC physician practices prosper on being fully transparent and consistent with their costs that the patient can access at any time," the letter stated. "The AAFP has seen DPC practices nationwide negotiate substantially lower prices with local imaging and diagnostic centers because their patients are paying out of pocket for the services."
CMS noted that it wants to promote Medicare Advantage as a route to better outcomes and lower costs, and the agency asked for ideas about initiatives that could assist in achieving that goal.
The AAFP suggested that CMS consider testing models similar to a co-branded Medicare Advantage plan that is offered in Ohio by Humana and the Cleveland Clinic. The plan carries no monthly premium, no copays for primary care physician office visits, and no copays for 30-day supplies of tier 1 prescription drugs. In addition, patients do not need referrals to visit in-network subspecialists.
"The AAFP considers this plan to be consistent with our advocacy efforts and with our 'Health Care for All' policy, which supports certain primary care services with no financial barriers," the letter stated. "The AAFP believes this type of plan design would encourage beneficiaries to engage and participate in new models."
Medicaid programs at the state level have been identified as a major source of innovation, especially through a federal waiver program that allows for plans to be designed based on local needs. The AAFP indicated its support for such plans that emphasize primary care.
"If primary care practices are given the tools through Medicaid to redesign how they operate such that they are more accessible to deliver consumer-directed care, promote prevention, proactively support patients with chronic illness, and engage patients in self-management and decision-making," the letter stated, "health care quality and competition (especially for small, independent practices) improves along with the cost efficiency of care."
One drawback to Medicaid is the low physician payment in many states, an issue the AAFP emphasized needs to be addressed.
"It is critical that rates paid by states, to either providers or plans, must be adequate and sufficient to encourage provider and plan participation and cover the cost of care for Medicaid patients," the letter states.
The AAFP insisted that any new payment models should not add to physicians' administrative burden and called on CMS to prioritize streamlining the entire administrative process.
"Why should a physician who is successfully helping his or her patients with diabetes manage their condition, as evidenced through quality reporting, be subject to all the current hassles associated with prescribing and ordering diabetic testing supplies, which are otherwise driven by CMS concerns with fraud, waste and abuse?" the letter asked.
Throughout the letter, the AAFP reminded CMS of the guiding principles(2 page PDF) that inform the Academy's approach to the design and evaluation of new alternative payment models. Those principles call for
- longitudinal, comprehensive care;
- improved quality, access and health outcomes;
- coordination with the primary care team;
- promotion of evidence-based care; and
- multipayer design.
Related AAFP News Coverage
Advanced Primary Care Alternative Payment Model
AAFP Accepts Challenge, Submits Primary Care-based Payment Proposal