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Comprehensive Primary Care Initiative Called a Gamble

      The federal government's Comprehensive Primary Care Initiative could initially be a boon for physicians who participate, but may prove to be a more difficult proposition for them in the program's later years, say some participants.
      For the first 2 years, the 500 physician practices in seven regions selected for the program – sponsored by the Center for Medicare & Medicaid Innovation – will receive from Medicare a per member monthly payment averaging $20, in addition to their normal fee-for-service payments.
      Doctors are being given the fee in exchange for meeting certain goals and criteria, all with the aim of providing comprehensive primary care. CMS wants practices to better and more intensively manage patients with multiple conditions, ensure better access to care by keeping longer hours and via tools such as e-mail and patient portals, increase preventive care, and better coordinate care with specialists.
      A handful of additional payers are participating in each state. Those payers – private insurers and, in some states, Medicaid – also will give physicians a per patient/per month fee. The additional payers were selected in April, so that doctors would know how many of their patients might be covered by the added monthly payments when deciding to apply for the program.
      But, by the third and fourth year of the program, the Medicare monthly fee will be reduced to an average of $15, and it's not clear what private payers will do. Physicians will have an opportunity to share in savings, but it still represents a gamble, say some.
      Dr. Stacey Zimmerman, an internist in Clinton, Ark., is looking forward to the revenue stream that will be provided by the primary care initiative, but says she is concerned about how she will manage once the payments drop. With better care coordination, patients will not need as many services, which means practice revenues will drop, she said in an interview. Meanwhile, expenses are not likely to moderate. “So how do we meet our overhead?” she asked.
      According to CMS, the practices were selected through a competitive application process. The practices, representing 2,144 providers caring for 313,000 Medicare beneficiaries, are in Arkansas; Colorado; New Jersey; the Capital District/Hudson Valley, N.Y., region; the Cincinnati/Dayton region of Ohio and Kentucky; the greater Tulsa (Okla.) area; and Oregon.
      Under this initiative, the monthly fee will help cover services delivered by e-mail, phone, group visits, or by allied health professionals like nutrition and behavioral counselors, said Dr. Robert A. Gluckman, chair of the American College of Physicians Medical Practice and Quality Committee and chief medical officer for Providence Health Plans. Providence is one of the participating payers in Oregon.
      “This is going to be a tremendous opportunity for primary care practices to have the revenue to practice medicine differently,” he said.
      The primary care initiative will help a practice “pull in additional human resources,” he said. That would include case managers, health coaches, and behavioral health specialists. The idea is to offer truly comprehensive care, said Dr. Gregory Reicks, an initiative participant with Foresight Family Physicians in Grand Junction, Colo.
      The uncertainty over the revenue stream is a familiar, but vexing problem, he said. CMS is requiring the participating practices to submit a plan detailing how the monthly fees will be spent. “And we don't know how much will be coming in,” Dr. Reicks said.
      It begs the question of why a practice would seek out participation in this initiative.
      Besides improving patient satisfaction and health outcomes, “we're hoping this will somehow restore the joy of practicing medicine again,” he said.