Colorado is joining a pilot program called Making Care Primary (MCP) that was announced by the federal Medicaid and Medicare programs. MCP is designed to offer primary care providers up-front reimbursements and additional resources in exchange for transitioning to value-based care. Colorado’s Department of Health Care Policy and Financing (DHCPF) says that by participating in this pilot program, the state stands to benefit from better services and access to health care. It is one of eight participating states. The model is also being tested in Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina, and Washington.

The Centers for Medicare & Medicaid Services (CMS) states that MCP will actually launch July 1, 2024, as a model that “will improve care management and care coordination, equip primary care clinicians with tools to form partnerships with healthcare specialists, and leverage community-based connections to address patients’ health needs as well as their health-related social needs (HRSNs) such as housing and nutrition.” CMS describes it as a decade-long model and is working with Medicaid agencies in the eight participating states to engage in what it calls “full care transformation.” CMS adds that the model “will attempt to strengthen coordination between patients’ primary care clinicians, specialists, social service providers, and behavioral health clinicians, ultimately leading to chronic disease prevention, fewer emergency room visits, and better health outcomes.” 

Colorado doctors would be rewarded for improved care

Traditional healthcare providers typically offer care on a fee-for-service model, meaning that patients and insurers pay a standard fee for a specific visit or procedure. Under “value-based care,” providers instead get paid based on the quality and outcome of the care, with consideration also given to equity issues and the cost of providing care.

Kim Bimestefer, executive director for DHCPF, says about the rationale behind MCP that “Money talks. We want to financially reward primary care doctors who improve care quality, help their patients better manage their health, and save Coloradans money on health care.” She said value-based payment will reward primary care providers for improved health outcomes and for reducing health disparities.

MCP designed to help Coloradans with care coordination

CMS notes that primary care clinicians are the first line of defense for prevention, screening, management of chronic conditions, and overall wellness. “Patients are increasingly diagnosed with multiple chronic conditions,” CMS says, “which only intensifies the importance of accessible, affordable, high-quality primary care teams that can help anchor their overall health care. However, care coordination is increasingly challenging as patients see a greater number of specialists more frequently. Through MCP …  patients can access more seamless, high-quality, whole-person care.” 
According to CMS, the MCP model will include several payment innovations to support participants in delivering advanced primary care. To support team-based care, MCP will include prospective payments for primary care that will reduce organizations’ reliance on fee-for-service payments. Risk-adjusted enhanced services payments, which will also be paid prospectively and represent an additional investment in primary care, will allow participants to expand care management, screen for health-related social needs, and integrate with specialty care.

Care delivery in Colorado would involve three domains

CMS says the MCP care delivery approach communicates its vision for care delivery through three “domains” as follows:

  • Care Management: participants will build their care management and chronic condition self-management support services, placing an emphasis on managing chronic diseases such as diabetes and hypertension, and reducing unnecessary emergency department (ED) use and total cost of care. 
  • Care Integration: participants will strengthen their connections with specialty care clinicians while using evidence-based behavioral health screening and evaluation to improve patient care and coordination. 
  • Community Connection: participants will identify and address health-related social needs (HRSNs) and connect patients to community supports and services.

MCP model in Colorado involves three tracks with increasing skill sets

The MCP model is designed around three tracks that providers can choose from based on their current resources and experience in providing value-based care, according to CMS.

Track 1, “Building Infrastructure.” This is reserved for those with no experience in value-based care and will continue a fee-for-service model accompanied by federal financial support to lay the groundwork. Here participants will begin to develop the foundation for implementing advanced primary care services such as risk-stratifying their population, reviewing data, building out workflows, identifying staff for chronic disease management, and conducting health-related social needs screening and referral. Participants can begin earning financial rewards for improving patient health outcomes in this track.

Track 2, “Implementing Advanced Primary Care.” This will be a 50/50 blend of fee-for-service and prospective, population-based payment. It will also require partnering with social service providers and specialists and screening for behavioral health conditions. CMS will continue to provide additional financial support at a lower level than Track 1, as participants continue to build advanced care delivery capabilities. Participants will be able to earn increased financial rewards for improving patient health outcomes. 

Track 3, “Optimizing Care and Partnerships.” In this track participants will expand upon the requirements of Tracks 1 and 2 by using quality improvement frameworks to optimize and improve workflows, improve care integration, develop social services and specialty care partnerships, and deepen connections to community resources. Payment for primary care will shift to fully prospective, population-based payment while CMS will continue to provide additional financial support, at a lower level than Track 2, to sustain care delivery activities. Here participants will have the opportunity to earn greater financial rewards for improving patient health outcomes.

MCP aims to give providers and organizations flexibility, allowing them to choose their participation track and receive payments that reflect their experience with accountable care.

Attention will be given to health equity in Colorado

Regarding the health equity component of this new MCP concept, CMS says it believes that equitable care is crucial to achieving high-quality care for Medicare and Medicaid beneficiaries and is critical to MCP’s success. The agency says it defines health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes. The term ‘underserved communities’ refers to populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life.” DHCPF notes: “Access to high-quality primary care is associated with better health outcomes and equity for people and communities.”

MCP will require participants to develop a strategic plan for how they will identify disparities and reduce them. Participants will also be required to implement HRSN (health-related social needs) screening and referrals, which CMS will monitor and measure. CMS will also collect data on certain demographic information and HRSNs to evaluate health disparities in Colorado’s MCP communities.

DHCPF said in a news release that Colorado has a strong history in multi-payer alignment strategy and by investing in behavioral and medical care integration and other capabilities, primary care teams will be better equipped to address chronic disease, improve the health of Coloradans, and lessen the likelihood of avoidable emergency department visits and hospital stays.

“Colorado’s collaboration with CMS on the Making Care Primary model will boost Colorado’s current efforts to strengthen the state’s primary care infrastructure, especially for safety-net and smaller or independent primary care organizations,” DHCPF says on its website. “Strong relationships with primary care teams are essential for patients’ overall health. Primary care clinicians provide preventive services, help manage chronic conditions, and coordinate care with other clinicians. This ultimately improves patient satisfaction and patient health, while saving Coloradans and our employers money on health care. This model will also help improve health equity and reduce health disparities across Colorado.”