Halfway through the four-year Comprehensive Primary Care (CPC) initiative(innovation.cms.gov) CMS' Center for Medicare and Medicaid Innovation launched in October 2012, two recent reports shed light on what about 1,300 family physicians participating in the groundbreaking program have learned.
The first report summarizes participating practices' expenses and revenue; the second provides a snapshot of the practices' performance to date. Together, they offer insight into the progress of this multipayer initiative designed to foster collaboration between public and private health care payers to strengthen primary care.
Revenues and Expenses
According to a CPC Fast Facts report(innovation.cms.gov) that discusses the initiative's 2013 practice revenues and expenses, 496 primary care practices, 2,494 providers and 2,534,506 patients were participating in the project as of January 2014.
In addition, CPC practices in seven areas -- Arkansas, Colorado, New Jersey, New York, Ohio/Kentucky, Oklahoma and Oregon -- had received $141 million in care management payments from Medicare and other payers during the 2013 program year.
The median total care management fee paid to individual practices between October 2012 and December 2013 was about $228,000, or close to $70,000 per provider. Care management fees paid out among the regions ranged from a high of $29.2 million in Ohio/Kentucky to $15.1 million in Oklahoma.
In all, CPC practices spent about $116 million on CPC-related activities in the 2013 program year. The report showed that 51 percent of that spending across all regions -- nearly $59 million -- went toward care management fees, or risk stratification and care management activities.
- The latest CMS reports on the Comprehensive Primary Care initiative show that practices are making good progress on achieving initiative milestones.
- Providing care management for high-risk, high-cost patients -- also referred to as risk-stratified care management -- is a key component of the project.
- The initiative also stresses patient access and continuity of care, and 99 percent of practices reported offering patients 24/7 access to care.
In addition, practice spending totals during the above time period included
- $15 million on other CPC program planning and operations,
- $11.1 million to provide 24-hour access and non-visit related care,
- $9 million to provide care coordination,
- $7.3 million for electronic health record (EHR) upgrades, and
- $1.6 million for patient surveys and patient-family advisory councils.
Patient Care Milestones
The CPC 2014 mid-year update Fast Facts report(innovation.cms.gov) summarizes information submitted by participating practices and outlines those practices' progress on nine specific CPC milestones. The report notes that the number of participating practices and providers had dropped slightly by this point, but the number of active patients involved in the initiative rose to 2,712,169.
Since its launch, care management for high-risk patients -- also called risk-stratified care management -- has been at the heart of the initiative. Practices were asked to assign each patient a risk status and then provide care management resources to those at high risk who would benefit from the provision of extra services.
The report shows that care management services, most often provided by registered nurses and designated care managers, increased as the initiative progressed. In fact, before the initiative began, 284 of the 496 participating practices had no full-time care managers involved in patient care. But by the end of the 2013, those 284 practices had 394 full-time individuals dedicated to care management services.
Furthermore, the percentage of patients assigned a risk status increased from 65 percent in December 2013 to 73 percent in July 2014, when 298,036 patients were receiving care management services.
CPC-participating practices also were asked to implement at least one of three strategies in 2014: behavioral health integration (employed by 167 practices), comprehensive medication management and review (80 practices) or self-management support (273 practices).
Most often, physicians, behavioral health specialists, and physician assistants provided behavioral health services (e.g., screening, evaluation/diagnosis, referral coordination) in the practices that implemented behavioral health integration. Although not required by the CPC initiative, 65 percent of practices reported having employed behavioral health specialists.
Practices that chose to implement patient self-management used strategies such as developing a care/action plan (88 percent) discussing patient goals (88 percent), conducting between-visit coaching and follow-up (82 percent), doing team preparation (60 percent), and offering group visits (28 percent).
Finally, of those that chose to work on medication management and review, nearly all hired a pharmacist directly or worked out a participation agreement with a local college of pharmacy. On average, practices used pharmacist services for 18 hours per week.
24/7 Patient Access
Given that the CPC initiative overall stresses patient access and continuity of care, all CPC practices were instructed in 2014 to offer patients around-the-clock access to a care team member with real-time access to the EHR.
A full 99 percent of practices did so.
Practices also enhanced patient access in other ways, for example, by offering patients messaging via a patient portal (419 practices), conducting patient visits via telephone (137 practices), and using email (83 practices) and text messaging (39 practices) to communicate.
Improving the patient experience was another milestone practices sought to achieve, and most practices tackled this goal by using office-based patient surveys and/or convening patient/family advisory councils. The latter option generally included eight patients or family members and four members of the practice staff. According to the report, "Action plans from these PFACs (patient-family advisory councils) have emphasized two common themes: improving front desk processes or patient access," with an emphasis on reducing waiting times, extending hours or opening time slots for walk-in patients, as well as improving communication with patients.
Other milestones on which participating practices reported were use of data to guide improvements, care coordination, shared decision-making, and health information technology.
According to the report, 84 percent of participating practices were using 2014-certified technology by the end of June 2014, and 93 percent could exchange health information electronically with at least one other care setting, such as an acute care hospital, a pharmacy or another physician office.
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