News & Commentary

Julie Schilz: Primary Care Payment Models – Building on Value

November 28, 2016

Anthem, Inc.’s Julie Schilz, staff vice president of Care Delivery and Transformation, discusses care delivery models and the future of value-based care. 

The health care landscape is shifting toward value-based payment and away from traditional fee-for-service (FFS) models. The Centers for Medicare & Medicaid Services’ (CMS) Comprehensive Primary Care Plus (CPC+) initiative, a five-year program that builds on the agency’s mammoth Comprehensive Primary Care Initiative (CPCI) launched in 2012, was a landmark component of this change. The CPCI program, which sunsets at the end of 2016, was developed to determine whether financial support for primary care practices can help transform care to meet the quadruple aim of accountable care organizations:

  1. Improving the patient and family experience of care (including quality and satisfaction)
  2. Improving the provider and health care team experience
  3. Improving the health of populations
  4. Reducing the per capita cost of health care

Beginning in January 2017, the new CPC+ program will build on the foundations established by CPCI, and will supplement regular FFS payments made to providers with monthly rewards for meeting quality targets. CMS hopes to include up to 5,000 primary care practices in 14 regions for this next phase, as well as national insurers, to create a holistic approach towards the future of the FFS model. 

As I’ve discussed before, primary care is foundational to a strong, patient-centered coordinated health care system. Anthem will continue to work with CMS and private sector payers to make investments in primary care that I hope we can translate into the right value-based models across the entire health care continuum. 

What we’ve learned

At the beginning of the CPCI program, there was a general feeling that the fee-for-service payment model was not a way to help measure value. CMS’ introduction of alternative payment models as part of the CPCI program was an interesting opportunity for both providers and payers to examine how these new models could bring the health care community more value. 

Together with CMS and other payers, we created a very transparent process to examine the operational aspects that are important in the move toward value-based payment models. This united front helps to ensure all private and public sector payers are on the same page as the health care landscape continues to shift. A key lesson learned is that as we move forward, we must think about value as both quality and cost. 

Where we’re going 

The CPC+ program incorporates some lessons learned from CPCI with the next steps in the value-based payment model. This public-private initiative aims to significantly broaden value-based payment offerings to primary care physicians, which could involve more than 20,000 physicians and 25 million Medicare, Medicaid and privately-insured patients across 20 states. CMS has introduced two tracks for primary care practices: 

  • Track 1: CMS will pay practices a monthly care management fee in addition to the fee-for-service payments the practice receives. 
  • Track 2: Practices will continue to receive a monthly management fee, but instead of full Medicare fee-for-service payments, they will earn “hybrid” reimbursement of reduced Medicare fee-for-service payments and upfront comprehensive primary care payments for services. 

These tracks focus on implementing advanced payment models onsite for primary care delivery, so that primary care can build its capacity. Additionally, this program will change the overall structure of local and regional engagement between providers and payers. CMS has worked to develop a new primary care action network that will meet nationally, but also within each of the communities selected for CPC+ to foster transparent conversations across all markets and between all payers involved. 

Another important aspect of this new program brings patients to the table, as they are a key component in all of this work. The established structure fosters open communication across all levels of the health care continuum, and allows all parties to discuss the best ways to move forward together. 

We are still learning how value-based payment models should be structured, not only for primary care, but also for specialists and hospitals. Anthem’s participation in CPC+ will help us to better understand the aspects needed to achieve the right payment model structure for primary care providers. As we achieve value at this fundamental level of patient-centered care, we can better implement value-based care across all health care delivery sites, and ultimately achieve a true patient-centered coordinated health care system.


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