This is the most serious and weighty topic in all American healthcare. Let’s have a little fun with it. Over more than a decade, there have been several taxpayer funded initiatives designed to transform primary care in a way that improves health and saves money. They all failed. The latest one, Comprehensive Primary Care Plus, also failed. On December 15, 2023, a report appeared in the Journal of the American Medical Association (JAMA) saying that the Comprehensive Primary Care Plus (CPC+) program from the Medicare Center of innovation had failed to save any money or improve quality measures when compared with similar primary care practices not in the program. There is a long history of failed efforts to improve health while reducing spending in American primary care practices beginning with the first major medical home study published in JAMA in 2008. An editorial about this early primary care medical home study was very helpful in examining the reasons this initiative failed.
I am going to examine these failures in detail in the next few posts because they tell us what we must do to make real progress over the coming year. I have been writing for three years. It is time to do something!
The children’s fable, the Wizard of Oz is a nearly perfect parable to explain America’s medical journey over the last two or three decades. Think of Dorothy as primary care on a journey to better health at lower cost. The yellow brick road is the path to get there. The Scarecrow in need of a brain, the Tin Man in need of a heart, or the Cowardly Lion, in need of courage are the healthcare leaders helping Dorothy on her journey. They are all trying to get to the great and powerful Wizard behind the curtain who has the answer to everything in his beautiful Emerald City. The Wizard represents the big insurance companies who run the whole show and project the image of having all the answers. “We are off to see the Wizard and the Wonderful things he does.
The wizard and Emerald City are the legend of American healthcare as the best in the world, but the Wizard hides behind a curtain. There is nothing real about his Emerald City. You can’t see any of the data on costs and quality the Wizard produces. He hides it on purpose. A constant barrage of ads works like the green glasses that make Emerald City look great. It is all smoke and mirrors. The Wizard has no malignant purpose, he is just trying to keep everyone satisfied with a white lie. The great and glorious Oz has all the answers. “The green spectacles and the Wizard’s other gifts represent how slightly changing a person’s perspective, even if through deceit, can change someone’s personal reality for the better.” Emerald City isn’t green and American healthcare is far from the best.
Between doctors and patients in our country is an opaque, secret system with a Wizard behind a curtain leading to the worst clinical outcomes in the developed world at the highest cost. Comprehensive Primary Care Plus (CPC+) is the latest stop on the yellow brick road. Hopefully, the lessons learned there will lead to primary care that improves health and reduces costs!
CPC+ is just the latest stop on the yellow brick road. There have been several massive efforts expending hundreds of millions of dollars to improve primary care so that it produces better health at lower cost. They all made sense and they failed completely to show improvements in healthcare quality or reductions in healthcare cost. All other developed countries provide healthcare to all their citizens for half the impact on gross domestic product and they live longer. Citizens of Singapore live longer for one fourth the impact on gross domestic product. The key common denominator is primary care that is available to every citizen. Singapore has advanced primary care. Our system is upside down and backwards. We don’t provide good primary care for everyone, but when you develop a serious expensive complication because you did not have primary care, we will pay for your dialysis and give you a disability pension. Madness!
No one has a system like ours. We are an outlier. Our very high costs and poor outcomes are an outlier as well. Entire countries have improved health and dramatically reduced costs compared to the United States and we can’t even do it in a primary care demonstration project. There are rare examples of what can be done in this country. The Southcentral Foundation in Alaska provides care for half the cost experienced by other Alaskans, and they have quality scores in the 75th to 90th percentile. Vestra Health runs a worksite clinic for the Coushatta tribe in Louisiana. Compared with patients seen in the broader community, those seen in the Vestra clinic cost half as much and they are in the hospital one fifth as often and in the ER one third as often. The Vestra stats are based on detailed claims data from their third-party administrator.
These primary care efforts were large and ambitious. The predecessor of Comprehensive Primary Care Plus (CPC+) was the Comprehensive Primary Care (CPC) initiative. It enrolled 502 primary care practices. “In total, 2,188 participating providers are serving approximately 2,700,000 patients, of which approximately 410,177 are Medicare & Medicaid beneficiaries. There are 38 public and private payers participating in the Comprehensive Primary Care initiative.”
Here is the detail on what the practices were required to do:
Access and Continuity: Because health care needs and emergencies are not restricted to office operating hours, primary care practices optimize continuity and timely, 24/7 access to care guided by the medical record. Practices track continuity of care by provider or panel.
Planned Care for Chronic Conditions and Preventive Care: Participating primary care practices proactively assess their patients to determine their needs and provide appropriate and timely chronic and preventive care, including medication management and review. Providers develop a personalized plan of care for high-risk patients and use team-based approaches like the integration of behavioral health services into practices to meet patient needs efficiently.
Risk-Stratified Care Management: Patients with serious or multiple medical conditions need extra support to ensure they are getting the medical care and/or medications they need. Participating primary care practices empanel and risk stratify their whole practice population, and implement care management for these patients with high needs.
Patients and Caregiver Engagement: Primary care practices engage patients and their families in decision-making in all aspects of care, including improvements in the system of care. Practices integrate culturally competent self-management support and the use of decision aids for preference sensitive conditions into usual care.
Coordination of Care Across the Medical Neighborhood: Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients’ experiences with medical care. Practices work closely with patients’ other health care providers, coordinating and managing care transitions, referrals, and information exchange.i
Similarly, CPC+ required practices to improve in very similar ways. (1) access and continuity, (2) care management, (3) comprehensiveness and coordination, (4) patient and caregiver engagement, and (5) planned care and population health. “Compared with CPC Classic, the CPC Plus initiative provided more financial and tactical support for participating practices, along with greater expectations for change. It also shifted performance-based financial incentives from the regional level to the practice level. About 85% of primary care practices that participated in CPC Classic chose to continue participating in CPC Plus, demonstrating their commitment to ongoing practice transformation and the associated financial incentives.”
CPC, CPC+, The Multipayer Medical Home Initiative and all the other efforts to improve clinical outcomes while lowering cost have failed. Every one of them! There are very few quality improvement efforts at any level that improve quality measures while lowering costs. The next post will discuss why they failed.
OMG I love this!!! But what about the wicked witch? and her flying monkeys
This tragic outcome was predictable. Without a fundamental overhaul of how chronic diseases are diagnosed, measured, and monitored, this tragedy will never end. Primary Care needs better access to effective early detection systems to address the early signs of physiological dysfunctions which lead to chronic diseases such as heart disease, diabetes, stroke, dementia, cancer, and to intervene early enough to prevent and reverse them before too late. We can help.