CMS Selects 14 Markets to Take Part in Primary Care Payment Model

CMS today announced 14 statewide or regional markets that will take part in its Comprehensive Primary Care Plus payment reform effort. Known as CPC+, the medical home initiative will let primary practices of all sizes take part in an overhaul of the way basic care is delivered, with the goal of improving care coordination, patient engagement and preventive care.

CPC+ is a piece of CMS’ current effort to improve rewards and create incentives for care coordination among those who deliver primary care. Several proposals in the 2017 Physician Fee Schedule seek to compensate practices that bring behavioral health and primary care under one roof, improve advanced care planning, and prevent diabetes.

According to a statement, CMS estimates that 5000 primary care practices could take part in CPC+, reaching 3.5 million people. The effort is based on a smaller demonstration known as CPC that reached 500 primary care practices. During a panel on population health held at the American Diabetes Association Scientific Sessions, an official from the Center for Medicare and Medicaid Innovation said the early results for that program were mixed, and CMMI was trying to figure out why it was working in some markets and not in others.

This spring, the New England Journal of Medicine published results from the first 2 years of CPC, which showed that practices were “transforming delivery” but not get creating savings for Medicare Part A or B after management fees.¹

For CPC+, markets were selected based on payer interest and coverage. Because CPC+ is a multi-payer model, Medicare, state Medicaid agencies, and commercial payers must work together to support primary care practices to make decisions that best meet patient needs. Practices in the markets announced today have until September 15, 2016, to apply. CPC+ starts in January 2017.

The statewide markets selected are: Arkansas, Colorado, Hawaii, Michigan, Montana, New Jersey, Oklahoma, Oregon, Rhode Island, and Tennessee. In addition, CMS selected the Greater Kansas City region, covering parts of Kansas and Missouri; the North Hudson-Capital region of New York State; Ohio and Northern Kentucky; and the Greater Philadelphia region in Pennsylvania.

CPC+ will operate on 2 separate tracks, with more complex cases getting their own track. In a statement, CMS said, “Payment redesign will offer the ability for greater cash flow and flexibility for primary care practices to deliver high quality, whole person, patient-centered care and lower use of services that drive total costs of care.”

Practices will be asked to make changes in 5 areas: (1) access and continuity, (2) care management, (3) comprehensiveness and coordination, (4) patient and caregiver engagement, and (5) planned care and population health.

Under the model, CMS will introduce care management fees, paid per beneficiary per month on a sliding scale, with Medicare payments averaging $15 for most patients depending on level of risk in the first track. Payments rise to an average of $28 for the second track, which is reserved for more complex cases such as dementia. “Practices may use this enhanced, non-visit based compensation to support augmented staffing and training to meet the model requirements,” based on the needs of the Medicare population attributed to the practice.

Other new payment features include a hybrid of old fee-for-service and newer models to support complex case management. The model allows some payment upfront to ensure good cash flow but calls for practices to boost the “depth and breadth” of care delivery. Also, the model includes performance-based incentives.

Horizon Blue Cross Blue Shield New Jersey, the largest payer in that state with 3.8 million enrollees, praised the “bold commitment” from CMS to push the envelope on value-based care. Horizon took part in the earlier demonstration known as CPC, that launched in 2012 and ends December 31, 2016.

“Through CPC and our own value-based efforts, Horizon has made tens of millions of dollars in value-based payments and other investments over the last 6 years to give primary care doctors and their care teams the tools to transform their practices,” said Allen Karp, Horizon’s senior vice president for Healthcare Management. “CPC+ will help infuse millions more in payer dollars so that additional practices can bring this improved care delivery approach to their patients.”

CMS will select the practices that take part in the 5-year project. It seeks practices of varying size and location, including some rural practices, which have been exempt from some value-based mandates.

Reference

Dale SB, Ghosh A, Peikes DN. Two-year costs and quality in the Comprehensive Primary Care intitiative. N Engl J Med. 2016; 374:2345-2356.