Volume-Based delivery models have been the standard payment structure in the US, otherwise known as fee-for-service. Incentives for payment to providers and organizations were based on the volume and cost of care that was provided. This type of payment model achieved high-profit margins, with little or no emphasis on improving the quality of care that was given to patients. The shift to Value-Based care is intended to make the quality of care given the primary focus, shifting away from the high-profit margin model. Payments in this Value-Based model are used to now incentivize other objectives like improving quality of care and reducing cost of care. This model is also designed to help healthcare providers manage higher patient volume due to increased access to care, which can eventually lead to less out-of-network services. Special incentives also are given for the population suffering from multiple, chronic conditions. While this shift is far from seamless, efforts should create a major benefit for patients. For organizations establishing their value-based structure, implementation and training may strain resources while continuing to provide care.
The Comprehensive Primary Care Plus program is supported by fifty-two payer partners
such as regional Blue Cross/Blue Shield, United Healthcare, and statewide Medicaid in eighteen regions across the US. The program has five main goals: Access and Continuity, Care Management, Comprehensiveness and Coordination, Patient and Caregiver Engagement and Planned Care and Population Health.
In order to meet all goals, there are three payment models:
- Care Management Free (CMF)- paid by Medicare on a quarterly basis. Payment adjusted based on the care management services for a practice’s specific population.
- Performance-Base Incentive Payment– based on how well a practice performs on patient experience measures clinical quality measures and total cost of care.
- Payment under the Medicare Physical Fee Schedule– continues the fee-for services (FFS) model, but payment is reduced to account for Medicare shifting a portion of payment into Comprehensive Primary Care Payments (CPCP) quarterly. Eventually the hope is to shift all to CPCP payments and away from FFS (CMS, n.d.)
The Comprehensive Primary Care plus program designated the primary care provider as the “gatekeeper” for the patient, which in turns ensures care continuity and coordination. Primary Care providers identify quality indicators that meet the standards during patient visits, that also align with payer(insurance) expectations. Reduction of unnecessary treatment, procedures, and readmission to hospitals are goals that are aligned with the IHI Triple Aim Initiative.
The CPC+ program has so far been successful with the transition from Volume-Based to Value-Based payment models. The implementation of quality measures with patient visits are now integrated within a practices’ EMR, but since there are multiple EHR and EMR’s, work continues to be able to get shared information across all platforms.