Six years after President Obama’s health reforms became law, officials in his administration told POLITICO they are launching the largest-ever initiative to transform primary care in America, an effort to give doctors more flexibility and reward them for producing better results for their patients.

The experiment the administration will announce today, a program called Comprehensive Primary Care Plus, is intended to shake up the way 20,000 doctors and clinicians treat more than 25 million patients when it goes into effect in January 2017. In a sharp departure from the current “fee-for-service” system, which offers reimbursements per visit or procedure, providers who volunteer to participate will received fixed monthly fees for every patient and bonuses for meeting various quality goals. When their patients stay healthier and require less-expensive care, many primary care doctors will also share in the savings to Medicare, Medicaid or private insurers.

Most of the attention devoted to the Affordable Care Act has involved its coverage expansion for the uninsured and its new rules governing insurance, but its little-noticed changes to the actual delivery of care could be just as consequential in the long run. This new five-year primary care initiative would be its most ambitious delivery reform yet, designed to serve twice as many Americans as are now enrolled in the higher-profile Obamacare exchanges.

Health reformers of varied ideological stripes generally agree that the current fee-for-service system creates perverse incentives for providers, who get paid according to the quantity and volume of the treatments they provide rather than quality and value. Family doctors in particular complain that fee-for-service pressures turn their practices into assembly lines with mountains of paperwork at the end. The “cognitive medicine” that good primary care depends on—talking to patients, keeping in touch about what’s happening in their lives, figuring out their risk factors, nudging them in healthier directions—just isn’t as easy to bill as MRI’s or back surgeries.

The new initiative essentially offers participating practices a deal.

They will be required to give patients 24-hour access to care and information, and to meet various metrics for managing and coordinating care. Otherwise, though, they can treat their patients just about however they want, and their reimbursements will no longer depend as heavily (and in some cases not at all) on the protocols they follow or tests they administer. They will receive more money up front, and if they help keep their patients healthier, they can receive extra money on the back end.

“We’re trying to shift the incentives, to give physicians the freedom to meet the needs of their patients as they see fit,” said Dr. Patrick Conway, the chief medical officer at the Centers for Medicare and Medicaid Services. “In the future, we’d like to see better coordination of care and smarter spending of health care dollars.”

The initial rollout of Obamacare created an innovation center inside CMS with the power to launch experiments in delivery reform, and then to expand those experiments once they’re proven to improve quality and cut costs. The new program expands on a more modest Comprehensive Primary Care experiment already in progress, which offers practices a $20-per-patient-per-month care management fee as well as some bonuses for improving the health outcomes of their patients. Officials say it has produced significant quality improvements, including reduced hospitalizations, though its first two years of data suggest that it has not reduced overall costs.

Nevertheless, the administration is rolling out CPC-Plus as a separate and more radical experiment 10 times the size of CPC, hoping to launch shortly before President Obama leaves office. Participating practices will choose between two tracks—one similar to the original CPC, the other featuring a much sharper departure from fee-for-service. This summer, the administration will choose 20 states and regions that will be eligible for CPC-Plus, and will partner with private insurers so that the reforms will not just apply to government payments.

The new initiative may sound like a juicy target for Republicans who hate Obamacare, an obvious effort to double down on an unproven approach in the final days of Obama’s administration. But delivery reform has far more bipartisan support than Obama’s coverage expansion or insurance overhaul.

That’s especially true with primary care. People like their doctors, and their doctors don’t like the status quo. They don’t get reimbursed for calling or emailing patients, which helps explain why many rarely do. They don’t get paid much more for having a long chat with a patient than they get paid for a short chat. The hope is that the new incentives will encourage more talking, more emphasis on prevention and wellness and more telemedicine. It could also inspire staffing changes, encouraging practices to hire more nurses, behavioral health specialists and social workers to make daily calls and even home visits to the sickest patients.

“The good news is, just about everyone seems to be buying into this kind of reform. You don’t hear people defending the current system of primary care,” said Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative. “The bad news is, wow, it’s complex, and it’s hard to make these reforms work.”

The administration has already met its 2016 goal of moving 30 percent of Medicare payments into alternatives to fee-for-service, and it’s hoping for 50 percent by 2018. The innovation center has promoted better-coordinated approaches to diabetes care and joint replacements, as well as structural models like “accountable care organizations” that can share savings with taxpayers. It’s all based on the notion that providers should be paid not according to how many patients they see or how many tests they administer, but what value they provide.

Studies have shown that about a third of all healthcare is a waste of money; the joke in the medical world is that nobody knows which third. The “managed care” craze that flamed out in the late 1990s basically empowered HMOs to try to figure it out. In some ways, CPC-Plus uses a similar per-patient payment model, except the primary care doctor rather than the insurer will be responsible for managing the care.

“Primary care doctors are under so much pressure right now. They just want to be able to practice medicine,” says Dr. Meena Seshamani, director of the administration’s Office of Health Reform. “We’re saying, take care of your patients the way you think is most effective, and you’ll be rewarded for good outcomes.”

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