CPC+ Breaks the Traditional Medicare-only CMS Value-based Payment Mold and Pays Up Front

The CMS Center for Medicare and Medicaid Innovation (CMMI) has spent the last six years testing out a variety of models for value-based care and payment--the Medicare Shared Savings Program (MSSP) and other ACO models, the Bundled Payments for Care Improvement (BPCI) Initiative, the Comprehensive Care for Joint Replacement Model, and various Medicaid and CHIP initiatives. As the Administration doubles down on its commitment to shift payments away from fee-for-service (FFS), it continues to innovate, building programs to align incentives to person-centered, comprehensive, high quality health care. In that vein, in July of this year, CMS will begin taking applications from practices for participation in a new CMMI program: the CPC+ program.

CPC+ is based on the current CPC model, which is being implemented in 500 primary care practices across the country. The original program will come to an end on December 2016. During its course, CPC generated gross savings, was nearly cost neutral, and achieved positive quality results. The new CPC+ is a 5-year model, set to begin in January 2017, and will build on the successes of CPC, but will add a few new twists. The purpose of both the new program and its predecessor is to tie payment for Medicare services to quality and value, which aligns with the Administration's stated goal of having 50% of all Medicare FFS payments made via alternative payment models by 2018. Specifically, however, the program has three primary goals:

1. Advance care delivery and payment to allow practices to provide more comprehensive care that meets the needs of all patients, particularly those with complex needs

2. Accommodate practices at different levels of transformation readiness through two program tracks, both offered in every region

3. Achieve Delivery System Reform core objectives (“Triple Aim”) of better care, smarter spending, and healthier people in primary care

CPC+ is a Multi-payer Model

Unlike other CMMI models, such as the Medicare Shared Savings Program (MSSP), CPC+ is NOT a Medicare-only program. It does require a minimum of 100 Medicare beneficiaries per practice, but it also requires that its provider participants have access to multiple participating payers. This includes commercial plans, Medicare Advantage plans, Medicaid/CHIP FFS and managed care, Medicare FFS, self-insured groups (TPA/ASO), and public employee plans. Public and private payers will be expected to cooperate with each other and their affiliated practices to align quality metrics, assess practice readiness, provide actionable data and performance-based incentives to practices, and share best practices through a CPC+ learning system.

CPC+ has Two Program Tracks

A key threshold for eligibility for CPC+ is a demonstration by practices of a plan for care transformation. CMMI has acknowledged, however, that primary care providers are at various stages of readiness for the kind of comprehensive patient-centered care delivery reforms that the shift from volume to value requires. For this reason, CMMI created two tracks for the CPC+ program--one for “early stage” practices, and one for practices that have already implemented care delivery transformation plans. The program will accept 2,500 practice in each of the two tracks. The amount of up-front payments to practices differ to which track a practice chooses to pursue. In general, however, there are 3 primary components of the payment model:

1. Comprehensive Primary Care Payment (CPCP). This payment, available only to Track 2 practices, is an up-front (pre claim submission) payment called a CPCP. The CPCP is a portion of the fee-for-service amount for any particular service, that is paid in advance to participating Track 2 practices. After the claim is submitted, the practice would receive the remainder of the fee-for service amount. Notably, the CPCP actually increases the total FFS reimbursement by about 10%.

2. Monthly Care Management Fee (“CMF”). This payment, for both Track 1 and 2 practices, is a prospective non-visit-based per attributed beneficiary per month (PBPM) fee made to practices, based on beneficiary risk tiers. A sample chart of CMFs can be found here on Page 6.

3. Performance-Based Incentive Payment. CMS and other commercial payers will pay practices performance-based incentives based on patient experience, clinical quality, and utilization measures. (Note: To demonstrate eligibility for the performance-based incentives, practices must annually report CAHPS and electronic clinical quality measures (eCQMs) to CMS.) To improve cash flow, these payments will be made prospectively, but may be clawed back if practices fail to demonstrate quality and utilization performance.

This payment structure is meant to ease the financial burden of care transformation (including investments in staffing, training, and health IT) on practices. Only the incentive payments may be clawed back. Track 1 practices can expect an average CMF of $15, and eligibility for a performance-based incentive payment of $2.50 per beneficiary per month (prepaid at the beginning of performance year) in addition to the FFS amount for each service. Track 2 practices can expect an average CMF of $28 PBPM, a CPCP (hybrid FFS payment), and will be eligible for a performance-based incentive payment of $4 per beneficiary per month.

