CMS Escalates Primary Care Reform

CMS is looking for payers willing to align their payment structures, quality metrics, and data sharing with those of Medicare to meet the goals of its two-track successor to the Comprehensive Primary Care initiative.

Federal officials are intensifying their efforts to promote and lead transformational change at primary care practices across the country.

Four years ago, the Centers for Medicare & Medicaid Services launched the agency's first national primary care reform program, the Comprehensive Primary Care (CPC) initiative, which is set to end in December. Last week, CMS announced a two-track successor to CPC, Comprehensive Primary Care Plus (CPC+).

On April 14, CMS conducted a webinar to introduce CPC+ to the program's key stakeholders: physician practices, payers and healthcare information technology vendors. Laura Sessums, MD, the CMS Division of Advanced Primary Care director, led the webinar.

"We know practices around the country have varying levels of experience and readiness to jump into the care delivery redesign that we envision; hence, we offer two tracks with different eligibility and care delivery redesign requirements," Sessums said to kick off the webinar.

As of October 2015, more than 400 primary care practices were participating in CPC, which has seven "regions" encompassing eight states: Arkansas, Colorado, New Jersey, New York, Ohio and Kentucky, Oklahoma, and Oregon.

When CPC+ launches its five-year span in January 2017, there will be as many as 2,500 primary care practices in each of the two tracks of the program across 20 regions, Sessums said. The regions will be selected by June 30 on the basis of payers who are willing to participate in the program, she said.

"CPC+ will be a multi-payer model to ensure practices have sufficient financial resources from the majority of payers who insure the patients they serve to support the staffing and other resources required to deliver the care we expect in CPC+," Sessums said.

Achieving alignment between Medicare, Medicaid and commercial payers has been essential for primary care practices to achieve success in the CPC initiative.

For CPC+, Medicare is "looking for payers willing to align their payment structures, quality metrics and data sharing with those of Medicare to meet the goals of CPC+," Sessums said.  

Payment alignment, is sought in the three features of CPC+ payment, she said:

• A care management fee.
• For Track 2 only, at least a partial alternative to fee-for-service that can help practices deliver clinical care more efficiently and in a more patient-centered manner that does not necessarily require an office visit.
• An incentive payment based on performance outcomes for each track.

The payment model for Track 1 of CPC+ is relatively simple compared to Track 2:

• For Medicare beneficiaries, there will be a per beneficiary per month (PBPM) care management fee ranging from $6 to $30. The care management fee will be based on a four-tier risk-stratification scale tied to Medicare's Hierarchical Condition Category (HCC) model.
• Standard Medicare fee-for-service payments.
• A Medicare performance-based payment incentive pegged at $2.50 PBPM will be paid to primary care practices at the beginning of a CPC+ performance year. Medicare could claw back this payment incentive if practices fail to meet quality and utilization performance thresholds.

The payment model for Track 2 is potentially more lucrative for participating primary care practices:

• For Medicare beneficiaries, there will be a PBPM care management fee based on a five-tier risk-stratification scale. The lowest four tiers mirror the risk-stratification scale for Track 1, with fees ranging from $9 to $33. In the fifth tier, Medicare will pay a $100 PBPM fee to practices for complex patients such as people with dementia.
• Practices will receive Comprehensive Primary Care Payments (CPCPs). These payments will be a hybrid of Medicare fee-for-service and a value-based reimbursement model.
• A Medicare performance-based payment incentive pegged at $4 PBPM will be paid to primary care practices at the beginning of a CPC+ performance year. Just as with Track 1, Medicare could claw back this payment incentive if practices fail to meet quality and utilization performance thresholds.
• Practices will have to submit a letter of support from at least one healthcare IT vendor that outlines vendor commitment to boost advanced healthcare IT capabilities at physician practices.

Sessums outlined eligibility requirements for the two tracks of CPC+. "Track 1 is appropriate for practices ready to build the capabilities to delivery comprehensive primary care." Track 2 "is appropriate for practices poised to increase the comprehensiveness of care through enhanced health IT, to improve the care of patients with complex needs, and to inventory resources and community support to meet patients' unmet pyscho-social needs."

CMS plans to begin the CPC+ selection process for primary care practices on July 1, with participants announced in October. If more than 2,500 practices apply to participate in either track, CMS will use a lottery selection process.

Playing for High Primary Care Stakes

CMS should be applauded for attempting to revolutionize primary care, but CPC+ is a high-risk endeavor for the federal agency and for the primary care practices that will be participating in the program, says C. Timothy Gary, JD, MBA, CEO of Nashville, TN-based DW Franklin Consulting Group.

CMS has achieved a significant measure of success prodding health systems and hospitals to adopt value-based payment models such as accountable care organizations because those organizations have the financial resources necessary to development essential capabilities, including actuarial and data analytics muscle. The vast majority of primary care practices are relatively resource-poor, Gary says. "Physicians are in the best position to control costs; but at the same time, they don't have the infrastructure to manage the cost of a patient population."

In addition, accessing and interpreting data will be a daunting challenge for practices participating in CPC+, he says. "The real issue is getting actionable information to physicians and getting it in a form that they can feel good and safe applying to individual patients."

CPC+ has many elements similar to aborted attempts to introduce capitation to the healthcare industry three decades ago, and the program could suffer a similar fate if CMS botches the rollout of the agency's ambitious primary care reform effort, Gary says.

"I'm hoping they put enough data and information out there that it gives the system time to figure it out, and I hope they do it quickly… If they roll this out and it fails, either financially or in patient outcomes, physicians will be gun-shy."

The largest primary care practices will have the highest likelihood of success in CPC+ because they will be able to bank the biggest PBPM payments, says Chad Mulvany, director of healthcare finance policy, strategy, and development at the Westchester, IL-based Healthcare Finance Management Association. "If your practice is large enough, then those payments become more meaningful," he says.

For all practices that participate in CPC+, coding will be the critical factor in maximizing PBPM payments, Mulvany says. "Those payments are driven by HCC, which is driven by ambulatory coding… Practices have to understand patient needs and make sure the resources are there to ensure a good outcome. The accuracy of ambulatory coding becomes exponentially more important."

CPC+ is a high-risk gamble for CMS if there are high-profile failures in the program next year, but the agency has built up experience playing for high stakes, he says. "There has been risk in every program where CMS has stubbed its toe coming out of the gate.