CPC+, a public-private payment structure supports private practices willing to make the change, but the transformation can still be challenging and costly.
The way we think of a primary care practice may be changing. Many traditional practices are transforming into medical homes, where patients can get comprehensive and personalized team-based care with some type of advanced capabilities.
“They might have believed all along this was a better way to deliver primary care, but it never made sense before,” says Mark Friedberg, MD, MPP, a health policy researcher at the RAND Corp.
Friedberg says it might be making more sense now because of the Comprehensive Primary Care Plus model from the federal Centers for Medicare & Medicaid Services. According to the CMS website, CPC+ is “an advanced primary care medical home model that rewards value and quality by offering an innovative payment structure to support primary care practices to improve quality, access, and efficiency.”
The financing comes through a public-private partnership that includes regional payers aligned with the program. CPC+ began in 2017 with 53 payers and 2,891 practices, with a second phase slated to begin in 2018.
“There is some kind of enhanced funding going to the practice to support the transformation into a medical home.” Friedberg says, “It’s now a better investment.”
The changes in the Medicare reimbursement structure are enticing many physician leaders to make a switch, and some did even before CPC+.
“To stay ahead of the changes and take advantage of the new payment system, many practices are changing to a medical home model,” Friedberg says.
There is no standard of what a medical home is, Friedberg says, but usually it means additional services are available to patients. For example, nutrition services, nutrition counseling and patient care coordinators may be available for people with chronic conditions such as diabetes.
“It just makes clinical sense. You want your patients to be as informed as possible,” he says.
Having these resources on site makes it easier for the patient to utilize them, however studies have shown mixed results about how well these types of practices improve patient outcomes and reduce overall medical costs, Friedberg says.
“It’s too early still to know what the best recipes are for making medical homes, we just don’t know yet,” he says. As for patient outcomes, “some studies have shown improvements, some have shown no difference, some have shown worsening, some studies have shown all three and have looked at multiple measures.”
Interventions such as CPC+ provide the financial support to practices wanting to make the change, but there is still a cost involved. A RAND study published in 2015 showed practices incurred a median one-time cost of $30,991 and ongoing yearly median costs of $147,573 per practice to transform into a medical home. That’s not taking other costs into account.
“It’s challenging for a lot of practices to transform,” Friedberg says. “You have people doing tasks they have never done before.”
Changing how people think about primary care often involves job changes and means changing how things have always been done.
“That’s the price you have to pay to get to the steady state,” Friedberg says. “Some people love it. Some people don’t like it. It’s uncontroversial to say the transition is usually challenging.”
Friedberg says medical homes will be with us for the foreseeable future, meaning many more practices will make the change.
“Really read the research carefully and don’t rely on evidence reviews,” Friedberg says, adding physician leaders should look at full articles and talk to the researchers involved before embarking on the road to change.
Customization is very important.
“Every practice is different, and they all serve different patient populations,” he said. “You’re not trying to force a cookie-cutter transformation on practices.”
Leadership is different, staffing is different, and even state laws and regulations are different.
“Look before leaping and try to envision your practice doing it. Talk to people who have done it and who seem to have had a good result,” Friedberg says.
One of those experts is Robert Gabbay, MD, PhD, chief medical officer at the Joslin Diabetes Center in Boston. In 2009, as a faculty lead, he helped 150 practices in Pennsylvania transition to being medical homes as part of the Pennsylvania Chronic Care Initiative.
“To improve quality was the key focus. As a result of improving quality, we lowered health care costs,” Gabbay says.
Understanding the shift from an acute care approach to a population center approach takes time, Gabbay says. In a traditional practice, patients see their physicians when they are sick and don’t often come into an office again until they require care. That approach worked when most people died from infectious disease, he says, adding most deaths now occur from complications relating to chronic conditions, which is where the medical home approach can do the most good.
For example, in a person with diabetes, if blood sugar is maintained, there are fewer complications such as blindness, kidney failure and amputations, thereby lowering treatment costs.
“Most of the costs are related to long-term complications, and many of the long-term complications are preventable,” Gabbay says.
Find the patients who are the sickest and arrange care for them since they’re driving most of the costs.
“That’s the person you really don’t want to go six months without being seen,” he says.
But learning to practice medicine differently takes time.
“Physicians had to change their mental model about being responsible for a population of patients as opposed to the patient in the office in front of them today,” Gabbay says.
Medical homes require outreach to patients who might not have come into the office recently, and takes new systems in place to reach out to those patients who need it most and those procedures are different for each practice.
Finding what works is not simple.
“You will likely need help to do this. There are many groups out there to help provide technical assistance,” Gabbay says.
One group he suggests is the CMS’ Center for Medicare & Medicaid Innovation.
“There are many programs, many of them free, that are supporting this effort,” he says. “This takes a lot of time. This is a journey. This is not easy stuff.”