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The AAFP and Payment Reform — They’re Screwing It Up, Again, Part 2 – A Poor Foundation

January 26, 2017

The AAFP’s recent statement on Advanced Primary Care calls for adopting the “five key functions of the Comprehensive Primary Care Plus Initiative.” This was an experiment under Obamacare where CMS tried to create innovative primary care payment approaches, which was mostly patterned after NCQA PCMH thinking. It started in 2012.

Mathematica Policy Research published a review of the program in early 2016. The report concluded, “CPC reduced average monthly Medicare expenditures without care management fees by a statistically significant $11 per beneficiary per month (PBPM), or 1 percent (p = 0.074), over the initiative’s first two years.” (To put this in perspective, Medicare spends roughly $1000 per beneficiary per month.) However, this savings did not include the upfront fees paid to the practices. The report goes on to conclude, “Although these findings are promising, CPC has not generated savings net of care management fees. The average PBPM fee paid was $18…. A one-sided equivalence test does not support the conclusion that reductions in expenditures without fees exceeded the $18 PBPM payments (p = 0.87). The change in average expenditures including the care management fees was $7 higher for CPC than comparison beneficiaries (p = 0.27, 90 percent CI -$3, $17).” And, “There was no effect on visits to specialists.”

A report by Mathematica published in December 2016 built on this report. Some of its major conclusions were:

  • CPC reduced emergency department (ED) visits for attributed Medicare FFS beneficiaries (a 2% less increase in the rate of growth of ED visits, not a reduction of ED visits), but did not generate enough savings to cover Medicare’s CPC payments.
  • CPC had minimal effects on the limited claims-based quality-of-care process and outcome measures examined.
  • Improvements in CPC practices’ care delivery between the start of CPC and the third program year (2015) had few statistically significant associations with reductions in hospitalizations, ED visits, expenditures, and other outcomes over the same time period.

And once again:

  • [A]lthough CPC did reduce Medicare Part A and B expenditures slightly relative to comparison practices, it is highly unlikely that these Medicare savings generated by CPC were enough to cover Medicare’s CPC care management payments.

So just as the AAFP leadership 13 years ago pinned there hopes on the unproven EMR, maybe now it’s worse. Maybe now they’re pinning there hopes to an approach so far proven to NOT change very much of the status quo. But they dream. They dream that perhaps in a few years this program will generate the hoped-for savings. Just like they dreamed that the EMR would one day make our jobs easier and patients would love us for being the technological masters of the EMR.

Those dreams turned into nightmares. The AAFP is leading us into another restless night.

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