The Center for Medicare and Medicaid Services (CMS) recently announced its largest-ever multi-payer initiative to improve primary care in America. Comprehensive Primary Care Plus (CPC+) is an advanced primary care medical home model that rewards value and quality by offering an innovative payment structure to support delivery of comprehensive primary care. The model is based on experiences from the original Comprehensive Primary Care (CPC) model which started in 2012 and warps up at the end of 2016. CPC+ is unique in that CMS is attempting to proactively align the necessary parties to enable success.

First Things First: Align the Payers

Unlike previous CMS Innovation Center (CMMI) models like the Medicare Shared Savings Program (MSSP, ACO), CPC+ is taking a multi-payer approach. In order to ensure that participating practices have the support they’ll need CMS won’t even specify the eligible regions until they have secured interest from a sufficient payer base there. The model starts with the payer solicitation period running from April 15, 2016 to June 1, 2016. CMS hopes to have support from the 7 original CPC regions plus up to 13 more.

The application assesses the payers’ willingness to adopt new payment models, share data and align electronic clinical quality measures (eCQMs) with others in the region. This is a big deal as it will allow participating practices to innovate care delivery around a single, unified model. This is a welcome change and is in major contrast to what practices deal with today when they must report different things to different parties at different times with a varying level of support. The administrative overhead involved with many public and private alternative payment models has clearly impacted participants’ ability to perform and this is a major step in the right direction.

Next: Get The Practices On Board

Once the payers have been selected, CMS will be able to identify eligible regions that have adequate payer support. This will lead into the practice application period expected to run between July 15, 2016 and September 1, 2016. Practices will apply to operate in one of two tracks.

Track 1 is for practices that have multi-payer support and the necessary HealthIT infrastructure in place, but are less experienced in delivering comprehensive primary care.

Track 2 is for practices that have the multi-payer support and the tools, but are already proficient in delivering comprehensive primary care and are ready to take the next step.

The payment models have several interesting features:

  • The Medicare care management fee (Average payment of $15 PBPM in Track 1; $27 PBPM in Track 2) will support practices in executing on the CPC+ initiatives. This is a non-visit-based, prospective payment that’s intended to provide practices with the resources needed to hire necessary staff and purchase necessary tools.
  • Track 1 will continue to receive Fee For Service (FFS) payments like they do today. Track 2 will be paid in a hybrid model with FFS paid at the time of the visit and FFS prospectively paid through what CMS is calling Comprehensive Primary Care Payments (CPCPs).
  • ‍The Medicare incentive payment ($2.50 PBPM in track 1 and $4 PBPM in track 2) will be paid proactively, but practice swill only be allowed to keep it if they meet specified quality goals in both clinical and patient satisfaction measures. Prospective payment is powerful for two major reasons. First, it lowers the barrier for entry by giving the practice some operating capital up-front (as opposed to self-financing in the hopes of a later return). Secondly, as this JAMA report points out, it capitalizes on the behavioral economics theory of loss aversion, thereby heightening practices’ focus on the utilization and quality measures. Simply put, the fear of losing something I have is a more powerful incentive than the possibility of gaining something I don’t yet have.

CMS is looking to pull in as many as 5,000 practices (2,500 in each track) with 20,000 providers covering up to 25 million lives.

Practices will be focused 5 key functions of primary care (the usual suspects for the most part):

  1. Access and Continuity
  2. Care Management
  3. Comprehensiveness and Coordination
  4. Patient and Caregiver Engagement
  5. Planned Care and Population Health.

And Don’t Forget IT!

Both Track 1 and Track 2 require the use of certified electronic health record technology (CEHRT), but track 2 takes it a step further. Health IT vendors participating with track 2 practices will be required to write a letter of support that outlines their commitment to supporting the practice(s) required health IT capabilities. Further, the IT vendors will memorialize their commitment to support Track 2 practices in a Memorandum of Understanding (MOU) with CMS. The contents of that MOU are unclear at this time. It’ll be interesting to see how willing IT vendors are to sign that MOU, but I would suspect that it will limit the available pool of vendors available for track 2 practices to work with. One might argue that it will weed out the lesser vendors, but depending on the MOU contents it could give strength to the “old boys” and scare away some of the smaller, nimbler and more innovative companies that are crucial for meaningful transformation.

Overall, I appreciate CMMI’s approach to testing, reviewing and tweaking the alternative payment models they deploy. While the first year in the original CPC program saw an overall savings, only 1 region qualified for shared savings (Greater Tulsa, Oklahoma earned $500,000). Still, with more than 90% of the practices meeting quality targets on patient experience and utilization measures, and all regions achieving lower-than-targeted hospital readmission rates, CMS is encouraged by the results. They point out, and I agree, that transformation takes time. I’m glad they aren’t waiting around to take the next steps. The adjustments made for CPC+ are intriguing and I look forward to watching the program progress.

Discuss Details

On Wednesday, April 27, 2016 the Business of Healthcare community will take on the topic of CPC+ and the CMMI approach in general.

12:00 PM EST – Tweet Chat

First, the #hcbiz tweetchat beginning at 12 EST will ask 3 questions in 30 minutes:

Q1: Do you think that CMMI is iterating at the proper pace or should they wait for results to materialize more substantially before starting a new model?

Q2: Do you support proactive incentive payments like we see in CPC+, or should practices be required to perform before getting paid?

Q3: What do you think about HealthIT vendors being required to sign an MOU with CMS? Are they being paternalistic or realistic?

(Follow the #hcbiz hashtag on Twitter or use an app like tchat.io to join the conversation).

12:30 PM EST – Blab

Then at 12:30 PM EST we’ll launch into the #hcbiz Show on blab. My co-host Shahid Shah and I will be joined by David Harlow  and Marci Nielsen, CEO, Patient-Centered Primary Care Collaborative (PCPCC) to dig deeper into these issues. As usual, we’ll focus in on the business realities that will be faced by everyone involved (CMS, commercial payers, practices, Health IT vendors and, of course, patients). Subscribe here!