Rob Mechanic Discusses the Focus of High-Need Patients Under New Primary Care Models

Rob Mechanic, MBA, senior fellow at the Heller School of Social Policy and Management at Brandeis University and executive director of the Institute for Accountable Care, discusses the importance of HHS focusing on high-need patients in their 5 new primary care payment models.

HHS recently announced their 5 new primary care payment models, one of which focuses on high-need patients under the Primary Care First path. What is the importance of HHS identifying the need for a payment model that focuses on these patients?

I think it’s great to have payment models that focus on these patients. I think the thing to know is that this is not a new thing. There are a whole series of programs that focus on high-need, high-cost patients. We’re at the spring meeting at the National Association of ACOs [accountable care organizations]. This is a very important population for them, and we’re actually doing a session that looks at some of the specific care models. That’s growing in importance, and we have the social determinants of health. But, there are a lot of other programs. The PACE [Program of All-inclusive Care for the Elderly] program, all-inclusive payment for the elderly, which integrates the Medicare and Medicaid funding for people who otherwise would be in a nursing home to allow them to be in a community. There’s the Independence at Home Program through the ACA [Affordable Care Act], which is physician house calls to people who are very frail and very sick. The Accountable Health Communities, which is to try and organize researchers around social determinants in the Medicare-Medicaid financial alignment initiative.

So, there’s a lot of things in the CMS arsenal that focus on these patients. With respect to Primary Care First, I’m all for any program that really tries to promote and send resources to primary care, and so this is great. The Primary Care First Program is sort of an evolution of CPC+ [Comprehensive Primary Care Plus], but it’s also fairly different. If you recall CPC+, the big element of that is hey provide investments and practices to build practice capacity. The range from the evaluation report is basically $100,000 to $200,000 per practice, which is a lot of money. The new Primary Care First program does not have that practice support. It’s more of a capitation type of program with then some financial risk. As we always say, the devil is in the details. So, the question is: how are they going to set that capitation payment and what’s the risk adjustment going to look like. And that’s going to determine if a lot of practices sign up. I suspect that practices that already in CPC plus will not switch out of CPC+ to Primary Care First because CPC+ is such a good program for primary care practices.

The second thing about Primary Care First is you have to be an advanced primary care group, you have to have experience with value based payment. Those 3 things together, a lot of them are already in CPC+, and you need to have experience, I don’t know what the take up will be, and that will be totally dependent on what they set the payment rates. But, as I said, within the ACO model, this is very consistent with the ACO model, and I think it could work very well within the ACO model. Frankly though, to do a good job with these patients, you need to have a system around you and a structure. It’s something that larger, well-integrated primary care groups can do. It’s probably not something for small practices.