New CMS multi-payer initiative to impact 20K doctors

CMS has unveiled a far-reaching multi-payer initiative that could have major implications for how primary care is delivered and reimbursed. In an April 11 release, CMS announced the Comprehensive Primary Care Plus (CPC+) model will be implemented in up to 20 regions, affecting as many as 5,000 practices, 20,000 doctors and clinicians and 25 million patients.

The initiative introduces monthly-fee based tracks of care with the goal of improving doctors’ freedom to care for patients, a change from the current system in which providers submit a payment claim to Medicare after providing a service.

“Strengthening primary care is critical to an effective health care system,” said Patrick Conway, MD, CMS deputy administrator and chief medical officer. “By supporting primary care doctors and clinicians … we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars.”

Primary care providers will participate in one of two programs, both of which include upfront incentive payments.

In Track 1, CMS will pay monthly fees to practices that provide specific services in addition to regular fee-for-service payments under the Medicare Physician Fee Schedule.

Practices in Track 2 will also receive management fees along with reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services. The combination of payment methods is designed to encourage practices to offer enhanced IT services, serve patients with complex needs and offer care outside of in-office visits.  

The up-front incentive payments for providers in both tracks will be kept or repaid based on performance and utilization metrics.

According to the CMS release, the CPC+ model will partner Medicare with commercial and state health insurance plans to promote primary care practices. To qualify for the up-front payments, practices will have to ensure:

• Enhanced in-person hours and 24/7 telephone or electronic access are available;
• Highest risk patients receive proactive, relationship-based care management services;
• Practices offer comprehensive care that can meet the majority of each patient’s physical and mental health care needs, including prevention. Care is also coordinated across the healthcare system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits;
• Care is patient-centered and actively engages patients to design care that best meets their needs; and
• Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements and develop new capabilities.

The new CPC+ program is a five-year model that will begin January 2017. CMS will begin accepting payer proposals in a staggered application process from April 15 through September 1. The regions for implementation will be identified based on interest from providers.

Steven Stack, MD, president of the American Medical Association released a statement in support of the CPC+ announcement, because it emphasizes improvements in care instead of cost reductions outside of physicians’ control.

“We look forward to reviewing the proposal in detail and working constructively with CMS to ensure physicians have flexible and workable payment models that support high-quality patient care and put less administrative burden on physician practices to alleviate physician burnout,” he said.