The Sweet Spot of Value-Based Care: Integrating Primary Care Models and ACOs

June 6, 2023

By Travis Broome and Sean Cavanaugh

Public and private health plans have been experimenting with a variety of new payment models to incentivize better care at lower cost. The Centers for Medicare & Medicaid Services (CMS) has set out a goal of accountable care for every traditional Medicare beneficiary by 2030. Many of these models either support advanced primary care or provide accountability for total cost of care and quality. Interestingly, as the evidence accumulates, it appears that the intersection of these two approaches may be the sweet spot for achieving high-value health care.  

The Center for Medicare and Medicaid Innovation (CMMI) has tested three primary care models: Comprehensive Primary Care (CPC), Comprehensive Primary Care Plus (CPC+) and Primary Care First (PCF). When CPC+ was first announced, CMMI considered prohibiting practices from participating in both the primary care model and the Medicare Shared Savings Program (MSSP). After discussions with stakeholders, however, CMMI made adjustments to ensure there would be no double payment of incentive bonuses and opened up the model to MSSP participants as well. Half (50%) of CPC+ practices chose dual MSSP and CPC+ participation. 

CPC+’s final year was 2021, and the most recent evaluation found that the model did not generate net savings to the Medicare program. However, the evaluation did note that CPC+ practices that were also in ACOs performed noticeably better than those that were not. The evaluators even speculated, "If Track 1 practices are able to generate even greater reductions in expenditures for services in PY 5, they could plausibly achieve cost savings – even after accounting for the enhanced payments – by the end of the model period.” This experience may have influenced the design of ACO REACH. 


These CPC+ findings are consistent with the Aledade experience. Aledade has collaborated in the MSSP with numerous practices that separately received CPC+ support. We found great success in the synergy of CPC+ and MSSP. All of our ACOs with joint participation generated savings on total cost of care, even though the enhanced payments counted as costs to the ACO. Not only did they generate savings, our ACOs with CPC+ practices at the core have some of the highest savings rates in all of Aledade. Each of them is projected to save more than 10% against its benchmark in 2022.  

Another model showing similar results is the Maryland Total Cost of Care Model. This model has multiple components, including a significant new investment in primary care known as the Maryland Primary Care Program (MDPCP) and accountability for total cost of care enforced through hospital global budgets across all payers. In 2021, over 500 primary care practices participated in the MDPCP. According to the CMMI evaluation, total Medicare spending in Maryland declined over the period 2019 to 2021, making it one of only a handful of CMMI models that has generated savings for Medicare.

CMMI has signaled that it will soon announce a new primary care model targeted, at least in part, at safety net practices. This would be consistent with CMS’ Strategic Plan, which calls for advancing equity by supporting providers who care for underserved communities. We support continued exploration of ways to better support all types of practices and organizations providing primary care. Underinvestment in primary care is one of the major failings of our health care system, and the evidence indicates that strong primary care is the foundation of successful accountable care models. And, as our health care system shifts from volume to value, these communities may need the most support to develop new capabilities for enhanced care management.  

Moreover, thanks to past and present CMMI models, we know that practices receiving enhanced primary care support are most likely to achieve better care at lower cost if they are also participating in MSSP. In the most recent Primary Care First (PCF) evaluation report, practices mentioned that the PCF model aligned with incentives from their Medicare Shared Savings ACO, Patient-Centered Medical Home (PCMH) or other value-based and quality initiatives. There are some misconceptions that some practices, especially safety net practices, are not ready to take accountability for total cost of care and thrive in value-based models. But, our experience shows that when safety net practices join networks, focus on prevention and wellness, and hold each other accountable for outcomes, they can succeed. 

The fourth highest performing MSSP ACO was an Aledade FQHC-only ACO in Mississippi with the community health center mission at its core. These health centers in historically under-resourced urban and rural areas of the poorest state in the country have shown that, with the proper support, they can provide high-value health care to their communities. And, the highest performing ACO in the entire MSSP was an Aledade ACO in Pennsylvania with a core of former CPC+ and current PCF practice locations.

These data points strongly suggest that the best version of value-based care lies in enhanced primary care investments coupled with accountability for total cost of care, rather than viewing these as two separate models. Innovating in the sweet spot of primary care investment and accountability creates the greatest opportunity for accomplishing CMS’ goal of having all beneficiaries in accountable care.