CMS Launches Comprehensive Primary Care Plus, Value-Based Model for Primary Care Practices, Multiple Insurers
Program gives practices up-front incentive payments the physicians will either keep or repay based on their performance on quality and utilization.
By Susan Morse
Dallas, TX | Posted April 19, 2016
The Centers for Medicare and Medicaid Services (CMS) on Monday launched a new risk-based primary care initiative that it hopes will accelerate the movement towards value-based reimbursement for medical practices.
The five-year, Comprehensive Primary Care Plus, or CPC+, starts in January 2017 and will include up to 5,000 practices and 20,000 physicians in an estimated 20 regions.
It pays participating physicians under two tracks.
Both give practices up-front incentive payments the physicians will either keep or repay based on their performance on quality and utilization metrics, CMS said.
Under one track, physicians will be able to deliver care outside of the traditional face-to-face office visit, CMS said.
For the initiative to work, Medicare is partnering with commercial and state health insurance plans. CMS is selecting regions for CPC+ where there is sufficient interest from multiple payers to support participation by area practices, CMS said.
CMS will enter into a Memorandum of Understanding with payers that aligns goals for payment, data sharing, and quality metrics.
Under Track 1, CMS will pay practices a monthly care management fee in addition to the fee-for-service payments under the Medicare Physician Fee Schedule.
Track 2 is a hybrid design that allows for greater flexibility in how practices deliver care outside of traditional office visits. This encourages doctors to focus on health outcomes rather than the volume of visits or tests, CMS said.
The hybrid model pays practices a monthly care management fee. However, instead of receiving the full Medicare fee-for-service payments for evaluation and management services, physicians will get reduced Medicare fee-for-service payments and up-front comprehensive primary care payments, CMS said.
Under Track 2, physicians will also provide more comprehensive services for patients with complex medical and behavioral health needs, including a systematic assessment of their psychosocial needs and an inventory of resources and supports, CMS said.
Vendors for Track 2 practices will sign a Memorandum of Understanding with CMS that outlines their commitment to supporting the enhancement of health IT capabilities. This is vital to the practices’ success and aligns with the Office of the National Coordinator for Health IT priority to ensure electronic health information is available.
CPC+ builds on a 2012 Comprehensive Primary Care Initiative.
“Strengthening primary care is critical to an effective healthcare system,” said Patrick Conway, CMS deputy administrator and chief medical officer. “By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists we can continue to build a healthcare system that results in healthier people and smarter spending of our healthcare dollars.”
The advanced primary care initiative has five key components: Services are accessible through enhanced in-person hours and 24/7 telephone or electronic access; high-risk patients receive proactive care management services to improve outcomes; comprehensive physical and mental care includes preventative services; care is coordinated, including specialty care and community services; and patients receive timely follow-up after emergency room or hospital visits.
CMS will accept payer proposals to partner in CPC+ through June 1.
CMS will accept practice applications in the determined regions from July 15 through September 1, 2016.
CMS’s goal, under the Affordable Care Act, is to move the health system from quantity of care to quality of care.
In March 2016, the agency estimated that it had met the goal – eleven months ahead of schedule – of tying 30 percent of Medicare payments to quality and value through alternative payment models by 2016. The Administration’s next goal is tying 50 percent of Medicare payments to alternative payment models by 2018.
|Measure||Track 1||Track 2|
|Measure||Track 1||Track 2|
|Health IT Vendor Partner||N/A||Practices must submit a letter of support from their health IT vendor(s) that outlines vendors’ commitment to supporting practices with advanced health IT capabilities.|
|Medicare Care Management Fee||Average Medicare care management fee of $15 per beneficiary per month.||Average Medicare care management fee of $28 per beneficiary per month, which includes a $100 care management fee for patients with the most complex needs.|
|Medicare Payment Structure||Practices will receive regular fee- for-service payments.||Practices will receive “Comprehensive Primary Care Payments (CPCP)” – a hybrid of Medicare fee-for-service and a percentage of their expected Evaluation & Management (E&M) reimbursements upfront in the form of a CPCP. Practices will receive a commensurate reduction in E&M fee-for-service payments for a percentage of claims.|
|Medicare Payment Structure||Practices will receive regular fee-for-service payments.||Practices will receive “Comprehensive Primary Care Payments (CPCP)” – a hybrid of Medicare fee-for-service and a percentage of their expected Evaluation & Management (E&M) reimbursements upfront in the form of a CPCP. Practices will receive a commensurate reduction in E&M fee-for-service payments for a percentage of claims.|
|Medicare Performance-Based Incentive Payment||Practices are eligible for a performance-based incentive payment of $2.50 per beneficiary per month. Incentive payments are prepaid at the beginning of a performance year, but practices may only keep these funds if quality and utilization performance thresholds are met.||Practices are eligible for a performance-based incentive payment of $4 per beneficiary per month. Incentive payments are prepaid at the beginning of a performance year, but practices may only keep these funds if quality and utilization performance thresholds are met.|
|Multi-payer Support||Practices must have support from multiple payers partnering in CPC+.||Payers must have support from multiple payers partnering in CPC+.|
|Practice Capabilities||Pathway for practices ready to build the capabilities to deliver comprehensive primary care.||Pathway for practices poised to increase the comprehensiveness of care through enhanced Health IT, improve care of patients with complex needs, and inventory of resources and supports to meet patients’ psychosocial needs.|