CPC+ - The Good, The Bad and The Ugly

Updated: Nov 5, 2018

What is CPC+?

Comprehensive Primary Care Plus- is a new initiative driven by the Centers for Medicare and Medicaid Services (CMS) to create a new care delivery and payment model that aims to strengthen primary care through a regionally-based multi-payer payment reform and care delivery transformation program.

The CPC+ care delivery and payment model includes two separate tracks.

For Track One participants, CMS will pay a risk-stratified monthly service fee to pay for care management services for each beneficiary. This per beneficiary per month (PBPM) payment will be made in addition to standard fee for service payments for primary care visits.

For Track Two participants, participating practices will receive reduced fee-for-service payments but will receive larger upfront care management payments PBPM.

The program requirements ensure 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. 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 the use of unnecessary services that drive total costs of care. CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data, to guide their decision making.

As contrasted with shared savings, providers under CPC+ may have to return incentive payments if cost and quality targets are not met. Practices who are currently part of a Medicare shared savings program may apply for CPC+, but if accepted they will forego their shared savings program incentive opportunity. It is not possible to simultaneously be a member of a shared savings program and CPC+, a choice must be made.

CMS is reporting that the savings opportunity could be close to $2B over the five year program.

Who does it impact?

The primary stakeholders and constituents most impacted by this program include:

  1. Payers- Medicare, Commercial Payers, State Medicaid Agencies,

  2. Primary Care Physicians and Practices

  3. HIT Vendors

Multi-Payer Partnership CPC+ will bring together Medicare and other payers, including commercial insurance plans and state Medicaid agencies, in up to 20 regions, to provide the necessary financial support for practices to make significant 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.

Primary Care Practices Eligible practices in up to 20 regions around the country may apply for participation in one of two tracks. CPC+ will accommodate up to 2,500 practices in each track for a total of 5,000 practices across all regions and encompass approximately 20,000 clinicians and 25 million patients.

CPC+ targets primary care practices with varying capabilities to deliver comprehensive primary care. In order to participate, all CPC+ practices must demonstrate multi-payer support, use Certified EHR Technology (CEHRT), and demonstrate other capabilities. Track 1 practices will work for five years to develop more fully the capabilities necessary to deliver comprehensive primary care. Track 2 practices must demonstrate Track 1 clinical capabilities and commitment to enhanced health IT when they apply, and commit to increasing the depth, breadth, and scope of care offered, with particular focus on patients with complex needs.

Health Information Technology (Health IT) Vendors Comprehensive primary care requires efficient, advanced health IT to support its population-health focus and team-based structure. Practices in both tracks will be required to use certified EHR technology, and will be expected to report electronic clinical quality measures at the practice-level. We also expect Track 2 practices to work with vendors to develop and optimize a set of health IT functions that work for their practices. Health IT vendors will memorialize their commitment to support Track 2 practices in a Memorandum of Understanding (MOU) with CMS.

How Will It Work?

Step 1: Payer solicitation. 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.

Step 2: Provider Applications. CMS will publicize the CPC+ regions, and solicit applications from practices within these regions (July 15-September 1, 2016). Practices will apply directly to the track for which they believe they are ready; however, CMS reserves the right to offer practice entrance into Track 1 if they apply to, but do not meet the eligibility requirements for Track 2.

Practices applying to Track 2 will need to submit a letter of support from their Health IT vendor(s) that outlines vendors’ commitment to supporting the practice with advanced health IT capabilities. CMS will sign a Memorandum of Understanding with those health IT vendors supporting Track 2 practices selected to participate in CPC+.

Step 3: Providers selected and announced in October 2016

Step 4: ACTION!

If the plan stays as is, beginning in January of 2017 the following actions will take effect:

Care Management Fee

CMS and other payers will provide prospective monthly care management fees (CMFs) to Track 1 and 2 practices based on beneficiary risk tiers. Medicare CMFs will average $15 per-beneficiary per-month (PBPM) across 4 risk tiers in Track 1. In Track 2, the Medicare CMFs will average $28 PBPM across 5 risk tiers, which includes a $100 CMF to support care for patients with the most complex needs. Practices may use this enhanced, non-visit-based compensation to support augmented staffing and training needed to meet the model requirements according to the needs of their Medicare attributed patient population.

Comprehensive Primary Care Payments Track 1 practices will continue to receive Medicare fee-for-service payments. In Track 2 of CPC+, CMS is introducing a hybrid of Medicare fee-for-service payments and the “Comprehensive Primary Care Payment” (CPCP). The CPCP changes the cash flow mechanism for Track 2 practices, promotes flexibility in how practices deliver care that is traditionally provided face-to-face, and requires practices to increase the depth and breadth of primary care they deliver. For attributed Medicare beneficiaries, Track 2 practices will receive a percentage of their expected Medicare reimbursement for Evaluation & Management (E&M) claims payment upfront in the form of a CPCP and reduced Medicare reimbursement amounts for E&M claims.

Performance-Based Incentive Payment CPC+ will reward practices based on their performance on patient experience, clinical quality, and utilization measures through performance-based incentive payments. The CPC+ incentive payments will be $2.50 PBPM for Track 1 and $4 PBPM for Track 2, based on practice performance on utilization metrics and quality, measured at the practice level. Performance-based incentive payments will be prepaid at the beginning of a performance year, but CMS will recoup all or a portion of payments made to the practices if they do not meet thresholds for quality and utilization performance.

What are the IT factors?

Participating physician practices and health IT vendors will need to work together to create technical solutions to address risk stratification of identified patients. Specifically, the six key Health IT Capabilities that will be expected in CPC+ Track 2 are:

  1. Risk Stratify the practice site patient population

  2. Screen for social and community support needs and link the identified need(s) to practice identified resources

  3. Empanel patients to the practice site care team

  4. Produce and display eCQM results at the practice level to support continuous feedback

  5. Establish patient focused care plans to guide care management

  6. Document and track patient reported outcomes

Optional: Practice site care delivery and care touch documentation

Why are we doing this?

The goal of CPC+ is to improve the quality of care patients receive, improve patients’ health, and spend health care dollars more wisely. Practices in both tracks will make changes in the way they deliver care, centered on key Comprehensive Primary Care Functions: (1) Access and Continuity; (2) Care Management; (3) Comprehensiveness and Coordination; (4) Patient and Caregiver Engagement; and (5) Planned Care and Population Health.

For additional information on CPC+, feel free to contact us at info@ellisandadams.com