Although the proposed Medicare phys

Although the proposed Medicare physician payment reform is an important step in the right direction, we believe that a bolder approach is needed to accelerate the adoption of APCP. We propose that Medicare adopt APCP as a new provider category, with its own eligibility standards and accountability for performance on patient outcomes, care, and resource use, linked to a new payment approach.

As policymakers struggle to find pathways to accelerate transformation to high-value models of advanced primary care, they are challenged by two things: the lack of a clear definition of the clinical model they are trying to create and the transformed practices' need for a business case for deploying it. Current approaches to strengthening primary care included in the Affordable Care Act have focused on increasing reimbursement for primary care (e.g., increasing Medicare payment for primary care by 10%), and proposed recent changes in payment rules for 2014 include new non–visit-based codes (e.g., for care management services and care coordination) that may be used by primary care physicians as well as other clinicians providing these services. Though these changes do direct increased resources toward primary care, they do not drive practice transformation to any particular clinical model.

Our proposed new APCP category would be best thought of as a bundle of services provided by a team using a technology platform designed to support a variety of visit-based and non–visit-based activities rather than as a discrete cognitive service offered by physicians. Efforts to graft this new bundle of services onto existing primary care practices using visit-based fee-for-service payment will always face the challenge that much of what policymakers want to see delivered in primary care adds overhead to an existing primary care practice without offering any corresponding revenue source to support those activities. And in a fragmented payment system, if each payer specifies a different bundle of services and varying payment methods, the national rate of real practice transformation will be unacceptably slow.

As a standard setter in payment, the Centers for Medicare and Medicaid Services (CMS) plays a critical role in establishing new payment models for new services. Two multipayer pilots deployed by the Center for Medicare and Medicaid Innovation (CMMI) are informative.3 In the Multi-Payer Advanced Primary Care Practice initiative, Medicare joined with approximately 27 private insurers and state Medicaid programs in eight states. States used their antitrust authority to create a safe harbor for private payers to collaborate on defining and determining how to pay for advanced primary care. CMS joined in later, once the states and payers had agreed on both the criteria for practice participation and the model for payment. Most states used the PCMH credential offered by the National Committee for Quality Assurance (NCQA), and they offered a payment model typically comprising a combination of fee-for-service payment, monthly per-person care management fees, and rewards for performance on quality metrics, shared savings, or both.

Under the Comprehensive Primary Care Initiative (CPCI), 44 private payers and state Medicaid agencies joined with Medicare in seven market areas, engaging 500 high-performing primary care practices including more than 2000 providers. Under this 4-year program, Medicare specified the clinical model before the private payers chose to sign on. Practices applying to participate had to commit to achieving a set of milestones by the end of the first year (see The Nine Comprehensive Primary Care Initiative Milestones to Be Achieved by the End of Year 1). In addition to Medicare fee-for-service payment, the initiative provides a payment of $20 per Medicare beneficiary per month in years 1 and 2 (almost 40% more than what Medicare now pays for primary care) and the opportunity for shared savings starting in year 2. All the participating commercial payers agreed to offer similarly structured payment and shared-savings opportunities, but they varied in amount.

Though both these programs are in process and clinical and financial results are not yet available, the programs have already demonstrated several important things: payers are willing to pay more for advanced primary care, practices are willing to transform to a new model if they're assured of a revenue stream to support such change, and the private market is willing to partner with Medicare in defining the clinical model and the payment approach.

Several common features of the programs could lay the foundation for designing a payment system for advanced primary care under Medicare: a clinical model specifying practice capacities and a payment model offering care management fees that flow on behalf of a defined population in a predictable way, incorporating accountability for population health outcomes and opportunities for shared savings.

Creating a new APCP provider category would give policymakers multiple tools for accelerating the broad availability of enhanced primary care. Medicare already recognizes different categories of providers, and it administers both “Conditions of Participation” (specifying the infrastructure and capacities that must be in place to make a provider eligible to bill using that provider type) and a fee schedule unique to each category of provider (designed to support requisite infrastructure). Both the NCQA PCMH credential and the CPCI milestones could inform the criteria that Medicare would require for participation. The APCP category could be open to all providers meeting requirements on eligibility, reporting, performance, and accountability. It would have its own payment method — a blend of fee-for-service payment, a monthly care management fee per Medicare beneficiary served, and the opportunity for shared savings — similar to the method used in the CPCI.

Establishing the APCP as a provider category would accelerate the deployment of care teams (including such health care professionals as nurses, care managers, health educators, social workers, and pharmacists4) and would foster the development of the information infrastructure for delivering patient-centered, coordinated primary care. To encourage broader use of this coordinated care model, Medicare beneficiaries enrolling in APCPs should have their primary care services covered with no deductible and no copayment for the care management payments, along with reduced coinsurance (e.g., 10% rather than the usual 20% coinsurance) for specialist care obtained through referral from their APCP. We believe that the combination of Medicare payment reform for APCPs and financial incentives for beneficiaries to seek this form of high-value care would induce most primary care providers to embrace practice transformation to ensure the best possible patient outcomes and experiences.5 Ongoing support for CMMI pilots and demonstrations can help to refine this approach over time, but the time for committing to advanced primary care has come.

