So how is the new program going to be a Plus for physicians and their patients compared to the current CPCi pilot and traditional fee-for-service Medicare?
For one thing, it’s Plus-sized: CMS envisions that the program will be available “in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve”—a 10-fold increase in the number of participating practices, and a nearly three-fold increase in the number of regions where the program will be offered.
CPC+ could also be a Plus for practices because it will offer more options. Physicians and their practices can choose from two different participation tracks, with different care delivery requirements and payment methodologies that reflect how advanced they are in incorporating PCMH principles into their care delivery. Track 1 is for those that are less advanced in fully implementing the attributes of advanced Primary Care Medical Homes; track 2 is for more advanced practices.
CPC+ could be a Plus for practices, especially compared to traditional FFS Medicare, because it gives them more Medicare dollars upfront, which will be in addition to the amounts they get reimbursed for individual patient encounter (evaluation and management service) codes:
- Track 1 practices will receive an average risk-adjusted payment of $15 per beneficiary per month; they can earn another $2.50 PBPM if they do well on metrics of quality and utilization.
- Track 2 practices would receive an average risk-adjusted PBPM payment of $27 and up to $100 PBPM for the highest risk patients); they can earn an additional $4 PBPM based on performance.
However, CPC+ also adds financial risk to the equation. If track 1 practices do not meet their performance metrics, they will have to repay Medicare for the $2.50 PBPM incentive payment. If track 2 practices don’t meet their metrics, they would repay Medicare for the $4.00 PBPM incentive payment.
My back-of-the envelope calculation shows how much more in upfront Medicare money this could mean for participating practices. A track 1 practice with 1000 Medicare beneficiaries would on average receive $15,000 in monthly (PBPM) payments, or $180,000 over 12 months. If they are able to keep the $2.50 PBPM incentive payment, it would be $17,500 per month, or $210,000 for the year. Track 2 practices with 1000 Medicare patients would on average get $27,000 per month in PBPM advance payments, or $324,000 for a year; with the additional $4 PBPM incentive payment, it would be $31,000 per month, or $372,000 for the year.
For track 1 practices, these upfront PBPM payments would be in addition to getting 100% of their usual Medicare FFS payments for office visits and procedures billed a la carte.
It’s more complicated, though, for track 2 practices, because their upfront PBPM payments will be offset by reduced payments for separately-billed office visits and other evaluation and management services. In an editorial published in the Journal of the American Medical Association, CMS officials explain how this will work:
“Track 2 practices will receive an up-front payment of a portion of their expected evaluation and management claims on a per capita basis, independent of claims. Subsequent claims for evaluation and management services will be paid at a commensurately reduced rate. As the ratio of the hybrid payment is titrated up during the model, the reduced payment for billed evaluation and management services will pay practices for the marginal cost of an office visit, making practices ‘incentive neutral’ to the mode of care delivery and allowing them the flexibility to deliver care in the manner that best meets patients’ needs—without being tethered to the 20-minute office visit. Practices might offer non–face-to-face visits (e.g., electronic or telephone), offer visits in alternate locations, or simply provide longer office visits for patients with complex needs. CMS will monitor practices to ensure delivery of quality health care.”
Their non-evaluation and management services would continue to be paid 100% of the usual rates.
So for Track 2 practices especially, it comes down to them deciding whether having a big pot of “bird-in-the-hand” upfront PBPM payments, and the financial support and flexibility it provides to manage things without being “tethered” to visits, is worth being paid commensurately less when they have to bill separately for a visit.
Or, to put it another way, do they prefer getting more of their revenue upfront from risk-adjusted capitation and less downstream from FFS billings?
The Comprehensive Primary Care Plus program could also be a Plus for practices by giving them access to extra support and revenue from payers other than Medicare: CMS will be seeking formal commitments from non-Medicare payers to support participating practices, and will only launch the program in localities where there is such a commitment from enough payers.
The CPC+ program could also be a Plus for participating physicians and their practices because it should give them a big leg-up in qualifying for higher payments under the new MACRA law, either as an Alternative Payment Model (APM) or under the Merit-based Incentive Payment System (MIPS) created by the legislation.
Finally, the Comprehensive Primary Care Plus program would also be a Plus for patients, if it truly achieves its goals of providing practices with the “financial resources [needed] to implement the processes and hire the staff needed to deliver the 5 primary care functions: (1) access and continuity, (2) risk-stratified care management, (3) planned care for chronic conditions and preventive care, (4) patient and caregiver engagement, and (5) comprehensiveness and coordination of care.”
ACP, in a supportive statement, noted several features of the program that will be critically important for it to be successful in meeting the goals of supporting and strengthening primary care:
· We strongly support the goal of ensuring that practices in each track will be able to build capabilities and care processes to deliver better care, which will result in a healthier patient population.
· We agree with the need for payment redesign that offers the ability for greater cash flow and flexibility for primary care practices to deliver high quality, whole-person, patient-centered care and lower the use of unnecessary services that drive total costs of care.
· We support the critical importance of obtaining commitments from other (non-Medicare) payers to join with Medicare to support CPC+ practices.
· We are encouraged that CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data, to guide their decision making.
Yet ACP’s statement concluded with a cautionary note: “The success of the Comprehensive Primary Care Plus program will depend on Medicare and other payers providing physicians and their practices with the sustained financial support needed for them to meet the goal of providing comprehensive, high value, accessible, and patient-centered care, with realistic and achievable ways to assess each practices’ impact on patient care. The College is committed to working with CMS on the details of implementation to ensure that the program is truly able to meet such requirements of success.”
While the verdict is still out, the Comprehensive Primary Care Plus initiative truly is a big deal for primary care, potentially offering a way for practices that embrace the PCMH model—as long championed by ACP—to get more upfront payments from Medicare and other payers to help them make their practices more accessible and responsive to the needs of their patients, while accepting a degree of financial risk for achieving the desired results.
Today’s questions: Do you think that the Comprehensive Primary Care Plus program will truly be a Plus for primary care physicians, their practices, and their patients? Would you consider having your practice participate?