New CMS initiative a pivotal point in primary care market

New Comprehensive Primary Care model to drive demand for patient communications/coaching solutions.

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Credit: Stephen Sauer

The federal Centers for Medicare & Medicaid Services recently announced a bold move to accelerate the Comprehensive Primary Care (CPC) program, news that I have been waiting on for a long time.

To provide a bit of background, CPC is a practice and payment model that rewards primary care physicians -- through an additional fixed monthly payment -- for taking care of patients in a proactive way instead of waiting for patients to show up at their clinics or hospitals. CMS initially rolled out CPC as a limited experiment through its innovation center.

This new initiative (now called CPC-Plus) will expand CPC to 20,000 primary care doctors treating up to 25 million patients on an annual basis. According to the CMS announcement, each participating practice will receive $20 per patient per month in care management fees to do whatever it can to improve patients' health. Additional bonuses can be handed out at year-end through shared cost savings from CMS. The initiative will kick off in January 2017, and care practice recruiting and contracting will start this summer.

CPC-Plus is a stimulus to the care delivery and payment model changes that have slowly but steadily been seeping into the current healthcare system. I would give a shout-out to the pioneer work from the patient-centered medical home (PCMH) model and Patient-Centered Primary Care Collaborative (PCPCC) that has been going on since 2008. Yes, it takes that long in healthcare to recognize a brilliant idea.

I would not celebrate too soon, either. CPC-Plus is a big leap forward, but even when it is fully implemented, it only covers about 6%-8% of the U.S. population. For this care model to have a deeper and more material impact on care quality and care spending, the private sector must join and pitch in its own resources.

CPC-Plus is one step in the process to fulfill CMS's plan that by 2018, 50% of the CMS payment would be performance-based.

While I welcome this move, I also caution that primary care physicians participating in CPC-Plus or similar initiatives from the private sector in the future must recognize the challenges of implementing such a program. Although the upfront $240 per patient per year payout is enticing, primary care doctors would enter an unfamiliar territory that would require them to offer more proactive and effective consumer communications and care coordination and advisory services. This would be a significant departure from their current care model that is passive and only responsive to consumer care needs when a health problem arises.

Doctors would have to make staffing changes. More nurses, behavioral health experts, social workers and home aides would need to be added to their clinical teams. Even data experts could be in high demand, as they can provide the insights from clinical and behavioral data to inform the clinical teams how to do a better job.

For large practices, their call center operation might need to be upgraded, and their health portal for patients would need a face-lift as well. These investments would eventually be factored into the economic model of CPC-Plus types of programs, and doctors would like to maximize profit by using the most efficient and cost-effective solutions and services.

There are two types of solution vendors that are likely to benefit most from a potentially booming primary care provider market for patient management services. The first includes patient communication platform providers such as Vocera, Voalte and Revation Systems. Their solutions help doctors and their clinical teams respond to inbound patient inquiries more efficiently or make outbound patient outreach and advisory experience more convenient and cost-effective. They usually supply an IP-based communications platform supporting multi-modal communications tools including email, text, social media, video and IVR, and offer software to clinical staff to handle communications protocols and document patient engagement efforts.

The second type of solution includes preventive care and health advisory/coaching services that doctors can partner with or outsource. These solutions help care providers design more effective patient self-care and care monitoring programs and track outcomes in the form of well-being status and positive health behaviors. Companies such as Welltok, Wellframe, Virgin Pulse and Sentrian may find a growing opportunity in the primary care service market.

An important element of a successful patient engagement and management program will require deeper knowledge about patients' lifestyles, attitudes and motivations. Primary care practices will gradually build up their expertise in this area, but they also need insightful data from various patient engagement points. As a result, I expect data aggregation platforms, coming from startups like Validic as well as large players such as Apple and Samsung, would have room to grow and prosper.

This transition will not be easy for primary care doctors, because the U.S. healthcare industry has limited experience. Parks Associates' 2015 survey data shows that among people with chronic conditions, only 12% have a team of three or more providers involved in patient care, and among people with three or more chronic conditions, only 28% have a team of three or more providers. At the same time, the primary care physician is the most trusted provider type that consumers want to engage with.

With CPC-Plus and hopefully private sectors joining, a new chapter in primary care is being written.

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