A Decade of Commitment to Primary Care Transformation Is Starting to Yield Positive Results

For more than 10 years, I’ve been advocating for innovations to strengthen and sustain primary care practices in my home state of Vermont and in partnership with colleagues around the country. Regional and national insurers in the public and private sectors have been asked (many more than once) to take a leap of faith to invest in promising if unproven interventions such as patient-centered medical homes and multipayer alternative payment models. The pot of gold at the end of the rainbow: improved health care quality and controlled costs leading to better health care value and population health equity.

We knew demonstrable success would not be an overnight or even electoral cycle phenomenon. My colleagues and I spent countless hours counseling patience, making the case that the desired impacts would eventually appear. We asked for sustained behavior change on the parts of payers, health systems, federal and state agencies, practices, and patients and families. Anyone who has kept a promise to break a habit or to undertake a new challenge understands what it means to overcome inertia over the long term. Making the changes and keeping at it is easier said than done, and often utterly devoid of immediate gratification.

Positive evidence has been slow to emerge. However, there is reason to be encouraged. It is becoming clear that this decade of persistent effort on the part of the primary care practices, supported by private and public payers through various programs, is starting to yield positive results. Commercial and public populations studied in Ohio and Oregon, both with years of investment in alternative payment models have observed improvements in utilization of expensive hospital-based services. Importantly, it now appears the degree of improvement increases with time invested.

Arkansas Blue Cross and Blue Shield has made a long-term commitment to primary care value-based programs. Starting in 2011, it implemented the federal Comprehensive Primary Care (CPC) Classic program, followed by the federal Comprehensive Primary Care Plus (CPC+) program while simultaneously investing financial and human resources in its own patient-centered primary care program. At Arkansas Blue Cross’ request, Clare Brown, PhD, MPH, and J. Mick Tilford, PhD, at the University of Arkansas for Medical Sciences looked at changes in health care spending and utilization from 2011 through 2018 in practices participating in these three value-based programs as compared to practices that were not participating.

The investigators looked at all Arkansas Blue Cross claims for patients attributed to the study and control group practices. They evaluated outcomes across the full duration of the CPC program and throughout the first two years of the CPC+ program for practices that participated in both programs. In a new Milbank issue brief, Drs. Brown and Tilford share their results and make several important points.

1. 1. Savings increased over time in all three programs, with larger amounts saved in later years. For example, the per member per quarter (PMPQ) savings for the CPC increased from $29.81 savings in 2014 to $37.99 savings in 2015, representing a 27% increase. This doubled to $81.78 PMPQ savings in 2016.

Returns on Investment, Overall and by Year

Note: Returns on investment were calculated by dividing average PMPQ savings (i.e., difference-in-difference estimates from Exhibit 2) by average quarterly care management fees. Positive numbers indicate savings for each dollar invested in the program. An asterisk (*) next to a given value indicates a return on an investment value calculated using a statistically significant difference-in-difference coefficient at P<0.05.
Source: Brown CC and Tilford JM. Value-Based Primary Care: Insights from a Commercial Insurer in Arkansas. Milbank Memorial Fund. July 2020.

1. Programs yielded a two-to-one “return on investment.” Every dollar spent by Arkansas Blue Cross on increased and prospective support for the practices, provided through care management fees, yielded two dollars in savings in beneficiary spending. Although they could not assign cause and effect, they posit that decreases in acute inpatient hospitalizations and emergency room visits contributed to the changes.
2. The impact on beneficiary spending may be greater for commercial and Medicare Advantage plans than in Medicare fee-for-service plans. Given inconclusive findings in Medicare evaluations of fee-for-service of CPC+ beneficiaries in Arkansas, the authors suggest that future analyses evaluate characteristics among the commercially insured population in Arkansas to assess whether the patient mix or other factors in Arkansas contributed to the positive findings from this study.
3. Encouraging members to identify a primary care provider may foster increased patient engagement. The practitioner–patient partnership cannot happen unless both parties are identified. Designating a primary health care resource may be a first step in developing that relationship, leading to increased personal responsibility for one’s overall health.
4. Primary care practices need support as they bear the lion’s share of the on-the-ground workload in these transformation efforts. Both Arkansas Blue Cross and Medicare provide funding and staff for practice facilitation and education to participating primary care clinics, at no cost to the practices or patients. This financial and human support around workflow change, virtual and in-person learning opportunities, and use of data and information technology are essential for the participants to take appropriate actions to address individual and population health.

We are pleased to share this issue brief and to add to the evidence of the effects of primary care transformation supported by an individual payer organization. The Milbank Memorial Fund will be publishing more regional analyses like this one later this year.