This Brave New World of Healthcare Reform

What we’re experiencing in our country today with regard to healthcare delivery system redesign and payment reform is unprecedented. Last week, The Center for Medicare & Medicaid Services (CMS) announced the launch of the Comprehensive Primary Care Plus (CPC+) program, its largest-ever initiative to transform and improve how primary care is delivered and paid for in America. CPC+ is the next phase of the Comprehensive Primary Care (CPC) initiative that has been underway for nearly three years. It will bring together Medicare, commercial insurance plans, and State Medicaid agencies to provide continued financial support for practices to make fundamental changes in their care delivery and advance the transition from fee-for-service models to value-based care. The engagement of these stakeholders has been, and will continue to be, integral to creating successful and sustainable change.

An “all-in” approach

Government and commercial payers are engaged. Medical practices are also investing time and effort to redesign the delivery system, and hospital systems – which own more than 60% of medical practices today – are engaged as well. The other key stakeholders in this unfolding story are patients and employers. They are two of the three payers in our healthcare system, along with Medicare/Medicaid. As a patient, I’m a consumer of services. As an employer with a company-sponsored health plan, HealthTeamWorks^® is a payer. On both sides, the ever-increasing healthcare cost burden is unsustainable, and consumers and employers are demanding change; that is, improved quality, better coordinated care, better patient experience, and lower costs.

Engagement by ALL stakeholders is driving momentum like I’ve not seen before in my 25 years working in healthcare. This time, it’s not just CMS-driven payment reform like it was in the days of managed care and capitated prospective payments to providers. They were both failed government attempts to reform the payment system without investing in systemic redesign of the way care and information are delivered.

Why this time is different

What’s different today is that the government is not only investing in payment reform but is also shifting the focus of the delivery system to population health management as a key ingredient for change. It’s a heavy lift and I believe it has a great chance of working. The New England Journal of Medicine recently studied two-year quality and cost results for the CPC program. The improvements observed in access to care and care management of high-risk patients are evidence that this is a work in progress, and I believe that improvements to date from the CPC pilot will pale in comparison to the greater improvements that will occur over the next three years; even more so with the implementation of CPC+. The return on stakeholders’ investments should be substantially greater in the post-pilot years ahead.

I think CMS leaders agree, as evidenced by their expanded investment in the CPC+ program and many other current Center for Medicare & Medicaid Innovation (CMMI)-funded initiatives like the State Innovation Model (SIM) and Transforming Primary Care initiative (TCPi). These programs are foundational investments in delivery redesign and payment reform. And although the results are not significant in terms of bending the cost curve just yet – that outcome will occur more quickly and dramatically as we advance toward the Medicare milestones for shifting to value-based payments under the MACRA/MIPS framework in 2017-2019. The takeaway here is that the short-term results should motivate us to keep working toward the long-term results.

Key threats to success

There are many who disagree with this approach and my enthusiasm for it. I share their concerns, particularly to the extent that we won’t see the results we’re working toward if we don’t: 1) make the simple changes to better coordinate and integrate patient care in our healthcare delivery system; 2) effectively address the complex social determinants of health at the community and national levels; and 3) achieve greater activation of healthcare consumers in accepting responsibility for their personal health status. These are three key elements among the many crucial pieces of the puzzle that define sustainable change toward better healthcare, better health and the solvency of Medicare and Medicaid for future generations of Americans.