Note: The Care Management Fee is assigned based on the beneficiary risk tier. In Track 1, there are 4 risk tiers, the highest representing a $30 per patient per month CMF. In Track 2, there are 5 risk tiers, the highest representing a $100 CMF.

Is My Practice Eligible for CPC+?

Both Track 1 and Track 2 practices must be able to communicate a plan to deliver comprehensive primary care to their patients, within each of the 5 “Corridors of Action”, described below. Track 2 practices must also commit to (1) increase the comprehensiveness of care through “enhanced health IT,” (2) improve care of patients with complex needs, and (3) build an inventory of resources and supports to meet patients' psychosocial needs. Eligibility for both Track 1 and Track 2 require a practice have a minimum of 100 Medicare beneficiaries. A high level overview of additional eligibility criteria is described below:

TRACK ONE

1. Submission of practice structure and ownership information;

2. Use of CEHRT;

3. Multi-payer interest and coverage;

4. Existing care delivery activities must include: assigning patients to provider panel, providing 24/7 access for patients, and supporting quality improvement activities.

TRACK TWO

1. Submission of practice structure and ownership information;

2. Use of CEHRT;

3. Multi-payer interest and coverage;

4. Existing care delivery activities must include: assigning patients to provider panel, providing 24/7 access for patients, and supporting quality improvement activities, while also developing and recording care plans, following up with patients after emergency department (ED) or hospital discharge, and implementing a process to link patients to community based resources.

5. Letter of support from health IT vendor that outlines the vendor’s commitment to support the practice in optimizing health IT.

In addition, to participate, practices must reimagine how they deliver primary care, specifically around the following "Comprehensive Primary Care Functions":

1. Access and Continuity;

2. Care Management;

3. Comprehensiveness and Coordination;

4. Patient and Caregiver Engagement;

5. Planned Care and Population Health.

These are the 5 “Corridors of Action”, and are detailed in the next section.

Note: Practices CANNOT be in both an ACO and CPC+ at the same time, but primary care practices currently participating in an ACO can terminate their ACO participation if they are accepted into CPC+.

The 5 "Corridors of Action"

As noted above, CMS requires that practices demonstrate a plan to provide comprehensive primary care. To do so, practices should have a plan to implement practices in 5 separate functions or "corridors of action" that CMS believes are necessary to deliver comprehensive primary care. The specific activities required in each corridor differs according to whether a practice is in Track 1 or Track 2.

Access and continuity

For Track 1 Practices: 24/7 access, assigned care teams

For Track 2 Practices: eVisits, expanded office hours

Care management

For Track 1 Practices: Risk stratification of patient population, short and long term care management

For Track 2 Practices: Care plans for high risk chronic disease patients

Comprehensiveness and Coordination

For Track 1 Practices: Following up after patient ER visit or hospital discharge

For Track 2 Practices: Behavioral health integration, psychosocial needs assessment and inventory resource and supports

Planned care and population health

For Track 1 Practices: Analysis of payer reports to inform improvement strategy

For Track 2 Practices: At least weekly care team review of all population health data

Patient and Caregiver Engagement

For Track 1 Practices: Convene a patient and family advisory council

For Track 2 Practices: Support patients’ self-management of high risk conditions).

How do I Apply for CPC+?

CMS will begin accepting provider applications on July 15, 2016 and will eventually accept up to 5,000 practices in up to 20 geographic regions across the U.S. Payer solicitation and practice applications will be a staggered process. First, CMS will solicit payer proposals to partner with Medicare in CPC+ (April 15-June 1, 2016). The choice of up to 20 CPC+ regions will be informed by the geographic reach of selected payers, with preferential consideration given to regions already participating in CPC. Currently participating regions include: (1) Arkansas: Statewide; (2) Colorado: Statewide; (3) New Jersey: Statewide; (4) New York: Capital District-Hudson Valley Region; (5) Ohio & Kentucky: Cincinnati-Dayton Region; (6) Oklahoma: Greater Tulsa Region; and (7) Oregon: Statewide.

After CMS has selected the CPC+ regions, CMS will begin to accept applications from practices. A “practice” can be any primary care practice site location with a TIN and NPI. Specialists and subspecialists are not eligible to participate. The current application period is July 15 to September 1, 2016. For practices interested in Track 2, both the application and a letter of support from the practice’s Health IT vendor is required. Accepted practices will be announced in October 2016.

For more information, or if you are interested in applying for the Comprehensive Primary Care Plus (CPC+) program, contact rebecca.gwilt@nixonlawgroup.com or carrie.nixon@nixonlawgroup.com. We will be happy to give you a free consultation to discuss your practice and plans.