CMS Initiative Aims to Shake Up Primary Care

By Nathaniel Weixel

April 11 — The CMS is launching what it says is the largest ever initiative to transform the way primary care in America is delivered and reimbursed for more than 25 million patients.

The Comprehensive Primary Care Plus (CPC+) model is a five-year voluntary program that will be implemented in up to 20 regions and can accommodate up to 5,000 practices. Payments under the model will encourage doctors to focus on health outcomes rather than the volume of visits or tests and will give doctors new flexibility, the Centers for Medicare & Medicaid Services said April 11.

Under the CPC+ model, Medicare will work with commercial and state health insurance plans to provide the necessary financial support for practices to make significant changes in their care delivery, the agency said.

The idea of the program is to move beyond simple fee-for-service (FFS) reimbursements in primary care. Unlike in FFS, participating providers will receive monthly care management fees based on beneficiary risk tiers. Doctors will also receive bonus payments based on their performance on patient experience, clinical quality, and utilization measures.

The initiative will contribute to the goals set by the administration of having 50 percent of all Medicare fee-for-service payments made via alternative payment models by 2018, the CMS said.

“The Comprehensive Primary Care Plus model represents the future of health care that we’re striving towards,” Patrick Conway, CMS deputy administrator and chief medical officer, said in a statement.

The CMS will select the participating regions this summer, and the agency will accept practice applications in the determined regions from July 15 through Sept. 1. The program will go into effect in January 2017— right as President Barack Obama is leaving office, so continued implementation will depend on the next administration.

Two Tracks Offered

The model will offer two tracks with different care delivery requirements and payment methodologies. The first track will pay providers on a fee-for-service basis, along with an average $15 per-patient per-month fee.

The second track will pay participants a hybrid of Medicare fee-for-service payments called a comprehensive primary care payment (CPCP). The care management fee will average $28 per beneficiary per month, including a $100 care management fee to support patients with the most complex needs. The hybrid payment is meant to allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter, the CMS said.

Physicians will be able to call or e-mail patients who can't make in-person office visits, and spend more time on patients who need it. The fee-for-service system reimburses doctors based on how many patients they see, regardless of quality, so the incentive is to see as many patients as quickly as possible.

“[Fee-for-service] care is transactional and undermines patient care. We want care to be relationship based. You can’t form a relationship in a 15-minute office visit,” Marci Nielsen, president and CEO of the Patient-Centered Primary Care Collaborative, told Bloomberg BNA April 11.

Wanda Filer, president of the American Academy of Family Physicians, said flexibility is crucial.

“Primary care is paid to make you come in the door,” and the requirements are focused on face-to-face encounters, Filer said in an April 11 interview. “As people become more and more complex you were being paid on volume, and that’s not a good structural system for primary care. Patients may look very different, the needs of patients may be very different and resources [needed to care for them] may be different. Hopefully this program allows us that flexibility.”

Earlier Initiative

The program expands on an earlier Comprehensive Primary Care (CPC) initiative, which the CMS said has produced significant quality improvements .

The CPC+ builds on the earlier program with advances in payment to support primary care practices to provide more comprehensive care that meets the needs of all their patients, particularly those with complex needs, the CMS said. The CPC+ is 10 times the size of the earlier initiative.

“[CMS] learned lessons from the CPC. The early evidence was mixed, so the lessons they learned they’ve incorporated,” Nielsen said. “We’re very encouraged by that. Practice transformation is hard work. [The CPC+] rewards them for the important work of primary care delivery.”

Nielsen also praised the CMS for learning that changing physician behavior requires a significant up-front investment.

“The changes that you ask practices to make in terms of workflow, technology use, team-based approach to care delivery, all requires investment,” Nielsen said. “Often we think of primary care practices as underfunded and overburdened with too many measures that don’t feel useful.” The CPC+ can change that, Nielsen said.

To contact the reporter on this story: Nathaniel Weixel in Washington at nweixel@bna.com

To contact the editor responsible for this story: Brent Bierman at bbierman@bna.com