Long-Term Effects of the Comprehensive Primary Care Model on Health Care Spending and Utilization

Abstract

BACKGROUND:The Centers for Medicare & Medicaid Services launched the 4-year Comprehensive Primary Care Initiative (CPC Classic) in 2012 and its 5-year successor, CPC Plus (CPC+), in 2017 to test whether improving primary care delivery in five areas-and providing practices with financial and technical support-reduced spending and improved quality. This is the first study to examine long-term effects of a primary care practice transformation model. OBJECTIVE: To test whether long-term primary care transformation-the 4-year CPC Classic and the first 2 years of its successor, CPC+-reduced hospitalizations, emergency department (ED) visits, and spending over 6 years. DESIGN: We used a difference-in-differences analysis to compare outcomes for beneficiaries attributed to CPC Classic practices with outcomes for beneficiaries attributed to comparison practices during the year before and 6 years after CPC Classic began. PARTICIPANTS: The study involved 565,674 Medicare fee-for-service beneficiaries attributed to 502 CPC Classic practices and 1,165,284 beneficiaries attributed to 908 comparison practices, with similar beneficiary-, practice-, and market-level characteristics as the CPC Classic practices. INTERVENTIONS:The interventions required primary care practices to improve 5 care areas and supported their transformation with substantially enhanced payment, data feedback, and learning support and, for CPC+, added health information technology support. MAIN MEASURES: Hospitalizations (all-cause), ED visits (outpatient and total), and Medicare Part A and B expenditures. KEY RESULTS: Relative to comparison practices, beneficiaries in intervention practices experienced slower growth in hospitalizations-3.1% less in year 5 and 3.5% less in year 6 (P < 0.01) and roughly 2% (P < 0.1) slower growth each year in total ED visits during years 3 through 6. Medicare Part A and B expenditures (excluding care management fees) did not change appreciably. CONCLUSIONS: The emergence of favorable effects on hospitalizations in years 5 and 6 suggests primary care transformation takes time to translate into lower hospitalizations. Longer tests of models are needed.

Transforming Primary Care Through Innovations in Medicare

“…The final 4-year evaluation reported substantially slower growth in ED visits in CPC Classic, but the interim 2-year findings were otherwise largely confirmed, particularly the lack of substantial reductions in spending or improvements in quality of care . A subsequent study found substantial reductions in the growth of ED visits and hospitalizations over 6 years in CPC Classic practices compared with comparison practices, but no significant differences in total Medicare spending were noted between these groups . In 2017, the CMS Innovation Center launched Comprehensive Primary Care Plus (CPC Plus) as a new 5-year initiative, building on lessons learned in CPC Classic.…”

“…4 A subsequent study found substantial reductions in the growth of ED visits and hospitalizations over 6 years in CPC Classic practices compared with comparison practices, but no significant differences in total Medicare spending were noted between these groups. 5 In 2017, the CMS Innovation Center launched Comprehensive Primary Care Plus (CPC Plus) as a new 5-year initiative, building on lessons learned in CPC Classic.In this issue of JAMA, a new study presents key findings from the final evaluation of the CPC Plus initiative. 6 Compared with CPC Classic, the CPC Plus initiative provided more financial and tactical support for participating practices, along with greater expectations for change.…”

“…4 A subsequent study found substantial reductions in the growth of ED visits and hospitalizations over 6 years in CPC Classic practices compared with comparison practices, but no significant differences in total Medicare spending were noted between these groups. 5 In 2017, the CMS Innovation Center launched Comprehensive Primary Care Plus (CPC Plus) as a new 5-year initiative, building on lessons learned in CPC Classic.…”

Health Equity: The Only Path Forward for Primary Care

“…The multiplayer demonstration project was associated with a reduction in hospitalization and emergency department visit rates over the long term. 21 Critical to the success of such models is appropriate risk adjustment in quality measurement and payment that accounts for social complexity. Thus, we are not penalized for caring for under-resourced patient populations that require specific interventions to address disparities and unmet health-related social needs.…”

The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality

“…38,39 While it is possible that expenditures might fall more over a longer period, the positive changes made by CPC+ practices during the model period may simply not be sufficient to reduce total expenditures. 40 Broader contextual factors also matter-primary care practices have little influence over specialists and hospitals. Without aligned payment incentives, practices may have limited ability to reduce unnecessary utilization and decrease total costs on their own.…”