The CMS Innovation Center’s Strategy to Support High-quality Primary Care

By Purva Rawal, Jacob Quinton, Dora Hughes, and Liz Fowler, CMS
Twitter: @CMSGov

Introduction

Primary care in the United States is in urgent need of investment and support following decades of inadequate payments, increasingly complex delivery of care, and growing administrative burden – all of which have been exacerbated by the pandemic. Access to primary care is associated with improved patient outcomes, increased equity, and lower mortality/higher life expectancy at similar or lower total costs. Despite these well-documented benefits, primary care spending remains low as a proportion of total health care spending, gaps in payment between primary care and specialist care persist, and fewer people report a regular source of primary care, particularly among underserved populations.

Primary care delivery has become significantly more complex for providers and patients. From 2000 to 2019, the percentage of Medicare beneficiaries seeing five or more physicians annually increased from 18% to 30%, and primary care providers must now coordinate with 80% more physicians, increasing from 52 to 95 over this period. This complex landscape was upended by an almost complete cessation of in-person visits in the first months of the COVID-19 pandemic. Despite a rapid transition to telehealth, surveys of primary care practices during the pandemic showed the significant strain of the pandemic on an already stressed system. In March of 2022, nearly half (46%) of primary care practices surveyed reported they believed primary care was “crumbling” – a consistent finding in two years of surveys. In the same survey, the top three recommendations from primary care clinicians to policymakers were: 1) protect primary care as a common good; 2) change financing of primary care; and 3) move away from fee-for-service toward alternative payment models.

Value-based payments have the potential to make the health system, and primary care in particular, more resilient. For instance, participants in the Centers for Medicare & Medicaid Services’ Center for Medicare and Medicaid Innovation’s (Innovation Center’s) Comprehensive Primary Care Plus Model received prospective, reliable, population-based payments – and reported this financing approach helped them weather the worst of the COVID-19-related financial shocks, maintaining key staff and activities such as care management and coordination. In spite of this promise, a recent Commonwealth Fund survey of primary care practices showed fewer than half (46%) were receiving any form of value-based payment. Internal CMS analyses show over half of primary care practices are not participating in CMS’ Accountable Care Organization (ACO) initiatives, the Shared Savings Program or the ACO Realizing Equity Access and Community Health (ACO REACH) Model, nor are they participating in the Innovation Center’s current advanced primary care model, Primary Care First. While these existing programs and models have wide reach nationally and support the movement away from fee-for-service to value-based care, more must be done to engage primary care practices and shift how we financially support primary care. CMS is committed to creating more opportunities for primary care to move from fee-for-service to value-based payment approaches that are more reliable, more supportive of thoughtful clinician practice and patient engagement, and provide a better foundation for supporting whole-person care, which includes relationships with specialty care and addressing health-related social needs.

This paper presents the Innovation Center’s portfolio-wide strategy and goals to strengthen the primary care infrastructure in the U.S. by creating multiple pathways to support improved financing for advanced primary care, equitable access to high-quality primary care, and sustainable transformation among a heterogeneity of practices. The paper provides an overview of the newest primary care model test – Making Care Primary (MCP), which has been designed with this strategy in mind – and outlines additional pathways the Innovation Center is exploring.

The CMS Innovation Center’s Approach to Rebuilding Primary Care: Financing, Equity, Sustainability

CMS has set a goal of having 100% of Traditional Medicare beneficiaries and the vast majority of Medicaid beneficiaries in accountable care relationships by 2030. Advanced primary care is a core mechanism for achieving this goal. While the Innovation Center has been testing primary care models since its inception in 2010, the current challenges facing the health system have given new urgency to this work. Renewed calls for reform, including the 2021 National Academies of Science, Engineering, and Medicine (NASEM) report on primary care and the Department of Health and Human Services (HHS) Initiative to Strengthen Primary Care, underscore primary care’s vital role in the health system. The Innovation Center is taking a portfolio-wide approach to rebuilding primary care focused on the following three dimensions:

1. Improving primary care financing through increased, stable revenue that moves practices away from fee-for-service payments that pay for the volume of services delivered and toward support for team-based care, coordination with specialty providers, and community-based supports.
2. Advancing health equity by increasing safety net provider participation, increasing payments to underserved areas, and requiring health equity plans from model participants; and
3. Supporting the sustainability of value-based payment models through multi-payer alignment, starting with Medicaid, and scaling successful models and features.

