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CMS Primary Care Fiddling Instead of Real Reform

CMS is proposing a 10-year comparison of primary care payment models (fee-for-service and capitation, with support for care delivery systems). At first glance, why not? On closer scrutiny, this is another delay for an experiment in our current flawed system that will yield limited and equivocal results. Let’s focus on real reform.

June 10, 2023

Making Care Primary (MCP) Model
Centers for Medicare & Medicaid Services
June 8, 2023

On June 8, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary primary care model – the Making Care Primary (MCP) Model – that will be tested in eight states. Launching July 1, 2024, the 10.5-year model will improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health related social needs (HRSNs) such as housing and nutrition. CMS is working with State Medicaid Agencies in the eight states to engage in full care transformation across payers, with plans to engage private payers in the coming months.

To support team-based care, MCP will include prospective payments for primary care that will reduce organizations’ reliance on fee-for-service payments. Risk-adjusted enhanced services payments, which will also be paid prospectively and represent an additional investment in primary care, will allow participants to expand care management, screen for health-related social needs, and integrate with specialty care.

Track 1 – Building Infrastructure. Payment for primary care will remain fee-for-service (FFS), while CMS provides additional financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities. Participants can begin earning financial rewards for improving patient health outcomes in this track.

Track 2 – Implementing Advanced Primary Care. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue to provide additional financial support at a lower level than Track 1, as participants continue to build advanced care delivery capabilities. Participants will be able to earn increased financial rewards for improving patient health outcomes.

Track 3 – Payment for primary care will shift to fully prospective, population-based payment while CMS will continue to provide additional financial support, at a lower level than Track 2, to sustain care delivery activities while participants have the opportunity to earn greater financial rewards for improving patient health outcomes.

To be eligible to participate in MCP, an organization must be a legal entity formed under applicable state, federal, or Tribal law authorized to conduct business in each state in which it operates.

Comment by: Don McCanne & Jim Kahn

At first glance, this may seem like a decent idea: explore different payment models for primary care within Medicaid and, if they agree, private insurers. Compare results over an extended period of time, between supplemented FFS, FFS-capitation, and fully capitated approaches.

But, then, it hits us: Here we go again! Ten more years of fiddling with a broken system, while avoiding real financing reform.

Of course, we need to ask, based on recent trends in Medicare and more broadly … who is going to own these “legal entities”? Private equity? The billionaires?

The hazards of capitation are clear: Increase the monthly payment level for providers who have better health outcomes, that is, healthy patients who may not need much care. And link these payments to diagnostic (up)coding via risk adjustment. The truly sickest and costliest patients can go elsewhere, to providers paid fee-for-service. Avoiding the chronically ill might not be the goal of the traditional health care providers with their Hippocratic traditions, but, under this CMS model, certainly it would be a primary goal of their entrepreneurial employers and their billionaire investors. That’s what we’ve seen in Medicare Advantage and in CMS ACOs.

If past experience informs, the benefits of new strategies will be modest and mixed, hard to interpret but with each slight drop in cost or isolated gain in outcomes lauded by CMS as major successes. Corporations will manipulate the evaluation findings to serve business purposes.

The unclear role of private payers is telling. What we need is primary care for all, not clunky semi-coordination of different payers in a hard-to-interpret demonstration project.

Real reform can’t be off the agenda for the next decade, while we wait for this and other tweaks to our broken system. This CMS proposal requires a response from us. We already have a great start: Medicare for All legislation in both the Senate and the House (Thank you Sanders, Jayapal, Dingell, and the many others). We need to go to the streets, not with guns, but with our placards and loud, passionate voices! And this time, let’s not just go home when the shouting is done. Let’s complete the job!

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