Life Science Compliance Update

August 03, 2016

CMS Comprehensive Primary Care Plus Initiative CPC+

CMS wants to pay practices a monthly fee to manage care for as many as 25 million patients in the agency's largest-ever plan to transform and improve how primary care is delivered and reimbursed. The Comprehensive Primary Care Plus (CPC+) initiative will be implemented in up to 20 regions and include up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians. The program would collaborate with commercial, state, and other federal insurance plans. Since April 15, CMS has started to solicit payer proposals to partner in CPC. From there, CMS will solicit applications from nearby practices. This solicitation will take place between July 15 and Sept. 1, 2016.

Advanced APM and CMS

As we noted in our MACRA article on alternative payment models (APMs), CMS proposes this model is one of the six APMs of the twenty-four reviewed by CMS that met all of the criteria to be Advanced APMs.

CMS argues strengthening primary care is critical to promoting health and reducing overall health care costs in the United States. CPC+ builds on the foundation of the Comprehensive Primary Care (CPC) initiative, a model tested through the Center for Medicare & Medicaid Innovation that runs from October 2012 through December 31, 2016. CPC+ integrates many lessons learned from CPC, including insights on practice readiness, the progression of care delivery redesign, actionable performance-based incentives, necessary health information technology, and claims data sharing with practices.

CPC+ will bring together CMS, commercial insurance plans, and State Medicaid agencies to provide the financial support necessary for practices to make fundamental changes in their care delivery. CMS will enter into a Memorandum of Understanding (MOU) with selected payer partners to document a shared commitment to align on payment, data sharing, and quality metrics throughout the five year initiative.


Provider practices will be able to participate in two ways. In Track 1, the agency will pay a monthly fee to practices that provide specific services. That fee is in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for care. Physicians who participate in Track 1 of the program will be reimbursed on a fee-for-service basis. Track 1 participants also will receive monthly payments for managing each patient's care that average $15 per beneficiary. Payments will be higher for beneficiaries with complex conditions.

Physicians who participate in Track 2 of the program will receive a combination of upfront comprehensive primary care payments (CPCPs), based on the expected costs of care management, and reduced fee-for-service payments. In addition, Track 2 participants will receive a monthly care management payment averaging $28 per beneficiary, including a $100 payment for managing the care of patients with complex conditions

However, one major question is how many private payers will sign up to participate. To date, the Comprehensive Primary Care Initiative has not shown improvements in care quality or savings sufficient to cover care management fees to providers. Given the similarities and differences between CPC+ and CPCI, it will be interesting to see if payers will have strong enough incentives to participate, which in turn will be an important factor in practices' decisions to apply for the new program.

It is also worth noting that CPC+ is not as focused on paying for outcomes as many other CMS alternative payment model programs, such as MSSP. Under that program, clinicians are rewarded based on how much money they save Medicare. The CPC+ program takes a different approach: It tries to reduce Medicare spending by investing in care redesign upfront and essentially believing in the care models that providers are committing to pursue.

CPC+ payments will be prospective and consistent, including monthly care management fees and the upfront potential performance bonus. At the end of the year, they can lose some of the performance bonus if they don't hit their goals. But the majority of dollars are guaranteed, which is an investment that CMS is making for providers to transform care, independent of whether those efforts save money down the road.

The Center for Medicare and Medicaid Innovation estimates that a practice participating in Track 1 of CPC+ that is similar in size to the average practice participating in CPCI will receive $126,000 annually plus performance payments of $21,000. For Track 2 the figures are $235,200 and $33,600 respectively.


Mark Hagland, the Editor-In-Chief at Healthcare Informatics writes in a recent article: "I read all this with real excitement. First of all, this program is exciting in and of itself. It provides for the kind of support—both with regard to reimbursement incentives, and also in terms of providing practical supports for physician practices to engage in serious care management—that will give an additional push that will help finally convince many doctors who have not yet done so, to move forward at last into chronic care management.

Beyond that, CMS officials' announcement of this program is yet further evidence—if anyone needed it—that those officials are, as they say, putting their money with their collective mouth is—in terms of pushing every policy and reimbursement lever they can, to push patient care organizations, and practicing physicians in particular, forward into care management, population health management, and new payment models. Along with the details of the MIPS (Merit-based Incentive Payment System), changes to the major accountable care organization (ACO) programs under Medicare, and other programs, this new one fills in one more area in which providers have needed help moving forward into the new healthcare."

However, there are concerns. One is the lack of incentives for primary care physicians to take steps to reduce costs for services beyond those delivered by their practices. These include referring their patients to efficient specialists and hospitals, as well as limiting hospital admissions. There are rewards in CPC+ for lower overall utilization by attributed beneficiaries and higher quality, but they are very small.

The American College of Physicians' statement on the program was interesting because of its positive, yet cautionary note. ACP says it strongly supports the goal of ensuring that practices in each track will be able to build capabilities and care processes to deliver better care, which will result in a healthier patient population. It agrees with the need for payment redesign that offers the ability for greater cash flow and flexibility for primary care practices to deliver high quality, whole-person, patient-centered care and lower the use of unnecessary services that drive total costs of care.

