CMS heeds concerns, allows ACOs to join CPC+

New strides toward better care and spending can stir up plenty of blowback along the way, but CMS has shown a willingness to listen and adjust, this time by allowing ACOs to jump aboard the Comprehensive Primary Care Plus (CPC+) train – an initiative with the potential to impact up to 5,000 practices, 20,000 providers and 25 million patients.

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“Moving the needle on payment reform and population health is devilishly difficult and fraught with unintended consequences,” says Cindy Ehnes, JD, executive vice president of COPE Health Solutions and an attorney who previously served as director of the California Department of Managed Health Care.

When the CPC+ initiative was first announced in April, primary care physicians (PCPs) were told they needed to choose between participating in shared savings programs like ACOs or the CPC+ model.

This either/or option created concern among primary care doctors already participating in a Medicare ACO because of the lack of up-front payments or care management fees for managing their patient populations, explains Carrie Nixon, JD, CEO of Healthcare Solutions Connection and managing member of Nixon Law Group.

PCPs felt they were losing out financially and many contemplated leaving the Medicare Shared Savings Program (MSSP) models altogether.

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“But PCPs are the quarterbacks for patient/population health management, and if the PCPs abandoned MSSPs to join CPC+ it would put the entire MSSP model at risk of collapse,” she adds.

Adjustments made

CMS listened to the comments calling for ACO inclusion and recognized that allowing physicians to participate in both CPC+ and ACOs could potentially boost both initiatives. This ultimately led to the May announcement that up to 1,500 (of the 5,000) CPC+ practices would also be allowed participation in MSSP ACOs.

“First and foremost, I think primary care service providers stand to gain as this is yet another opportunity for them to be financially rewarded for delivering high-quality care,” says Jeb Dunkelberger, MSc, McKesson Business Performance Services executive director of accountable care services and corporate partnerships.

Next: Looking ahead

“Medicare patients should gain the most as the financial incentives are all being aligned to innovate and deliver high-quality care, preventive services, increased access, and increased coordination,” he continues. “Participating CPC+/ACO providers will also gain a lot by introducing cash flow to pay for the services that shared savings alone incentivized but did not immediately pay for due to the delayed nature of the shared savings distribution.”

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The care management payments would defray the up-front cost barrier that many small independent primary care practices view as a major roadblock to effectively managing population health and the total cost of care outside of their offices, adds Ehnes.

Will the CMS adjustment negatively impact anyone? According to Dunkelberger, non-participating doctors or providers not chosen stand to miss out on an opportunity to innovate and be paid to redesign their care delivery pathways, and groups that do not make serious investments in training staff or investing in new resources run the risk of being financially penalized if they do not meet certain performance thresholds outlined in their track.

Providers will not be able to participate in CPC+ and bill chronic care management (CCM), so vendors who only offer CCM services also stand to lose.

Looking ahead

According to Ehnes, CPC+ will use either monthly payments or advance payments to incentivize certain primary care approaches, such as:

·      Supporting patients with serious or chronic diseases to achieve their health goals

·      Providing 24-hour access to care and health information

·      Delivering preventive care

·      Coordinating care with hospitals and other clinicians

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The Center for Medicare & Medicaid Innovation (CMMI) intends to roll out CPC+ to more providers in more regions beginning in January 2017. The model offers two tracks, including one that requires practices to develop more advanced capabilities than required under the Comprehensive Primary Care Initiative (CPCI).

Under Track 1, practices will receive risk-adjusted care management payments averaging $15 per Medicare beneficiary per month, which is similar to the size of payments under CPCI, Ehnes adds. Practices joining Track 2 will receive average risk-adjusted payments of $28 per Medicare beneficiary per month as well as a portion of projected fee-for-service payments up-front to support innovations in care delivery.

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The CMMI estimates that a practice participating in Track 1 of CPC+ that is similar in size to the average practice participating in CPCI will receive $126,000 annually in addition to performance payments of $21,000. For Track 2 the figures are $235,200 and $33,600, respectively.

Dunkelberger notes that these figures depend heavily on a provider’s number of beneficiaries and the track chosen. 

Paul Nicolaus is a Wisconsin-based freelance writer. Send comments, questions, or story ideas to nicolauswriting@gmail.com, or learn more at www.nicolauswriting.com.