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ACOs: CMS Enlists Insurers in Primary Care Effort

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Private health plans in 7 regions have agreed to participate in a Centers for Medicare & Medicaid Services (CMS) effort to improve the U.S. primary care system.

The participants in the CMS Comprehensive Primary Care (CPC) program will work with CMS to pay primary care medical care practices to do a better of managing and coordinating care for all patients in the targeted communities, officials say.

The CPC program is similar to but separate from the two major CMS initiatives designed to test the “accountable care organization” (ACO) concept.

In an ACO, a patient’s personal physician acts as a “patient-centered medical home.” The “medical home” tries to take responsibility for ensuring that a patient gets the optimal amount of care. In return, the primary care physicians and other individuals and entities responsible for taking care of a patient may share some of the financial risk involved with managing the patient’s care.

The CPC program calls for primary care physicians to set up medical homes, but it does not require the physicians to share financial risk with specialists and hospitals through ACOs.

Medicare will pay the providers a $20 monthly care management fee for each traditional Medicare enrollee in the medical home program. The medical home operators will get to split any savings Medicare gets as a result of the program, officials say. 

The CMS medical home test program will start out operating in Arkansas, Colorado, New Jersey, New York, the Cincinnati-Dayton region in Kentucky and Ohio, Oklahoma and Oregon.

In the Cincinnati-Dayton region, for example, the commercial carrier participant list includes Aetna, Amerigroup, the Anthem unit of WellPoint Inc., Humana, UnitedHealthcare, CareSource, HealthSpan, Medical Mutual and Centene. The Ohio Medicaid program also is participating. 

About 75 primary care practices in each market can participate in each primary care coordination market, officials say.

A participating practice must serve a minimum number of traditional Medicare plan enrollees and submit Medicare claims on standard paper or electronic claim forms. The practice cannot be participating in other Medicare “shared savings” initiatives, such as the Medicare ACO test programs.

The program could end up serving about 300,000 Medicare and Medicaid enrollees.

WellPoint, Indianapolis (NYSE:WLP), notes that WellPoint plans in Colorado and New York will join the WellPoint plan in Cincinnati-Dayton in participating in the CMS medical home program.

Sam Nussbaum, WellPoint’s chief medical officer, says in a statement that the company already has been experimenting with its own medical home programs.

“We are proud to have taken the lead in changing the relationship with primary care physicians by investing in their practices and in the health of their patients,” Nussbaum says.