ACP also supports the critical importance of obtaining commitments from other (non-Medicare) payers to join with Medicare to support CPC+ practices. Additionally, ACP is encouraged that CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data, to guide their decision making.

Yet ACP's statement concluded with a cautionary note: "The success of the Comprehensive Primary Care Plus program will depend on Medicare and other payers providing physicians and their practices with the sustained financial support needed for them to meet the goal of providing comprehensive, high value, accessible, and patient-centered care, with realistic and achievable ways to assess each practices' impact on patient care."

July 26, 2016

CMS Hosting Special Open Door Forum on Open Payments and the 2017 Physician Fee Schedule

On August 2, 2016, at 1:30 pm EST, the Centers for Medicare & Medicaid Services (CMS) Open Payments Program will host a "Special Open Door Forum" to receive live feedback from stakeholders on the solicitation to inform future rulemaking in the proposed 2017 Physician Fee Schedule.

CMS is soliciting feedback from Open Payments stakeholders on expanding and clarifying Open Payments program requirements and is not currently under no statutory deadlines or implementation schedules that require CMS to make any changes to the current rule. However, CMS does believe stakeholder feedback is important as they continue to move forward in enhancing their system and refining their reporting requirements.

To aid stakeholders, CMS has already provided quite a lengthy list of topics on which it would like to receive comments, a summary of the proposed schedule and requested input can be found here. CMS also published a slide show of questions they will be discussing, which can be found here.

Some requested input focuses on reporting on past years:

Other requested input involves pre-vetting:

And still other input requested focuses on ownership and investment interests:

This forum and effort to receive comments is separate from the third reporting cycle, which published data on June 30, 2016. Further, this solicitation will not impact any future reporting requirements without additional rulemaking or public notice.

If you are interested in attending, you can dial in to 1 (800) 837-1935 and use Conference ID# 44678813. If you cannot attend but are still interested in submitting comments, you may submit them to by September 6, 2016.

A transcript and audio recording of this Special ODF will be posted to the Special Open Door Forum website at for downloading.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions please visit our website at

July 25, 2016

CMS Reports $42 Billion Saved in Medicare and Medicaid

On July 20, 2016, CMS released a report that showed investments that are made in program integrity activities – such as stamping out fraud and reducing and deterring other improper payments – pay off for taxpayers and beneficiaries alike. For Fiscal Years (FY) 2013 and 2014, every dollar that was invested in CMS' Medicare program integrity efforts saved $12.40 for the Medicare program. With savings per dollar like that, Medicare and Medicaid programs have saved billions of dollars in that two-year period alone.     

The report highlights CMS' significant achievements in reducing potentially fraudulent and improper payments. CMS achieved almost $42 billion in cost savings over the aforementioned two-year period by using a multifaceted approach, ranging from provider enrollment and screening standards, to use of enforcement authorities, to use of advanced analytics, such as predictive modeling.

According to Shantanu Agrawal, M.D., Deputy Administrator and Director of the Center for Program Integrity,

CMS is dedicated to promoting better care, protecting patient safety, reducing health care costs, and providing people with access to the right care, when and where they need it.  This includes continually strengthening and improving Medicare and Medicaid programs that provide vital services to millions of Americans.  We take our responsibility to deliver better care at a better value seriously.

In collaboration with the DOJ, HHS recently announced the largest healthcare fraud takedown in its history. In that case, HHS helped to charge 301 individuals, including 61 physicians and licensed medical professionals, with allegedly participating in healthcare fraud activities, totaling $900 million in false medical billing. A large portion of the individuals charged were involved in home healthcare, psychotherapy, physical and occupational therapy, durable medical equipment services, and prescription drug services.

CMS' efforts to proactively prevent potentially fraudulent and improper payments from being made have been increasingly effective, moving efforts away from the "pay-and-chase" method of recovering payments after they had already been made. In fiscal year 2013, savings from prevention activities represented about 68 percent of total savings. In fiscal year 2014, the portion of savings from preventing potentially fraudulent and improper payments rose to nearly 74 percent. This development means that more taxpayer dollars intended to care for the beneficiaries are not being paid at all, avoiding the need to recover improperly paid amounts from health care providers and suppliers. Preliminary information from FY 2015 indicates that CMS's program integrity efforts continue to accrue savings of this magnitude and that the portion attributed to prevention continues to increase. CMS is set to release FY 2015 numbers later this year.

According to Dr. Agrawal, CMS remains committed to implementing a robust program integrity strategy to protect beneficiaries from harm and further safeguard taxpayer funds by paying only for appropriate health care items and services. CMS tries to continuously evaluate and update its program integrity strategy. They often welcome input from beneficiaries, providers, suppliers, and others to inform possible future enhancements to the program integrity strategy. CMS encourages stakeholders to reach out to CMS at 1-800-MEDICARE (1-800-633-4227) or TTY: 877-486-2048 with your thoughts or to report potentially improper billing.


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