Article Figures & Data
Figures
- Figure 1.
The 4 Cs of Primary Care.
Tables
- Table 1.
Scheduled Adjustments in APM Eligibility Criteria under Medicare Access and Children's Health Insurance Program Reauthorization Act
Year Eligibility 2019 and 2020 ≥25% of total Medicare revenue is from a qualified, eligible APM 2021 and 2022 ≥50% of total Medicare revenue OR ≥25% of total Medicare revenue and 50% of all-payer revenue (eg, Medicaid, private insurers) is from a qualified, eligible APM 2023 and beyond ≥75% of total Medicare revenue OR ≥25% of total Medicare revenue and 75% of all-payer revenue is from a qualified, eligible APM APM, alternative payment model; OR, odd ratio.
Adjustment 2019 2020 2021 2022 and beyond Baseline payment adjustment ±4% ±5% ±7% ±9% Maximum payment adjustment for high performers +12% +15% +21% +27% Description Prospective vs retrospective Financially discourages volume of services? Financially encourages high quality of care? Party that primarily bears the financial risk? Risk adjusts for patient complexity? Key Example Fee-for-service (FFS) Paid for each individual service rendered Retrospective No No Insurers No Medicare Patients (via cost-sharing: co-pays, deductibles) Traditional capitation (full-risk capitation, global payment) Paid to cover all services within a specific period of time Prospective Yes No, except for outcomes related to use Primary care practices No Medicare Advantage HMOs Pay-for-performance (P4P) exists in addition to underlying model (generally FFS or capitation) Paid for achievement of (or improvement in) a quality measure Both exist (most models retrospectively; however, can be paid prospectively and subsequently reconciled) Potentially (depends on quality metrics) Yes, for services being measured via quality metric Depends on underlying payment model Potentially Medicare Physician Group Practice Demonstration Project Primary care practices, if targets not met Bundled payment (episode-of-care) Paid for all services rendered for a given episode of care Mixed (generally retrospectively triggered and prospectively paid) Yes (but does not discourage volume of episodes) No, except for outcomes related to utilization Primary care practices, organizations No CMMI's Bundled Payments for Care Improvement Shared savings Paid based on spending below a predetermined benchmark over a period of time (contingent on meeting certain quality targets) Mixed (prospective at level of the ACO, but providers often still paid via FFS) Yes Yes ACOs Potentially Medicare Shared Savings Program ACOs Blended FFS and capitation Paid a predetermined amount intended to cover medical home services for a specific period of time in addition to FFS Mixed No (to the extent that FFS is the predominant payment mechanism) No Depends on underlying payment model Potentially Medicare Comprehensive Primary Care Initiative Comprehensive (primary) care payment Paid a risk-adjusted amount to cover all primary care services for a specific period of time; includes component of P4P Prospective Yes Yes Primary care practices Yes Iora Health Direct primary care Paid outside of third-party insurers (often directly from patients) a predetermined amount to cover all primary care services for a specific period of time Prospective Yes No Primary care practices for primary care expenses No Qliance Patients for other aspects of care (and insurers if patients have third party insurance) ACO, accountable care organization; HMO, health maintenance organization; CMMI, Center for Medicare and Medicaid Innovation.
- Table 4.
Impact of Primary Care Payment Models on the Quadruple Aim and Tenets of Primary Care
Payment Model Quadruple Aim Allows Proactive Investment in Primary Care The 4 Cs of Primary Care Elements Associated with Successful Programs Health Outcomes Experience of Care Cost Control Provider Satisfaction Contact (Access) Continuity Coordination Comprehensiveness Fee-for-service (FFS) ↓ ↓ ↓ ↓ ˟ ↓ ←→ ↓ ↑↓* Billing mechanisms available that recognize primary care tenets and non-face-to-face services Traditional (full-risk) capitation ←→ Mostly ↓ Mostly ↑ ↓ ✔ ↓ Insuff. evidence Insuff. evidence ↑↓ Risk limited to primary care services PMPM determination based on anticipated need rather than FFS* Pay-for-performance (P4P) ↓↑ ↓↑ ↓↑ ↓ ˟ ↓↑ ↓ ←→ ↓ Appropriate, aligned measures for use in primary care* Bundled payment (episode-of-care) ←→ (weak) Insuff. evidence Insuff. evidence Insuff. evidence ✔/˟ (retroactively triggered) Insuff. evidence Insuff. evidence ↑ (weak) Insuff. evidence N/A, may not apply to primary care given difficulty defining and assigning bundles Shared savings ↑ ↑ ↓↑ Insuff. evidence ✔/˟ (providers often paid FFS) Insuff. evidence Insuff. evidence ↑* Insuff. evidence Target high-needs patients Address psychosocial needs Appropriate risk-adjustment Non-FFS incentives at provider level* Physician-led or integrated ACO Blended FFS and capitation ↓↑ ↓↑ ↓↑ Insuff. evidence ✔/˟ ↑ ↑ ↑ Insuff. evidence Target high-needs patients Appropriate risk-adjustment Multipayer alignment Real-time data sharing Optimal FFS/capitation blend (more research needed) Comprehen-sive primary care payment ↑ (weak) ↑ (weak) ↑ (weak) ↑ (weak) ✔ ↑ (weak) Insuff. Evidence Insuff. evidence ↑ (weak) Appropriate risk adjustment Payments based on 10% total cost of care rather than prior FFS Direct primary care Insuff. evidence ↑ (weak) ↑ (weak) ↑ (weak) ✔ ↓↑* (better indiv. access, but affordability and workforce concerns) Insuff. evidence Insuff. evidence Insuff. evidence Coupling with appropriate wraparound insurance to avoid high patient costs for non-primary care services* ↑, evidence of positive outcomes.
↓, evidence of negative outcomes.
↓↑, evidence of mixed effects.
←→, no significant effect or change.
✔, allows proactive investment in primary care.
˟, does not allow proactive investment in primary care.
✔/˟, some components allow proactive investment in primary care, while others do not.
Insuff. evidence, no available evidence; (weak), limited or poor quality evidence (ie, <1 study examined and/or not a comparison study).
↵* No or limited evidence, but a strong theoretical likelihood of effect.
Proactive investment in primary care can support all of the 4 Cs.
ACO, accountable care organization; PMPM, per member per month.