Strengthening Primary Care Financing

Previous Innovation Center models have demonstrated that primary care practices benefit from predictable, prospective, non-visit-based revenue and, in many cases, upfront investments to support the provision of whole-person, equitable, team-based care. A core recommendation of the 2021 NASEM report was to increase investment in primary care and move practices to hybrid payments that provide prospective and stable payments. Higher and more stable payments allow providers to develop advanced primary care capabilities that prevent provider burnout and meet the whole-person needs of patients, while assuming greater accountability for quality and costs over time.

Making Care Primary – Strengthening Primary Care Financing
MCP is the newest Innovation Center primary care model. The model will feature three progressive tracks to help providers move from fee-for-service to more flexible prospective payments that can better support primary care teams. The ability to assume greater accountability for quality also increases over time. MCP will operate in eight states and targets the large proportion of safety net providers and primary care providers that have not participated in previous value-based payment models. In track 1, qualifying participants will receive an upfront infrastructure payment, and all will receive socially risk-adjusted prospective care management activities, in addition to fee-for-service payments – providing upfront and ongoing investment. In track 2, participants move to hybrid payment options with a blend of fee-for-service payment and prospective payments, an opportunity to receive increased performance-based payments, and a reduced care management payment. Track 2 participants also will begin to implement new e-consult codes to support electronic consultations or interprofessional consults between primary and specialty care providers. Finally, in track 3, participants will receive fully prospective payments, a greater opportunity for performance-based payments, and reduced care management payments. Track 3 will also involve a new ambulatory co-management approach for beneficiaries with either new diagnoses or conditions that require coordination between a primary care and specialty physician. For instance, a primary care practice and cardiologist would share responsibility for stabilizing a frail beneficiary with a new diagnosis of congestive heart failure. These payment changes support more advanced primary care capabilities from tracks 1 to 3.

Future Pathways to Strengthen Primary Care Financing
Evidence indicates that physician-led, primary-care-oriented ACOs generate more savings and have better outcomes compared to hospital-based ACOs. To better support ACO-based primary care practices, the Innovation Center is exploring ACO-based primary care model tests that may focus on practices in the Shared Savings Program. Such a model could consider ways to provide increased investment through prospective payments that allow primary care clinicians the flexibility to deliver care to improve beneficiary quality, outcomes, experience, and health equity. States are also implementing programs to strengthen primary care – and broader system transformation. To accelerate and support these efforts, the Innovation Center is exploring a state-based model to improve population-level health outcomes and advance health equity by testing total cost-of-care approaches to shift health care spending and utilization from acute care to primary care. The future state-based, total cost of care models under consideration by the Innovation Center will amplify Medicaid-led advanced primary care efforts by aligning Medicare FFS and other payers to these efforts.

Advancing Equity through Primary Care

Black and Hispanic beneficiaries are underrepresented and White beneficiaries were overrepresented relative to the national Medicare average in CPC+, which ended in 2021, and there are similar patterns in the current PCF model. Innovation Center models must deliberately address health equity from model design through implementation to reach a more representative group of beneficiaries – and to improve and reduce disparities in health outcomes. The Maryland Total Cost of Care Model’s Maryland Primary Care Program (MDPCP) has broken ground in this area via policies such as the Health Equity Advancement Resource and Transformation (HEART) payment, targeting specific payments to participants for patients with high social risk, and inclusion of FQHCs in the model. New primary care models are designed to advance equity in several ways, including increasing safety net provider participation, increasing payments to providers caring for underserved populations, and requiring health equity plans from participants to help primary care practices and organizations identify and close disparities in access, care, and outcomes for the populations they serve.

