Comprehensive Primary Care Initiative...The Future is Now

In 2004 the Future of Family Medicine report stated that if family medicine did not change and the U.S. health care system did not change, family medicine might cease to exist in 10 to 20 years. The report also laid out a vision for family medicine in what was then called the "New Model of Care." The attributes of that "New Model of Care" are now the foundation for the Patient-Centered Medical Home (PCMH). TransforMED was established by the American Academy of Family Physicians in 2005 to assist Family Physicians in transforming their practices to this new model of care.

Transforming family medicine practices to this new model of care was only part of the challenge. The U.S. health care system also had to change. For the U.S. health care system to change in a meaningful way, the perceived value of primary care had to change. In 2006 the AAFP along with the other primary care associations took on this task. They established the PCMH Joint Principles which outlined the principles of the Patient-Centered Medical Home, including appropriate payment that recognized the value of primary care practices and embraced the attributes of PCMH.

The associations also initiated an aggressive advocacy campaign to educate anyone who would listen including policy makers and payers that the solution for the challenges facing the U.S. health care system was primary care and Patient-Centered Medical Home. Organizations such as the Patient Centered Primary Care Collaborative were formed to serve as a strong voice in DC for primary care.

TransforMED would not do a payer pilot without a component of primary care payment reform and was involved in multiple pilots across the country. The concept of "pay for value instead of pay for volume" took hold. PCMH was a major component of the healthcare reform legislation as well as the meaningful use criteria. The CMS Center for Innovation was launched with a strong focus on primary care. Many different payment models were evaluated, leading the AAFP and others to advocate for a "blended" payment model. This model consists of an up-front care management/coordination fee, with fee-for-service and quality incentives on the back-end. As the national health care debate has evolved with the introduction of accountable care, the third component of payment has evolved to a shared savings model. Quality of care is not ignored, but is now the "price of admission" to participate in the shared savings.

The road to the future was paved by the Future of Family Medicine report and the dramatic developments in the national arena. The most recent development – the announcement of the Comprehensive Primary Care Initiative – has now defined the future. This new CMS initiative will compensate primary care practices via a blended payment of a risk-adjusted care management fee averaging $20 pmpm, continued fee-for-service and a shared savings component. The shared savings flows directly to primary care practices and not hospitals or large systems as in the ACO pilots. CMS has clearly defined the future in what is expected of primary care going forward. The future that everyone has been talking about since 2004 is now.

Primary care practices are expected to provide comprehensive primary care including care management, care coordination, enhanced access, patient engagement and proactive patient planning. Furthermore primary care practices are expected to be NCQA Level 3 or an equivalent (i.e. complete medical homes) and meaningful use certified. Payment reform is moving very quickly to "pay for value." Primary care is being redefined.

The road was paved with an incredible amount of hard work. Policy makers and payers are walking down that road. The road leads to comprehensive primary care. The days of speculative conversation have passed. When the Comprehensive Primary Care Initiative demonstrates improved quality and controlled costs, this blended payment model with the accompanying expectations of primary care practices can be expanded beyond the pilot practices.

Practices will not be ready if they do not start meaningful transformation now (if not yesterday). If primary care continues in the slow lane or worse yet – parked on the side of the road – the effort to transform primary care and the U.S. health care system will be for naught. Primary care practices must start transforming to comprehensive primary care practices today. That means NCQA Level 3 (or its recognized equivalent), meaningful use certified and PCMH transformed.

This is a daunting task with a ticking timeline. The saying "be careful what you ask for" comes to mind. The road now leads to what we have asked for and TransforMED is here and perfectly positioned to help. The future of primary care is unfolding before our eyes and is "now."

Click here to find out more about the Comprehensive Primary Care Initiative at the CMS Center for Medicare & Medicaid Innovation.