CMS Announces Medicare’s New Primary Care Reimbursement Initiative, “Comprehensive Primary Care Plus”

usa-dollar-bills-1431130-mCMS recently announced what it describes as the largest-ever multi-payer initiative to improve primary care in America,” known as Comprehensive Primary Care Plus (CPC+). Though much of the press release is couched in terms of improving patient care — and surely CPC+ is intended to do so — the real impetus appears to be the government’s critical need to control healthcare costs funded by federal programs.

Atlanta/Augusta, Georgia Physician Practice Lawyers

The idea is to support a new primary care delivery model that will incentivize and reward value and quality.  The current Administration’s goal is to have 50% of all Medicare fee-for-service payments made via alternative payment models by 2018.  The Center for Medicare and Medicaid Innovation, which exists pursuant to Section 1115A of the Social Security Act (added under the Affordable Care Act) for the purpose of testing new payment and service delivery models, developed CPC+ as part of its mission, to aid the federal government in its efforts to curb its healthcare costs and enhance the quality of healthcare delivery.

According to CMS, CPC+ will reward value and quality “by offering an innovative payment structure to support delivery of comprehensive primary care.”  The experiment will include two tracks with different primary care requirements and different payment models.  CPC+ has a five-year life that will begin next January.  The regions in which CPC+ will be tested have not yet been chosen by CMS; once the regions are known, physician practices eligible to participate may begin applying as early as July of this year.

CMS believes that the CPC+ 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.”  CMS has committed to provide physician practices with a “robust learning system” and “actionable patient-level cost and utilization data” to assist them in effectuating this payment model properly.  According to CMS, physicians who participate will be “expected to make changes in the way they deliver care” based upon the following primary care delivery factors: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement; and (5) planned care and population health.

The CPC+ payment model will provide prospective monthly care “management fees” known as “CMFs” that are tied to “beneficiary risk tiers.”  The Medicare CMFs will, on average, run about $15/beneficiary per month (“PBPM”) payable across four “risk tiers” in Track 1.  Track 2 will involve 5 risk tiers and an average $28 PBPM, including a $100 CMF payable to support care for patients with complex needs.  CPC+ will also include incentive payments to physician practices based on patient experience, clinical quality and utilization measures.  For Track 1, the incentive payment will be $2.50 PBPM and, for Track 2, $4 PBPM.  These incentive payments are paid in advance at the beginning of a year, and CMS will recoup payments where a practice does not meet its requirements for quality and utilization standards.

This Spring and early Summer, CMS will solicit payer proposals to be involved in CPC+.  Ultimately, CMS will select 20 regions within which this payment model experiment will be conducted.  CMS will then solicit applications from practices in the chosen regions.

Georgia Healthcare Law Firm

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*Disclaimer: Thoughts shared here do not constitute legal advice.

Source:  Centers for Medicare & Medicaid Services

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