Making Care Primary – Advancing Equity
A key goal of MCP is to increase the participation of Federally Qualified Health Centers (FQHCs) in value-based payment models. Participants will receive prospective care management payments adjusted by eligibility for the Part D Low-income Subsidy (LIS), Area Deprivation Index (ADI), and CMS Hierarchical Condition Category (HCC) risk score – and eligible participants will receive upfront infrastructure payments that are necessary for more safety net providers to engage in value-based payment models. They will also collect self-reported demographic data and complete health equity plans to help them identify disparities and needs of the communities they serve and will increase focus on hiring staff members from these communities to support patient navigation and accessing community resources.

Future Pathways to Advance Equity through Primary Care
ACO REACH is an early example of how equity-focused design can increase safety net provider participation. In 2023, over 820 FQHCs, critical access hospitals (CAHs), and rural health clinics (RHCs) are participating in the model – more than double in 2022. The model will provide important lessons for future ACO-based primary care models on how to increase safety net provider participation in value-based payment programs and make their participation sustainable and successful. Future state- and ACO-based models may adjust prospective payments or benchmarks to drive primary care investment in underserved communities, improve demographic data on beneficiaries so that interventions can be targeted to improve care and outcomes, and continue to support ACOs and practices in developing the capabilities to meet the needs of the people they serve.

Supporting Sustainable Transformation through Alignment

Alignment with other payers, including Medicaid, and scaling successful models and features to other payers and the broader Medicare program are critical to the long-term success of advanced primary care. The 2021 NASEM report provided a watershed moment for payers to align on testing new innovations to support advanced primary care and scaling successful approaches. Previous Innovation Center efforts have tested payer participation and close alignment on model design features to support and sustain primary care transformation. Alignment remains a core focus of all Innovation Center advanced primary care models to ensure effective care delivery and payment changes being tested are sustainable in the long term and more likely to spread to more payers and providers. The Innovation Center is testing a new alignment strategy that promotes payer partnership, alignment on key model design features, and encouraging payers to innovate for their unique patient populations.

Making Care Primary – Sustainable Transformation
MCP alignment efforts will focus on state Medicaid programs, given the importance of Medicaid payments to primary care practices, especially in the safety net. The model is starting with eight diverse states that will allow the model to be evaluated and potentially scaled if successful. Alignment with state Medicaid programs will facilitate longer-term multi-payer participation and commitment that can support the provision of high-quality primary care as envisioned in the 2021 NASEM report. With Medicare and Medicaid aligned in these states, efforts can shift to commercial payer alignment starting with key model design features, such as quality measurement.

Future Pathways to Support Sustainable Primary Care Transformation
A state-based total cost of care model would also focus on alignment with Medicaid and have a major primary care emphasis with Medicare fee-for-service supporting Medicaid advanced primary care efforts.

Aligning future ACO-based primary care models with the permanent Shared Savings Program is also important for making transformation sustainable. Designing ACO-based primary care models on the chassis of the Shared Savings Program will allow for easier scaling of a successful model or features of models into the national program. Taken together, these models and common approaches to bolstering primary care, advancing equity, and aligning across payers present an unprecedented opportunity to strengthen the financing of primary care, increase access to high-quality care in underserved communities, and improve care and outcomes for all populations.

Conclusion

Reflecting the heterogeneity of primary care practices, the Innovation Center is creating multiple pathways to bring new primary care providers into value-based payment arrangements – and to better support those already in value-based arrangements. New models will need to focus on different levels of the health care system that can support primary care, including practices and primary care organizations, health systems, ACOs, and state-based or regional models. The compounding challenges facing primary care, the complexities of the system – and the inequities in access and outcomes as a result – have taken decades to realize, and no single payment model can solve for them all. CMS is testing a range of options and approaches to meet primary care providers and their communities where they are and to offer value-based payment options that build infrastructure, support team-based care, and coordinate with specialty care – and improve the health outcomes for people, advance equity, and the overall resilience of our health care system.

Acknowledgments:

The CMS Innovation Center wishes to thank Asaf Bitton, Lauren McDevitt, Lauren Kuenstner, and Nora Lewis, who contributed to the intellectual content, drafting, and revising of this strategy blog, and Pauline Lapin, Sarah Fogler, and Tequila Terry, who contributed to the review.