Morris Manning & Martin, LLP

Primary Care: The Foundation of New Healthcare Initiatives

01.16.2012

Despite the upcoming Supreme Court hearings on the Patient Protection and Affordable Care Act (“Healthcare Reform Act”), healthcare reform initiatives continue to drive new models of how healthcare is delivered and reimbursed. Many of the initiatives focus on how patients interact and utilize a primary care physician (“PCP”).  Specifically, the Federal government projects encourage patient engagement with his or her PCP to improve communication and clinical care coordination.  The foundational concept is that the PCP will serve as the patient’s “home” for coordination of all of the patient’s healthcare needs through specialists, hospitals and other post acute facilities.   As the patient’s home, the PCP is supposed to ensure efficient and integrated clinical care delivery to the individual patient.  

Commencing about a year ago, the Centers for Medicare and Medicaid Innovation (“CMI”) began launching programs, demonstration projects and innovative healthcare models to test new ways of delivering healthcare in a more cost effective manner.  In early 2012, there are several programs that will focus upon an integrated model for primary care services as a foundational component of the integrated healthcare delivery model.  First, CMI announced 32 Pioneer Accountable Care Organizations (“Pioneer ACOs”) to test financially and clinically integrated systems that are designed to reduce the costs of healthcare.  If the costs are reduced below a set savings threshold, the Pioneer ACO may share in the savings achieved.  The Pioneer ACO model will continue for the next 3 years. One main component of the Pioneer ACO program is the patient centered medical home.  In that model, the patient has a designated PCP who is the “gatekeeper” of their care.  The PCP is the individual who coordinates the patient care through patient engagement, education and clinical care coordination with other specialists and the hospital. The patient’s engagement with a PCP will be critical to support patient compliance with treatment plans and achieve the best outcomes to ultimately reduce the cost of care. 

In addition to the Pioneer ACOs, CMI has also developed the Comprehensive Primary Care Initiative (“CPCI”).  The CPCI demonstration program creates a multi-payer program to provide enhanced funding for primary care services in five to seven designated regions within the United States.  The program will require a service delivery model to include care management, accessible care, care for chronic conditions and preventative medicine, patients and caregiver engagement and clinical care coordination across the medical community.  The payment model will be based upon a monthly fee per Medicare beneficiary.  In addition, there is also a component to share the savings that are obtained through the Medicare program with the provider.  The unique factor in this program is that it requires private payers to participate in the program and offer reimbursement for this service model.  The letter of intent for this program is due on January 17, 2012. 

In addition to CMI’s programs, in December 2011, the Federal government announced a program where interested practices can provide home based primary care to Medicare beneficiaries as part of a demonstration project.  The purpose of the project is to utilize a multi-disciplinary team of physicians, nurse practitioners, physician assistants, pharmacists, social workers and supporting staff to deliver care to at least 200 applicable beneficiaries during the year of the demonstration.  These participating practices will provide home visits to individual patients.  The practice must be available 24/7 to carry out plans for care.  The practice should also use electronic health information systems, including monitoring and mobile diagnostic technology.  The 200 Medicare beneficiaries must have at least 2 chronic illnesses and need assistance with 2 or more functional dependencies as a part of this program.  In addition, the individual patient must also have a non-elective hospital admission in the last 12 months and receive acute or sub-acute rehabilitation services within that same time period.  Similar to an ACO, Medicare will establish a spending target for the base population and to the extent the practices achieve savings below the target spending amount, the practices will share in the saving.  This will be a 3 year demonstration project.  Practices that are seeking to apply to participate in this demonstration program must apply by February 6, 2012. 

Primary care is a theme for the 2012 initiatives. Therefore, hospitals and physicians should evaluate how they integrate and operate with PCPs in their daily practice.  Primary care and patient centered home models should also be considered a component of future strategic plans.

This article was originally published in the January 2012 issue of Atlanta Hospital News.