Quality & Practice

Primary Care Transformation

CMS is putting a lot of time and money into improving primary care, as they believe that will be a foundational block in building a value-based health care system.  They have developed several different initiatives with more in development.  Models include:

Advanced Primary Care Initiatives

On the CMMI website, Medicare describes this initiative as “seeking input on initiatives to test innovations in advanced primary care, particularly mechanisms to encourage more comprehensiveness in primary care delivery; to improve the care of complex patients; to facilitate robust connections to the medical neighborhood and community-based services; and to move reimbursement from encounter-based towards value-driven, population-based care.  It is currently seeking information and suggestions from providers.

Comprehensive Primary Care Initiative

Since 2012, CMS has been working with multiple payers in seven U.S. regions to offer additional payment for services such as population-based care management fees and shared savings opportunities to participating primary care practices.  This initiative is meant to add extra funding to primary care practices in order to encourage certain actions.  Their aim is to support the provision of a core set of five “Comprehensive” primary care functions.
  • Risk-stratified Care Management;
  • Access and Continuity;
  • Planned Care for Chronic Conditions and Preventive Care;
  • Patient and Caregiver Engagement;
  • Coordination of Care across the Medical Neighborhood.

FQHC Advanced Primary Care Practice Demonstration

This initiative was designed to test out a Patient Centered Medical Home (PCMH) setting in Federally Qualified Health Centers.  FQHCs are currently paid quarterly on an inclusive basis – participation in this program would give them an additional $6.00 for any Medicare beneficiary attributed to their FQHC.  In signing up to participate in this demonstration, FQHS had to agree to pursue Level 3 PCMH recognition from the National Committee for Quality Assurance (NCQA) by the end of the 3 year demonstration period, which ended in 2014.  CMS is currently evaluating the data.  Additional information on achieving recognition from NCQA can be found on their website.

Frontier Extended Stay Clinic Demonstration

This initiative was for clinics that were at least 75 miles away from the nearest hospital and allowed clinics in the demonstration program to treat patients for extended visits, even for an overnight stay.  The clinics are normally paid on a per visit basis for comprehensive primary care.  Under the demonstration, they received additional funding in order to function like an emergency room.  Evaluation of the project found that it did improve quality and save some costs, but these were outweighed by the costs to set up the program, hire new staff, and provide 24 hour staffing, so the report concludes it would be unsustainable under Medicare.

Graduate Nurse Education Demonstration

Per its website, “CMS will provide reimbursement to up to five eligible hospitals for the reasonable cost of providing clinical training to advanced practice registered nursing (APRN) students added as a result of the demonstration.”  The reimbursement will be per student.  The purpose of the demonstration is to provide more Advanced Practice Registered Nurses to improve access to primary care.

Independence at Home Demonstration

This demonstration is to test the feasibility for practices to provide comprehensive primary care to patients in their homes, particularly chronically ill or functionally challenged individuals.  The participating providers can be single practices and multi-specialty group practices.  If they are able to save money for the Medicare program, they may share in the savings.

Medicare Coordinated Care Demonstration

This demonstration is no longer active.  It was designed for chronically ill Medicare fee-for-service beneficiaries, and was implemented in both urban and rural areas.  Medicare provided a “per patient per month” additional fee to provide for care coordination, education, and other aspects of care to decrease the costs and/or increase the quality.  It appears, from three different reports on the website, that the demonstration did reduce hospitalizations and mortality rates but only for a subset of patients - those with conditions related to coronary care disease.  However the overall program increased Medicare’s costs, so in order to make the program financially neutral, either the fee paid to providers would have to be substantially lowered and/or hospital readmissions would have to be further decreased.

Multi-Payer Advanced Primary Care Practice

Per the website, “The demonstration program pays a monthly care management fee for beneficiaries receiving primary care from advanced primary care (APC) practices. The care management fee is intended to cover care coordination, improved access, patient education and other services to support chronically ill patients. Additionally, each participating State will have mechanisms to offer APC practices community support and linkages to State health promotion and disease prevention initiatives.”  This demonstration tests out the Patient Centered Medical Home (PCMH).

Transforming Clinical Practices Initiative

This is the most recent initiatives as of this writing, put out by Medicare on 9/29/15.  It awarded “$685 million to 39 national and regional collaborative healthcare transformation networks and supporting organizations to provide technical assistance support to help equip more than 140,000 clinicians with tools and support needed to improve quality of care, increase patients’ access to information, and spend dollars more wisely.”  The goal of this initiative is to allow peer to peer training and exchange of ideas.