Applauding CMS?s Efforts in Primary Care

Thursday, May 12, 2016 | Larry Sobal

 

It can be fashionable these days to be critical of the Centers for Medicare and Medicaid Services (CMS). For example, one could point to the degree of ambiguity and level of complication associated with the MACRA legislation. Heck, I'll even admit to once writing that the “Centers for Medicare and Medicaid Innovation” was an oxymoron. But in this case, I am stepping out to publicly praise CMS's creative and multiple efforts to bolster primary care. Why the sudden praise? Read on to find out.

Continuing in its efforts to promote Alternative Payment Models (APMs), CMS announced the Comprehensive Primary Care Plus (CPC+) model on April 11, an initiative aimed at transforming the way primary care is delivered. CPC+ will be a voluntary five-year program that CMS hopes to implement in up to 20 regions, accommodating up to 5,000 practices. This program would potentially encompass more than 20,000 doctors and clinicians—and the 25 million people they serve.

Not unlike MACRA, CPC+ offers primary care practices the choice of two tracks in which to participate.

Like Accountable Care Organizations (ACOs) and other APMs, the CPC+ model is another step away from the traditional Fee-for-Service (FFS) method of reimbursement. The model requires the participation of multiple payers that are solicited, along with individual practices. According to CMS, the initiative is designed to provide doctors the freedom to care for their patients in the way they think will deliver the best outcomes—and to pay them for achieving results and improving care. The CPC+ model is expected to begin January 1, 2017, and builds on the Comprehensive Primary Care initiative launched by CMS in late 2012 (and terminates at the end of this year).

Not unlike MACRA, CPC+ offers primary care practices the choice of two tracks in which to participate. 

Track 1 can be categorized as FFS with care management fees and other incentives. It is geared towards practices that have health information technology and other basic infrastructure to deliver comprehensive primary care. In support of this work, practices will receive a per-patient, per-month Care Management Fee (CMF), averaging $15, along with the practice’s traditional FFS reimbursement. Participants in this track will also be eligible for performance-based incentives such as patient experience measures, clinical quality measures, and utilization measures that drive the total cost of care. Unlike other bonus programs by CMS, these incentives will be paid on a prospective basis, but practices will only be able to keep the funds if they meet the annual performance thresholds.

Track 2 can be categorized as a hybrid of FFS and a Comprehensive Primary Care Payment (CPCP). It is geared toward practices that are already proficient in comprehensive primary care and are also prepared to increase the depth, breadth and scope of such care, especially to those patients with complex medical needs. Like Track 1, practices in Track 2 will receive a monthly CMF (averaging $28 per patient, per month, with $100 available for complex patients), as well as performance-based incentives.

Track 2’s primary difference is found in its move away from traditional FFS reimbursement. Instead of Medicare’s traditional retrospective FFS structure—where a practice is paid solely based on services it provided in the past—Track 2 practices will be reimbursed through a hybrid of the traditional retrospective system and a new prospective payment system. Under this hybrid approach, practices will continue to bill FFS as they have historically done; however, CMS will pay the practices a reduced FFS amount to account for CMS shifting a portion of the FFS payments into a CPCP. The CPCP will be an upfront per-beneficiary, per-month payment that is paid quarterly.

The chart below highlights the similarities and differences between the two tracks.

CMS will accept payer proposals to partner in CPC+ from April 15 through June 1 and will accept practice applications in the determined regions from July 15 through September 1.

Of course, this is not the first effort CMS has made to better support primary are. Examples include:

• In 2005, CMS launched the Welcome to Medicare and initial annual and subsequent annual wellness visits (AWV). These were awarded a higher Work RVU and payment versus other office visits. Plus, Medicare allows a physician to bill a problem-oriented visit on the same day, as long as the documentation for the wellness visit isn’t used to select the level of problem-oriented visit. 
• In 2013, CMS launched Transitional Care Management (TCM) fees. TCM allows the group to be paid for the work the physician, NP and staff are already doing.
• In 2015, CMS launched Chronic Care Management (CCM) fees. Although this has proven problematic for practices to implement, the intention was to pay a monthly fee for 20 minutes of clinical staff time with patients who had two or more significant chronic illnesses. Again, this likely is work already being done.
• In 2016, CMS launched Advanced Care Planning. Beginning in 2016, physicians and NPPs can be paid for discussion of end-of-life issues with patients and/or family members. The Medicare payment is about $86 for a discussion of 30 minutes. 

These four programs represented earlier efforts by CMS to recognize that work performed by primary care was not adequately being reimbursed. I anticipate that CMS will continue to test a variety of alternative payment and delivery models. The CPC+ model is the latest, with its focus on delivery of comprehensive primary care. And for that, I stand up and say “good job.” I hope they keep trying new things since the old system isn’t working.

---

 

Larry Sobal is Executive Vice President of Business Development at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and insurance. As part of his current role, Larry consults, writes and presents on topics relevant to transforming physician practices and health systems.

 

---