CMS Announces New Alternative Payment Model for Primary Care Providers

On April 11 the Center for Medicare and Medicaid Innovation announced the launch of its largest investment in advanced primary care to date: the Comprehensive Primary Care Plus (CPC+) model. 

Back in 2012, the Center for Medicare and Medicaid Innovation (CMMI) launched the Comprehensive Primary Care Initiative (CPCI), joining with 38 payers to support 500 practices across 7 regions in transforming primary care.  With CPCI scheduled to end later this year, CMMI on April 11 announced the launch of its largest investment in advanced primary care to date: the Comprehensive Primary Care Plus (CPC+) model.

Application Process:

CPC+ is set to commence on January 1, 2017, and continue for five years.  To implement the program, CMMI is seeking commercial health plans and State Medicaid programs to participate.  Eligible payers must be willing to utilize a similar payment model (discussed below), align quality measures, and provide claims data to participating practices.  Interested payers must submit a proposal to CMMI by June 1, 2016.

CMMI then will select up to 20 regions to participate in CPC+ based on levels of payer participation.  Practices in these regions will have until September 15 to submit an application.  CMMI intends to have up to 5,000 CPC+ practices, ten times the number of participants in CPCI.  

Selected practices will use defined, stepwise requirements to develop the capacity to provide five comprehensive primary care functions: (1) access and continuity, (2) risk-stratified care management, (3) planned care for chronic conditions and preventive care, (4) patient and caregiver engagement, and (5) comprehensiveness and coordination of care.

Track 2 Option:

For practices experienced in delivering advanced primary care, CPC+ offers a Track 2 option.  CMMI anticipates one-half of the 5,000 selected practices will participate in this track.  These practices will focus on patients with complex needs, including psychosocial needs.   

A practice applying to Track 2 must submit a letter of support from its health IT vendor stating the vendor’s commitment to ensuring the practice maintains required health IT capabilities.  CMMI intends to convene health information technology vendors supporting Track 2 practices to ensure access to tools necessary to meet the model’s requirements.   

Monthly Care Management Fee:

To support their practice transformation initiatives, all CPC+ practices will receive monthly care management fees paid per attributed Medicare beneficiary from CMS and per attributed member from payer partners. For Track 1 practices, CMS will pay an average of $15 PBPM across four risk tiers – comparable to the PBPM amount CPCI practices now receive - while Track 2 practices will average $28 PBPM across four risk tiers.  For highly-complex patients assigned to a fifth tier, these practices will receive $100 PBPM.   

Pre-Paid Incentives:

While CPCI practices are eligible for shared savings in addition to the PBPM payments, CPC+ instead provides practices in both tracks with pre-paid incentives that must be refunded if a practice fails to meet specified scores on quality and utilization measures.  For Track 1 practices, the incentive payment will be $2.50 PBPM, while Track 2 practices will receive $4.00 PBPM.  According to CMMI, these pre-paid at-risk performance payments capitalizes on the behavioral economics theory of loss aversion, thereby heightening practices’ focus on the selected measures.

By way of illustration, a primary care practice with 500 attributed Medicare beneficiaries participating in Track 1 would realize $105,500 in additional payments (with $15,000 at risk), while the same group participating in Track 2 would realize $192,000 (with $24,000 at risk) even without any fifth tier patients.  In addition, the practice would receive similar payments from participating commercial health plans and State Medicaid programs in its region.

Track 2 Hybrid E/M Payments:

In addition to higher PBPMs and pre-paid incentive payments, Track 2 practices also will receive a hybrid payment that blends fee-for-service and global payment for evaluation and management services.  Specifically, a practice will receive an up-front payment of a portion of its expected E/M claims on a per capita basis, with actual claims for these services paid at a commensurately reduced rate.

CMMI officials offer the following explanation for this split E/M payment: 

As the ratio of the hybrid payment is titrated up during the model, the reduced payment for billed evaluation and management services will pay practices for the marginal cost of an office visit, making practices “incentive neutral” to the mode of care delivery and allowing them the flexibility to deliver care in the manner that best meets patients’ needs—without being tethered to the 20-minute office visit.  Practices might offer non–face-to-face visits (e.g., electronic or telephone), offer visits in alternate locations, or simply provide longer office visits for patients with complex needs.

Qualifying Alternative Payment Model?

Aside from the care management fees and incentive payments, it seems likely CPC+ will meet the definition of “qualifying alternative payment model” under the soon-to-be-launched Medicare Merit-Based Incentive Payment System (MIPS).  (More information on the advantages of participation in a qualifying APM is available here.)  However, there is no official word from CMMI at this time on whether CPC+ participation will meet this standard; hopefully, this will be resolved prior to the application deadline.     

Impact on Medicare Shared Savings Program?

A CPC+ practice is not eligible to participate in the Medicare Shared Savings Program (MSSP). This likely will create a challenge for provider networks now participating in MSSP as accountable care organizations (ACOs) or contemplating application to the program for 2017.  Because Medicare beneficiaries are attributed to an ACO based on primary care relationships, ACOs that cannot attract or maintain sufficient levels of participation by primary care physicians may no longer qualify for the MSSP.

Provider networks have relied on the promise of future shared savings to convince primary care physicians to participate in their ACOs.  Now, with the offer of a bird in the hand – monthly care management fees and pre-paid incentives – many of these physicians may elect to pursue CPC+ instead of betting on future shared savings through an MSSP ACO.

The timing may prove particularly challenging, as applications for the MSSP (for both new and renewing ACOs) are due July 31, but a practice will not know if it is in a CPC+  eligible region until late June or early July.  Both ACOs and primary care practices will need to consider carefully the impact of CPC+ on MSSP application and continued participation.  And provider networks should identify and articulate the unique value they can offer to primary care physicians as compared to CPC+. 

Summary:

For ease of reference, CMMI has published the following chart comparing CPCI and CPC+ (both Tracks 1 and 2): 

CMMI has scheduled a series of webinars to introduce providers, payers, and health IT vendors to CPC+.  We will keep you apprised of the latest developments regarding this new primary care alternative payment model.  

Martie Ross, Principal with PYA Consulting