Recently, the Centers for Medicare & Medicaid Services announced a new primary care payment paradigm—which could be a critical stepping stone to flip the traditional fee-for-service model on its head and increase the prominence of primary care. The demonstration, which CMS is calling the Primary Cares Initiative, represents a push to improve the value of care delivered by investing in flexible payment models for primary care.
Traditional primary care clinics as well as emerging primary care practices such as retail clinics run by Walmart and CVS, for example, or other clinics run by health plans or large employers would be eligible to participate. In order for providers to successfully compete under these new models and manage new levels of financial risk, they must partner with technology companies to find solutions to manage gaps in outreach, attribution, and preventive care with streamlined, cost-effective technology solutions.
Paying for value in primary care
The Primary Cares Initiative offers two primary pathways for primary care providers interested in experimenting in new primary care payments models. One called the Primary Care First institutes performance payment for providers to high-need patients with complex, chronic conditions, rewarding providers for lowering the cost of care and keeping patients healthy. The second, Direct Contracting, introduces different levels of capitated payment to large provider organizations offering primary care such as accountable care organizations and health plans. Participants in the Direct Contracting model would be particularly incentivized to attract and retain their patient base as patient volume and health outcomes would be the basis of payment, not service volume.
Secretary of Health and Human Services, Alex Azar, said in a press conference that the initiative “will radically elevate the importance of primary care in American medicine, move toward a system where providers will be paid for outcomes rather than procedures, and free up doctors to focus on the patients in front of them, rather than the paperwork we send them.”
The flexibility awarded to participating providers to pick up the phone and check in on a patient instead of scheduling a full visit or leveraging the full care team in care delivery could be huge for driving down health costs and improving the patient and provider experience alike. No longer tied to reimbursable billing codes or driven to maximize coding, providers can free up the administrative burden and focus on providing care of the highest quality and a competitive patient experience.
However, in order to be competitive under these models and manage the financial risk that comes with them, primary care providers must embrace new solutions that are responsive to the unique needs of primary care and that help streamline patient outreach.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Reach and retain patients
Under the Primary Cares Initiative, providers would be largely paid based on their patient volume, not on their service volume. As such, they will be increasingly incentivized to attract and retain a strong patient base. This means providers must implement streamlined processes to communicate with patients when they’re due for follow-up care, keeping patients attributed to their practice or clinic. To maximize the patient base, primary care providers will do well to update their patient communication strategies to better customize workflows.
Fill gaps in care
To ensure that providers are not cutting corners to cut costs, CMS will implement comprehensive quality metrics to hold providers accountable for the quality of care they deliver. To succeed on these quality metrics, providers need simple and sophisticated ways to bring patients in for needed preventive care measures ranging from diabetic eye screenings to blood pressure checks. Fortunately, patient engagement technology that integrates with EHR systems can easily identify and target outreach to patients in need of a visit or check-in.
Communicate with patients outside of the traditional appointment
No longer incentivized to maximize traditionally billable services, providers can focus on new and innovative ways to deliver patient care. When it makes clinical sense, that can mean a quick phone call, a telehealth visit, or even communication via a secure chat platform. For example, to check in on blood pressure progress, a patient could complete a simple, HIPAA-secure form. A provider could check in with an established patient via chat instead of bringing him or her into the office for a full visit. Sooner than later, patients will be able to choose to sync their heart rate, blood pressure, and other health data directly into the provider’s EHR.
Measure outcomes and track progress
Primary care providers and groups participating in the Primary Cares Initiative will need sophisticated ways to collect patient feedback and measure the impact of the new care delivery design on the patient experience. This will help them boost their patient experience scores with CMS as well as attract and retain a solid patient base. It will also help them understand the impact of any changes to care design—from preventive care reminders to secure forms for patient-provider conversations. Every primary care provider should implement technology to automatically request patient feedback after every encounter. From there, that data should be aggregated and visible in an interactive dashboard to help monitor progress and achieve success.
The Primary Cares Initiative offers primary care providers the flexibility they need to deliver care in the ways that work best for their patient population. The opportunity to eliminate the dependence on traditional billable codes will support innovation in care delivery, but it does not come without increased competition and financial risk. This is where providers and technology suppliers can work better together—to target, streamline, and monitor communications—ultimately helping primary care providers win under value-based care.
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