CMS Paving the Way for Consumer-Centric Care
The CMS Primary Cares Initiative is continuing to reform primary care in the US through value-based care
As a healthcare transformation company, Carium pays close attention to key shifts in the healthcare environment and how they impact care delivery. In the ongoing push toward value-based care and reducing costs, the Centers for Medicare & Medicaid Services (CMS) recently announced it will be releasing new payment models.
The CMS Primary Cares Initiative (PCI) is a voluntary program designed to shift more primary care providers to outcomes-based reimbursement, and the program includes five new payment options for small and large provider organizations. Starting in 2020, the program will allow organizations to take on varying levels of financial risk and reward for improving patient care and lowering costs.
I asked a few members of Carium’s executive team about the impact these new payment models are likely to have.
From a policy perspective, are the new payment models significant for the healthcare industry?
In my opinion, shifting from fee-for-service to value-based incentive models is the single most important policy step we can take to improve healthcare in the US. The Primary Cares Initiative signals an ongoing commitment by CMS — the country’s most powerful payor — to refining and expanding value-based payment models.
While the Primary Cares Initiative is, from my perspective, an evolution of CMS’ previous payment programs, as opposed to a radically new set of approaches, the very fact of that continuity is encouraging, particularly against the backdrop of a tumultuous political climate. It’s great to see renewed support not only for value-based care models, but also for increasing emphasis on primary care providers, who are at the front lines in supporting patients and guiding them toward prevention and appropriate healthcare services.
Throughout my career, I’ve been focused on promoting consumer and patient engagement in health, which is, of course, what all of us do at Carium. The link between value-based care and consumer engagement is strong because so much of healthcare outcomes are shaped by consumers and the context of their lives.
As consumers, our everyday behaviors, like what we eat and how we move, are among the biggest influences on our health. And even the professional healthcare services we receive are shaped directly by… us. It’s the consumer (or his or her family and caregivers) who decides when and where to seek professional care, and whether to follow through with clinical recommendations.
So in order to change outcomes to reflect greater value, it stands to reason that we *have to* engage consumers and their families as partners in achieving and maintaining better health. To do so well, we have to learn from them about their challenges and priorities, and co-create solutions together.
How will these new models change primary care?
In announcing the Primary Cares Initiative, HHS Secretary Alex Azar said: “For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision.”
There is little question that the road to the Triple/Quadruple Aim in healthcare will be paved with investment in value-based primary care. Like the programs that preceded it, PCI provides a runway to encourage and incent the development of advanced primary care models. There are many challenges in designing and implementing such models, and at Carium we’ve seen our health system partners really rolling up their sleeves to thoughtfully address those challenges.
Developing skill-optimized, team-based models of care delivery will be a core competency — including engaging and empowering patients, family and caregivers as active members of the team. The processes and technologies that support episodic, transactional care delivery won’t serve the emerging needs for continuous, collaborative, personalized care.
Access to reliable and timely health data is another key component, and the collection of data from the fabric of individual lives will contribute measurably to understanding each person and meeting their needs. For example, tracking how a person is feeling each day around a variety of subjective and objective dimensions can help guide therapeutic and lifestyle interventions, and contribute to deeper insights for patients and providers alike. We will need to redefine success metrics for value and create systems to make these measurable.
Knitting together these elements has truly transformative potential — to make care more proactive than reactive, to improve the experience of care for patients and providers, and to better manage chronic conditions and their associated human and financial costs. Carium is thrilled to help catalyze and enable these shifts in care delivery, and we believe that PCI will accelerate strategic thinking and action around how to make it happen.
Recognizing the complexity of change and change management for practices and systems to successfully navigate PCI, it will be a long road to the Triple/Quadruple Aim. Fire up your GPS and let’s hit the on-ramp!
How can technology help to enable new value-based payment models?
Before I share my thoughts about the role of technology, I want to first take a moment to emphasize the significance of this announcement. The CMS Primary Cares Initiative is another milestone that further reinforces healthcare in the United States is in the midst of transformative forces of change. It’s fascinating to me that payers are driving the change not only through the push toward value-based payment models, but also by going as far as launching their own healthcare delivery centers Blue Cross in Texas and taking on the redesign of care-delivery models Humana.
Shifting focus to the specifics of the CMS PCI, fully- or partially-capitated payment models drive very different provider behavior than fee-for-service (FFS) or cost-plus reimbursement models. In the FFS models, providers are paid to perform actions, with some post-measurement of quality and compliance and value. In my opinion, the latter measures are only band-aids applied to try to reign in reimbursement models that are not optimized for value to begin with. See Dan Munro’s Casino Healthcare for fantastic insights into how we got here.
As we move towards value-based reimbursed models like the CMS PCI, which emphasize outcomes, we will see a rapid need for technology that enables all of the following:
- Diverse synchronous and asynchronous channels for care delivery (e.g. in-person visits, video visits, text, voice, video, chatbots, etc.)
- Sensors and monitoring systems that extend outside the walls of the clinic and into people’s everyday lives.
- Comprehensive longitudinal data sets that provide holistic views of patients, including clinical records, patient-generated and reported data, social data, preferences, and even genomic data.
- Real-time, always-on, data analysis and insights that support care planning and meets the needs of clinicians and others using it.
These technologies will become key components and the de facto approach of such models. While current health IT solutions are predominantly enterprise-centric and designed for transactional-use, there is a whole new class of patient-focused and collaborative-care delivery solutions coming to market to address this gap — including ours at Carium.
This new breed of solutions are focused on the patient and provider journeys, take a total health and life-centric approach, and will be the underpinning of primary care delivery in the near future. A popular business model in software is SaaS — software-as-a-service — to which users subscribe. What we at Carium and our partners are building, by analogy, is a health-as-a-service (HaaS) model where consumers have access to technology and a team of people behind it keeping them in the best health possible all day, every day. This will enable people to get the support and care they need, personalized as necessary, maximizing value, strengthening connections with their providers, and driving better health. Sounds pretty exciting!
To keep up to date on the latest industry news and Carium updates, sign up for our newsletter.
