Medicare case management: Practices love it despite lack of cost savings

While early data show little in the way of quality improvement or cost savings, participants rave about Medicare’s Comprehensive Primary Care (CPC) initiative.

“I personally think it’s a great program,” Dr. Joseph Gregory, a family physician and regional medical director at Banner Health in Johnstown Colo., said in an interview. “We have seen a definite increase in resources for us to be able to use to help manage patients.”

Dr. Joseph Gregory

The CPC Initiative is a pilot project that provides primary care physicians with a case management fee and an opportunity to share in any savings generated. For the first 2 years of the program (2013-2014), the fee averaged $20 per Medicare beneficiary, dropping to $15 per beneficiary in the last 2 years of the test. Other public and private payers also are taking part, providing varying levels of monthly fees to participating practices.

The funds are provided so that practices can expand services and offer programs that generally are not covered by traditional fee-for-service Medicare. Potential uses include 24/7 access to providers; improving preventive care and care for chronic conditions; improving patient and caregiver engagement; and improving care coordination.

The goal is to improve outcomes and reduce costs in the long term.

But an analysis of CPC shows that it has yet to save money for Medicare.

Stacey Berg Dale, associate director of health research at Mathematica Policy Research, and her colleagues, analyzed data on the nearly 500 practices in seven regions that are participating in CPC. Incentive payments averaged $115,000 per physician, yet the only significant differences found between initiative practices and comparator practices were a 3% reduction in primary care visits and small increases in medication-based conversations with patients and in support for patients taking care of their own health (N Engl J Med. 2016 April 13. doi: 10.1056/NEJMsa1414953).

“Relative to comparison practices, the initiative has not yet generated savings in Medicare Parts A and B expenditures that are sufficient to cover care management fees,” Ms. Dale noted. But doctors on the front lines do see a difference.

Dr. Gregory noted that resources from CPC have allowed Banner Health to hire more support staff – primarily medical assistants – to serve as case managers who follow up with patients. As such, he said that the group has seen a “fairly substantial drop” in emergency department visits and readmissions.

“The work they are doing to be able to reach out to patients after they leave an ER or after they leave the hospital to make sure that they have everything they need, they have their questions answered, to check on them to see if they are feeling better, or if they are having problems to be able to address that more urgently by getting them in quickly if necessary ... That actually has been a big, big help to us and really having that kind of team approach is a wonderful aspect of CPC,” he said.

The CPC funds have allowed the practice to hire staff pharmacists – “another really big advantage,” Dr. Gregory said, noting that the pharmacists help monitor patients on anticoagulants, help patients with diabetes titrate their insulin dosages, and generally manage polypharmacy situations.

“That is really a very nice thing to have in a primary care office,” he said.

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Family Practice of Greeley(Colo.) also is seeing improvements that might not be obvious from a data standpoint. The practice also has used CPC funds to build a support staff that allows it to provide more diverse services.

The CPC funding “has allowed us to have behavioral health interventions, not for ongoing counseling but for emergent things and for following up on referrals in house,” Dr. Stacey Garber, who manages CPC for the practice, said in an interview. “That’s been an incredibly big service because behavioral health has been kind of a problem area in terms of facilitating referrals in our community.”

Family Practice of Greeley has formed a council to give patients a voice in how the practice operates. The council suggested the use of a cover sheet that allows patients to check off all the topics they wish to cover with their physicians, allowing the doctors to identify and prioritize the most important issues to address at a particular visit.

And like Banner, Greeley has used the funds to help improve diabetes education and can provide the services without copays. “It’s been great to have [diabetes education] in house and not having to charge patients, which was a real stumbling block,” Dr. Garber said.