CMS to Launch Enhanced Comprehensive Primary Care Test Model

Added on Apr 21, 2016

CMS to Launch Enhanced Comprehensive Primary Care Test Model
From Industry Edge April 2016

The Centers for Medicare & Medicaid Services (CMS) recently announced plans for a multipayer primary care test program that will begin in 2017.

Called Comprehensive Primary Care Plus (CPC+), the five-year test will provide practices with up-front incentive payments to help doctors offer services for which they traditionally have not been compensated, such as more detailed care coordination and telemedicine.

Building on experiences of and lessons learned in the Comprehensive Primary Care (CPC) program—in which 500 primary care practices across the United States worked with CMS as well as private insurers and state health insurance plans to test comprehensive primary care—CPC+ is designed to provide doctors the freedom to care for their patients in ways they think will deliver the best outcomes and to pay them for achieving results and improving care, Dr. Patrick Conway, CMS chief medical officer, said during a press conference.

In the CPC program, practices received a non-visit-based care management fee per patient in addition to regular fee-for-service payments and an opportunity to share in any savings. The incentive fees have provided participating practices with funding to create new workflows, hire staff and develop new relationships necessary to coordinate care, according to Conway.

In the CPC+ program, payment for some of the additional services will be contingent on performance. If relevant quality and utilization metrics (e.g., medication adherence, readmissions and care coordination) do not meet a minimum standard, physicians may have to repay these up-front payments.

Participants in the CPC+ test will practice into one of two tracks. In Track 1, CMS will pay practices a monthly management fee in addition to the usual Medicare fee-for-service payments. In Track 2, which is designed for practices that have more experience in delivering advanced services, participants will get the monthly care management fee, but their Medicare fee-for-service payments will be reduced in lieu of up-front comprehensive primary care payments for evaluation and management claims.

To participate in CPC+, practices must do the following:

  • Provide patients with 24/7 access to physicians via enhanced office hours as well as telephone and electronic access
  • Provide highest-risk patients with proactive, personalized care management
  • Provide care that is comprehensive to meet most patients’ preventive care and physical and mental health needs, as well as improved care coordination across specialty and emergency care
  • Recognize patients and their family members as part of the care team and work with patients to determine the care that best meets their needs
  • Analyze quality and utilization data regularly, seeking improvement and developing new capabilities

The care management fee for those participating in Track 1 will average $15 per beneficiary per month across four risk tiers, according to a CMS fact sheet. Track 2 participants will receive an average of $28 per beneficiary per month across five risk tiers, the fifth being a $100 care management fee per beneficiary per month to support patients with the most complex needs.

The up-front incentive payments for meeting quality and utilization targets are $2.50 per beneficiary per month for Track 1 and $4 per beneficiary per month for Track 2, though some or all of these payments could have to be returned if targets are missed.

The test will cover up to 5,000 practices across up to 20 regions, encompassing more than 20,000 doctors and clinicians who serve 25 million patients.