Pondering CMS' Ambitious "Making Care Primary" Model

APCs + Specialists = VBC Gold?

Is the CMS "Making Care Primary" (MCP) Model everything that Medicare Advantage is supposed to be, but isn't?

Advanced Primary Care models (APCs) have achieved clinical and financial success through leveraging the Medicare Advantage program and its risk-adjusted payments. Nearly every Big Retail company's entry point into primary care features MA as a key component. CVS (Oak Street), Walmart Health, Walgreens (VillageMD), and Amazon (Iora) all rely on Medicare Advantage to some degree to make their business model work. Well-known and respected independent APC provider ChenMed also offers value-focused care to MA patients.

Medicare Advantage is not without its controversies. Critics argue that it costs taxpayers too much money. Commercial insurers who offer MA plans are being audited for overpayments. A host of startups dabbling in the program have struggled financially with a few tanking on the public markets. Plans have been accused of cherry-picking healthy patients and lemon-dropping high-risk ones. The federal government has taken notice of such shenanigans, and a crackdown of sorts may be coming. The MA gravy train could be on its way off the tracks.

At its core, Medicare Advantage makes sense. Capitation that rewards high-value care, provides expanded benefits to members, and incentivizes primary care providers to reduce low-value treatment is a win for all involved (except specialists, more on that later). Despite the controversy, there is some evidence that MA achieves its value-based goals. An American Journal of Managed Care meta-analysis found that MA delivers better care quality, better health outcomes, and lower costs compared to Traditional Medicare. One caveat: one-third of the studies included in the analysis were low quality and half did not account for selection bias.

The flipside is that Medicare Advantage kind of stinks for specialists. It adds all the pain points of dealing with a commercial insurer not found yet in Traditional Medicare (such as denials and prior authorizations) without the ability to benefit from value creation. In many cases MA pays specialists less than traditional Medicare. While Medicare Advantage can serve as a form of VBC for advanced primary care models, the same is not true for specialists. APCs that save money in capitated, risk-adjusted MA plans benefit from the cost-savings achieved (in part by avoiding expensive specialist care). Thus, not only are specialists paid less in MA, but their PCP counterparts are motivated to utilize their services less. In summary, Medicare Advantage has its limitations as a government-backed alternative care model, and its day of reckoning may be nigh. Enter “Making Care Primary.”

MCP's focus on rewarding better coordination between primary and specialist care offers a tantalizing vision for healthcare delivery evolution. The program has three progressive tracks, each one representing greater integration and higher complexity. “Making Care Primary” feels a lot like CMS' attempt to create a nationwide Medicare IDN (or rather a network of small, jurisdictional IDNs). MCP builds off existing advanced primary care models that have demonstrated some success. Meanwhile specialist focused VBC programs have a mixed track record. Conventional wisdom is that CMS is preparing to sunset current specialist VBC programs in favor of newer models. In MSK care, both the Comprehensive Care for Joint Replacement Model (CJR) and Bundled Payment Care Initiative (BPCI) are running their course and seemed destined to fade away. Both programs revolve around surgical episodes of care but suffer from being too narrowly focused and providing diminishing returns.

Condition specific bundles are theorized to represent the next step in VBC, especially as it pertains to costly MSK care. These models encompass the entire patient journey as it pertains to a specific diagnosis such as knee arthritis or low back pain. In such a system, the surgical episode is “nested” within the larger bundle and becomes another step along the overarching treatment pathway. In such a model, non-surgical care, patient optimization, care coordination, and even postoperative care — long devalued — suddenly become as, or more, important than the surgical episode. Shifting financial incentives to reward this previously undervalued care makes management of MSK conditions in the primary care setting more appealing. The “Making Care Primary” initiative feels a lot like CMS’ attempt to usher in condition specific treatment whether it’s for behavioral health, GI disorders, or the biggest fish ($7 billion/yr and rising)— MSK conditions.

There are a few potential flaws in the MCP model. To start, PCPs often aren’t comfortable diagnosing and managing Orthopedic problems. MSK conditions represent something of a black box from primary care practices, even advanced ones. The result is often over-referrals, over-imaging, and low value care (done with good intention of doing right by the patient). Interestingly, existing MSK-focused VBC programs like BPCI and CJR created the reverse situation. Orthopedic Surgeons realized that success in such models hinged on embracing a more holistic approach. Surgeons recognized the value of optimizing a patient’s physical and mental health prior to surgery to avoid costly complications and readmissions (otherwise known as “bundle busters). In short, specialists found themselves doing more and more primary care. And they weren’t necessarily great at it. Non-optimized patients fell through the cracks, lemon-dropping and cherry-picking problems surfaced, and developing proper care pathways increased complexity and administrative costs. Even supposedly integrated systems where PCPs and specialists exist inside a larger organization struggle with true care coordination. Priorities are different and incentives aren’t aligned.

Does “Making Care Primary” solve these issues? Maybe. The program creates an opportunity as yet unexplored by alternative primary care models — moving specialist care upstream. For instance, by bringing MSK care in-house, an APC practice could solve the knowledge gap issue, deliver high-quality, condition-specific treatment, master care coordination, and maintain tight control over the process. With surgical episodes nested into the bundle, APCs benefit from developing relationships with high value specialists, powered by their own comprehensive data collection and analysis. One could imagine the APC negotiating payment and reimbursing the surgeon directly from the capitated or bundled payment. Add in a low-cost facility like an ASC or (ahem) physician-owned hospital, and you achieve CMS’ stated goals with the MCP program.

It’s curious that, until now, APCs have been reluctant to tackle specialist care themselves. The fear may be that specialist care (with its focus on procedures) is too complex, risky, and capital intensive. The MCP program could turn this notion on its head by creating financial incentives to manage everything from start to finish. Nesting the surgical episode into the larger care journey allows an APC to maintain control while navigating the patient to the best care. Currently, many APCs address the specialist care issue by forming relationships with Centers of Excellence or local health systems. Others use third-party services like care navigators, asynchronous second opinions, and virtual curbside consults. Cobbled together, these approaches may not be the most cost-effective and certainly aren’t the most coordinated.

How to structure such an APC under the incentives offered by the MCP program? One approach would be to hire intrepid Orthopedic Surgeons or Sports Medicine-trained primary care doctors directly. Bringing expertise in-house offers a slew of benefits under the MCP tenets. Another angle of attack would be to expand the Advanced Primary Care model to an Advanced Multi-specialty model with APCs partnering with independent, next generation specialists. The challenge here is the relative dearth of the latter. Perhaps MCP changes that. One final option is to develop an entirely novel approach: microcenters that offer a tightly integrated, tech-enabled, whole-person approach with a specialty flavor. I suspect something of this nature represents CMS’ ideal vision for the MCP program. By blurring lines and breaking down silos between primary and specialty care, the goal of creating a high-functioning health system can be achieved. Notably, “health system” here doesn’t refer to a lumbering monolith of consolidation — something CMS is actively trying to avoid. Instead, it refers to a tightly coordinated and integrated care model that’s great for patients and clinicians.