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."