Flexibility and tailored approaches are the watchwords of a multipayer primary care test program announced April 11 by the Centers for Medicare & Medicaid Services.
The 5-year test beginning in 2017, called Comprehensive Primary Care Plus (CPC+), will provide practices with upfront incentive payments to help allow doctors to offer more services for which they have not traditionally been compensated, such as more detailed care coordination and telemedicine, in an effort to improved quality of care.
“This initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care,” Dr. Patrick Conway, chief medical officer of the CMS, said during a press conference.
Dr. Patrick Conway
There is a catch. Physicians may have to repay these upfront payments if their quality and utilization metrics are low. Some metrics that might be considered are whether a patient was kept out of the hospital by improving medication adherence or preventive care or how well the care was coordinated for patients with multiple chronic conditions, Dr. Conway said.
In the current, straight fee-for-service environment, “we are getting the incentives wrong,”Dr. Conway said, adding that one-size-fits-all doesn’t work,yet the current system “encourages doctors to care for people that way, even if their patients need something different.”
Participants in the CPC+ test will practice into one of two tracks. In Track 1, the CMS will pay practices a monthly management fee in addition to the usual Medicare fee-for-service payments. Track 2 participants also will get the monthly care management fee, but their Medicare fee-for-service payments will be reduced in lieu of upfront comprehensive primary care payments for evaluation and management claims.
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Regardless of track, practices that participate in CPC+ must do five things:
• Provide patients with 24/7 access to physicians via enhanced office hours as well as telephone and electronic access.
• Provide highest-risk patients with proactive, personalized care management.
• Provide care that is comprehensive to meet most patients’ preventive care and physical and mental health needs, as well as improved care coordination across specialty and emergency care.
• Recognize patients and their family members as part of the care team and work with patients to determine the care that best meets their needs.
• Analyze quality and utilization data regularly, seeking improvement and developing new capabilities.
Track 2 is designed for practices with more experience in delivering advanced services, “and these practices will be expected to provide enhanced services within these five functions for patients with complex needs, including identification of psychosocial needs and resources and supports to meet those needs,” Dr. Laura Sessums of the CMS’ Center for Medicare & Medicaid Innovation and colleagues said in an article published April 11 in JAMA (doi: 10.1001/jama.2016.4472]).
In Track 2, “practices and their doctors will be given even more freedom to design the types and amounts of care that best meets the needs of their patients,” Dr. Conway said. “If telehealth makes sense, they can do that. If they think longer visits are needed because of the complexity of a patient, they can do that. The model can reduce fee-for-service payments by more than half while we invest in population-based payments focused on better outcomes for patients.”
Care management fee for those participating in Track 1 will average $15 per beneficiary per month across four risk tiers, according to a CMS fact sheet. Track 2 participants will receive an average of $28 per beneficiary per month across five risk tiers, the fifth being a $100 care management fee per beneficiary per month to support patients with the most complex needs. The upfront incentive payments for meeting quality and utilization targets are $2.50 per beneficiary per month for Track 1 and $4 per beneficiary per month for Track 2, though some or all of these payments could have to be returned if targets are missed.
The test will cover up to 5,000 practices across up to 20 regions, encompassing more than 20,000 doctors and clinicians who serve 25 million patients.
The CMS is hosting two webinars, on April 14 and April 19, to discuss this test program. Information on how to apply for participation in the program can be found here.
CPC+ is designed to build on experiences of and lessons learned in the Comprehensive Primary Care program, in which 500 primary care practices across the United States worked with the CMS and private insurers and state health insurance plans to test comprehensive primary care. Practices received a non–visit-based care management fee per patient in addition to regular fee-for-service payments and an opportunity to share in any savings. The incentive fees have provided participating practices with funding to create new workflows, hire staff, and develop new relationships necessary to coordinate care, according to the CMS.