CMS unveils plan for new payment model

[Updated April12, 2016] 

The Centers for Medicare & Medicaid Services (CMS) is preparing to take another step in moving primary care away from the traditional fee-for-service payment model.

The agency today announced it was launching Comprehensive Primary Care Plus (CPC+), a program CMS says will make it easier for primary care doctors to deliver the best outcomes for patients covered by Medicare and pay them for achieving results and improving care. The program also ratchets up the financial  consequences for physicians of not meeting quality and utilization metrics.

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“The Comprehensive Primary Care Plus model represents the future of health care that we’re striving towards,” Patrick Conway, MD, CMS deputy administrator and chief medical officer said in a press release. “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 health care system that results in healthier people and smarter spending of our health care dollars.”

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CMS says the initiative can accommodate up to 5,000 practices, which would encompass more than 20,000 providers and 25 million patients across the country.

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The unveiling of CPC+ represents the next step in CMS’s intention to emphasize quality and outcomes over volume when reimbursing primary care physicians. Early in 2015 CMS laid out a goal of tying 30% of Medicare payments to quality and value via alternative payment models by the end of 2016 and 50% by the end of 2018.

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Practices will participate in the initiative on one of two tracks. In Track 1, practices will receive a monthly care management fee from CMS in addition to fee-for-service payments under the Medicare physician fee schedule. Practices choosing Track 2 will also receive a monthly care management fee, but instead of full fee-for-service payments they will receive what CMS describes as “a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services.” The goal is to allow practices more flexibility in delivering care outside of the traditional face-to-face encounter.

According to CMS, the CPC+ program is designed to help primary care practices to:

• support patients with serious or chronic diseases to achieve their health goals,

• give patients 24-hour access to care and health information,

• deliver preventive care,

• engage patients and their families in their own care, and

• work with hospitals and other clinicians, including specialists, to provide better coordinated care

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Practices on both tracks will receive data on their costs and utilization patterns, as well as up-front incentive payments. Payments for practices on Track 1 will be $2.50 per beneficiary per month, while those on Track 2 will be $4 per beneficiary per month.  Practices will either keep or repay the incentive payments based on their ability to meet quality and utilization thresholds.

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CPC+ also calls for Medicare to partner with commercial and state health insurance plans to help practices deliver advanced primary care, a concept that focuses on elements such as accessibility to services, care that is proactive and comprehensive, and patient engagement.

Physician organizations were cautiously supportive of the initiative. In a written statement, the American College of Physicians (ACP) says it believes that “CPC+ offers the potential of greatly strengthening the ability of internists and other primary care clinicians…to deliver effective and accessible primary care to millions of their patients.” 

The ACP adds that it’s “encouraged” by the availability of two different tracks for participating in CPC+, “with different care delivery requirements and payment methodologies that reflect the diversity in primary care practices.” 

The American Academy of Family Physicians (AAFP) expressed similar support.

“(We) applaud the CMS announcement of the COC+ initiative,” the organization said in a written statement. “The American public has been calling for a health care system that provides comprehensive, effective and virtually seamless healthcare.”

AAFP says it feels the new payment program “is yet another important step toward transforming the way patients get care, the quality and efficiency of that care, and the overall improvement of health in the community.”