結果 (繁體中文) 2:

雖然提出了醫保醫師支付方式改革是朝著正確的方向邁出的重要一步，我們相信，一個更大膽的做法是需要加速採用鋁塑複合板。我們建議採用醫保鋁塑複合板作為一個新的供應商類別，擁有自己的資格標準和問責制對患者的治療效果，護理和資源利用，鏈接到一個新的支付方式的表現。作為政策制定者努力尋找途徑，以加快轉型到高先進基層醫療價值的車型，它們是由兩件事情的挑戰：缺乏的臨床模型，他們正試圖建立一個明確的定義和轉化實踐“的商業案例，部署它的需要。目前的辦法，加強包括在支付得起的醫療法的初級保健的重點是提高報銷初級衛生保健（如，增加醫保支付初級衛生保健10％），並於2014年提出的近期變化的支付規則，包括新的非訪為主代碼（例如，護理管理服務和護理協調），可用於初級保健醫生以及其他臨床醫生提供這些服務。雖然這些變化做對初級保健直接增加資源，他們不開車的做法轉變為任何特定的臨床模型。我們提出了新的鋁塑複合板類將是最好的思想作為使用的技術平台，旨在支持由一個團隊提供服務的捆綁各種訪問和基於非訪為基礎的活動，而不是由醫生提供了一個獨立的認知服務。努力嫁接服務，這種新的捆綁到現有的訪問使用基於有償服務金將始終面臨的許多東西決策者希望看到在初級保健交付增加了開銷，以現有的基層醫療實踐中沒有提供的挑戰初級保健的做法任何相應的收入來源，以支持這些活動。在一個支離破碎的支付系統，如果每個納稅人指定一個不同的捆綁服務和不同的支付方法，真正實踐轉化的全國速度會慢得不可接受。作為支付標準的制定者，該中心的醫療保險和醫療補助服務（CMS）起著在建立新的支付模式對新服務的關鍵作用。部署中心醫療保險和醫療創新（CMMI）兩個multipayer飛行員informative.3在多付款人高級初級護理實踐舉措，醫保與參加八國約27私營保險公司和國家醫療補助計劃。美國用他們的反壟斷機構，以創造一個安全港的私人納稅人來定義和確定如何支付對先進基層醫療協作。CMS加入後，一旦國家和納稅人同意雙方的標準，實踐參與和模型付款。大多數州使用由國家質量保證委員會（NCQA）提供的PCMH憑證，他們提供的質量性能支付模式通常包括有償服務金的組合，每月每人護理管理費和獎勵衡量標準，共享的儲蓄，或兩者兼而有之。根據綜合初級保健計劃（CPCI），44私有納稅人和國家醫療機構參加醫療保險在七個市場領域，從事500高性能的初級保健的做法，包括2000多供應商。在這個4年的計劃，醫保規定的臨床前模型私人納稅人選擇了簽署。申請參加實踐必須承諾在第一年（見九全面的初級保健倡議里程碑是由1年結束時實現的）年底實現一套里程碑。除了 ​​醫療有償服務金，主動提供了支付每月每醫療保險受益人20美元的1年和2（比醫保現在支付初級保健更接近40％），並有機會共享節省首發今年2.所有參與商業納稅人同意提供同樣結構的支付和共享節省機會，但他們的數量變化。雖然這兩個項目都在過程中和臨床和財務結果尚未公佈，該項目已經顯示了幾個重要東西：納稅人願意支付更多先進的初級保健，做法都願意轉換到一個新的模式，如果他們一個放心的收入流來支持這樣的改變，而私人市場，願與醫保合作夥伴在確定臨床，模型和方法的付款程序的幾個共同的特徵可以奠定在醫療保險中設計一個支付系統為先進的初級保健的基礎：一個臨床模型指定的實踐能力和支付模式提供護理管理費的流向代表特定人群的在可預見的方式，納入人口健康狀況和機會的共享節約責任制。創建一個新的鋁塑複合板供應商類別會給決策者多種工具，加快提高基層醫療服務的廣泛可用性。醫保已經認識到不同類別的供應商，並負責管理這兩個“參與條件”（指定的基礎設施和能力必須到位，以使供應商有資格使用該供應商類型單）和費用表獨特的每一類供應商（旨在支持必要的基礎設施）。無論是NCQA PCMH憑證和CPCI里程碑可以告知醫保需要參與的標準。鋁塑複合板類可能是開放的資格，報告，績效和問責所有提供會議的要求。這將有自己的付款方式-融合了有償服務金，每醫療保險受益人每月護理管理費服務，並有機會共享的儲蓄-類似於CPCI使用的方法建立鋁塑複合板作為一個供應商類別將加速服務團隊（包括例如醫療保健專業人員為護士，護理管理，健康教育工作者，社會工作者，和pharmacists4）的部署和將促進信息基礎設施的發展，為提供以患者為中心，協調的初級衛生保健。為了鼓勵更廣泛地使用這種協調的護理模式，醫療保險受益人招收APCPs應該覆蓋不計免賠，無共付額的保健管理費的初級保健服務，以及減少共同保險（如10％，而不是通常的20％共保）專科護理，通過他們的引薦鋁塑複合板獲得。我們認為，APCPs和財政激勵受益人醫保支付方式改革相結合，尋求這種形式的高價值關懷會導致最基層醫療機構接受改造的做法，以保證最佳的治療效果，為CMMI experiences.5持續支持飛行員和演示可以幫助完善這一做法在一段時間，但時間的承諾，以先進的初級保健已經到來。