Revenue Cycle Management Blog | GroupOne Health Source

CMS Launches Comprehensive Primary Care Plus: Value-Based Model for Primary Care Practices, Multiple Insurers

Written by Kaitlyn Houseman | April 11, 2016

The Centers for Medicare and Medicaid Services on Monday launched a new risk-based primary care initiative that it hopes will accelerate the movement towards value-based reimbursement for medical practices. The five-year, Comprehensive Primary Care Plus, or CPC+, starts in January 2017 and will include up to 5,000 practices and 20,000 physicians in an estimated 20 regions.

 It pays participating physicians under two tracks.

Both give practices up-front incentive payments the physicians will either keep or repay based on their performance on quality and utilization metrics, CMS said.

[Also: Healthcare Metrics You Need to Track in an Age of Value-Based Payment ]

Under one track, physicians will be able to deliver care outside of the traditional face-to-face office visit, CMS said.

For the initiative to work, Medicare is partnering with commercial and state health insurance plans. CMS is selecting regions for CPC+ where there is sufficient interest from multiple payers to support  participation by area practices, CMS said.

CMS will enter into a Memorandum of Understanding with payers  that aligns goals for payment, data sharing, and quality metrics.

Under Track 1, CMS will pay practices a monthly care management fee in addition to the fee-for-service payments under the Medicare Physician Fee Schedule.

Track 2 is a hybrid design that allows for greater flexibility in how practices deliver care outside of traditional office visits. This encourages doctors to focus on health outcomes rather than the volume of visits or tests, CMS said.

The hybrid model pays practices a monthly care management fee. However, instead of receiving the full Medicare fee-for-service payments for evaluation and management services, physicians will get reduced Medicare fee-for-service payments and up-front comprehensive primary care payments, CMS said.

[Also: 6 FAQs About the Merit Based Incentive Payment System ]

Under Track 2, physicians will also provide more comprehensive services for patients with complex medical and behavioral health needs, including a systematic assessment of their psychosocial needs and an inventory of resources and supports, CMS said.

Vendors for Track 2 practices will sign a Memorandum of Understanding with CMS that outlines their commitment to supporting the enhancement of health IT capabilities. This is vital to the practices' success and aligns with the Office of the National Coordinator for Health IT priority to ensure electronic health information is available.

CPC + builds on a 2012 Comprehensive Primary Care Initiative.

"Strengthening primary care is critical to an effective healthcare system," said Patrick Conway, CMS deputy administrator and chief medical officer. "By supporting primary care doctors and clinicians to spend time with patients, serve patients' needs outside of the office visit, and better coordinate care with specialists we can continue to build a healthcare system that results in healthier people and smarter spending of our healthcare dollars."

The advanced primary care initiative has five key components: Services are accessible through enhanced in-person hours and 24/7 telephone or electronic access; high-risk patients receive proactive care management services to improve outcomes; comprehensive physical and mental care includes preventative services; care is coordinated, including specialty care and community services; and patients receive timely follow-up after emergency room or hospital visits.

  • CMS will accept payer proposals to partner in CPC+ through June 1.
  • CMS will accept practice applications in the determined regions from July 15 through September 1, 2016.
  • CMS's goal, under the Affordable Care Act, is to move the health system from quantity of care to quality of care.

In March 2016, the agency estimated that it had met the goal – eleven months ahead of schedule – of tying 30 percent of Medicare payments to quality and value through alternative payment models by 2016. The Administration's next goal is tying 50 percent of Medicare payments to alternative payment models by 2018.