Medicare Set to Release Areas, Insurers for Primary Care Model

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By Mindy Yochelson

July 20 — The Medicare agency is set to announce the insurers and regions that will be part of a major project to give primary care practices funds to test new ways to deliver care.

Scheduled to begin in five months, the Comprehensive Primary Care Plus (CPC+) is a medical home model that can be implemented in as many as 20 regions. Up to 5,000 doctor practices can be involved in two simultaneous tracks.

Although developed by the Centers for Medicare & Medicaid Services Innovation Center, the five-year multipayer program involves commercial insurers, Medicaid agencies, Medicaid managed care and Medicare Advantage plans.

When it was announced, the agency said it would be the largest ever initiative to transform the way primary care in America is delivered and reimbursed (70 HCDR, 4/12/16).

The goal of CPC+ is for doctors to focus on health outcomes rather than the volume of visits or tests.

‘Robust Interest.'

Health insurers and state agencies showed “robust interest” during the application period that closed in June, Laura L. Sessums, director of the CMS Division of Advanced Primary Care at the Innovation Center, told Bloomberg BNA in a recent interview.

However, she cautioned that the agency may not end up with enough qualified payers to cover the maximum number of areas.

“We’d love to have 20 regions,” Sessums said. However, the CMS won’t sacrifice quality just to meet a certain number, she said. “If we don’t find that payer proposals are sufficiently aligned to give practices what they need in those regions, we won’t just take them for quantity.”

In Line With CMS

Primary care practices need to have the right insurer support to succeed, she said. That means the agency will only accept those payers that are aligned with the CMS in such areas as quality measurement, data feedback and payment redesign.

The geographic areas and a list of provisionally selected payers should be announced either the week of July 25 or Aug. 1, according to the CMS. Regions are described as “overlapping, contiguous geographic locales” and may encompass multiple areas within a state or may extend across states.

Current Program

The model is the second chapter in this area for the agency. CPC+ is a progeny of a similar program that concludes at the end of 2016—the four-year Comprehensive Primary Care Initiative, referred to as “CPC Classic.”

The ongoing program has 38 players in seven regions and includes 500 practices.

CPC+ integrates lessons learned, Sessums said. For example, for CPC+'s more advanced track, the CMS will require electronic health record vendors to be partners so they can better understand care delivery requirements and help build practices' infrastructure. The CPC Classic program has EHR requirements but vendors aren't official partners.

Delivering data feedback to practices on claim utilization will also be improved, she said.

Mixed Reviews

The current program has received mixed reviews.

In October 2015, the CMS said that for the first performance year the program had resulted in hospital readmissions that were lower than national benchmarks as well as high patient satisfaction.

But an article in the New England Journal of Medicine in April found that practices have not yet shown savings for Medicare after accounting for care-management fees. They also had not shown appreciable improvement in quality of care or patient experience.

An editorial on the initiative, also published in the online journal, said that one of the problems is that physicians aren't able to share in savings from their patients’ care unless participating practices in their region also achieved overall savings (74 HCDR, 4/18/16)

This has been an area of redesign in the new program.

Anthem In

CPC Classic participants are to be given preference when the CMS evaluates proposals for CPC+.

Anthem Inc. is now in three of the seven regions.

Kelly Owen, a regional vice president for Anthem who's based in Ohio where the program is still going on, told Bloomberg BNA July 19 that the company applied to be in CPC+ in different areas.

“I think our market is very much primed to have a high level of interest” in the new program, she said.

Payers don't receive any additional funding from the CMS for their work.

Explaining Anthem's interest, she said that without programs like this, care costs continue to rise for payers. For practices, under fee-for-service, “the more services they perform, the more claims they submit, the more they get paid.”

Doctor Interest

Shari M. Erickson, vice president of governmental affairs & medical practice at the American College of Physicians, told Bloomberg BNA July 19 that, based on her discussions with members who are current CPC participants, “there's a strong interest in continuing.”

Erickson said ACP members who are involved in the first program had expressed concerns that the program was ending on Dec. 31.

Many had made significant changes in their operations and payment model and had become reliant on the financial and service support they were receiving. They had restructured their practices and didn't want to return to fee-for-service, she said.

“There's a lot of work” but the resources made it worth it, she said.

Humana Out

However, one insurer that won't be coming back is Humana Inc., the second largest in the Medicare managed care program.

While the company shares the CMS's goal of strengthening primary care, it prefers to act on those goals through its own value-based care programs, a Humana spokesman told Bloomberg BNA.

Although Humana is participating in the current CPC program, “we determined participating in the continuation program, CPC+, would duplicate our existing efforts,” the spokesman said.

Program Goal

The program significantly increases reimbursement, makes generous up-front payments available and pays for many activities that providers today perform for free, according to Caravan Health, an advisory company that's offering a “boot camp” for practices that need help in setting up the CPC+ infrastructure.

Eligible practices have to have doctors who are in family medicine, internal medicine, general practice or geriatrics. They can choose to participate in one of two tracks, depending on their level of experience in running a medical home. Both tracks offer monthly care management fees and incentive payments based on performance.

Doctors use the money for such activities as developing alternatives to traditional office visits; providing longitudinal and episodic care management; and adding additional services within the practice that might have previously required a referral. The object is to avoid more costly urgent care.

Practice Applications

After the CMS announces the regions, practices may apply through Sept. 15. Practices will be selected and notified in late fall. The program is slated to start Jan. 1, 2017.

Up to 2,500 practices will be selected in each of the two tracks, which have different care delivery requirements and payment methodologies.

Both Tracks One and Two offer care management fees and prospective payments to reward practices for quality improvement and cost reductions.

Practices in both tracks must offer patients round-the-clock access to medical advice and have certified EHRs, among a variety of other requirements such as transition care.

Track One Doctors

The first, more basic track, will pay providers on a fee-for-service basis, along with an average $15 per-patient per-month care management fee that's risk adjusted.

A performance payment of $2.50 per patient per month will have to be returned if cost and quality targets aren't met.

In exchange, practices must show progress on five primary care functions: care management; patient and caregiver engagement; planned care and population health; comprehensiveness and coordination; and access and continuity.

Track Two Doctors

The second track—for practices more experienced with advanced care management—will reimburse participants based on a “comprehensive primary care payment.” This is a mix of Medicare fee-for-service payments and a percentage of their expected evaluation and management reimbursements based on the prior year's charges.

The care management fee is close to twice as high as in the first track—an average $28 per patient per month.

An additional $100 a month is available for practices to support each patient with the most complex needs, such as dementia.

The prospective performance-based incentive is $4 per patient per month.

More Requirements

The extra money in Track Two is to help practices use health information technology, improve care of patients with complex needs and offer support to meet patients’ psychosocial needs, among the requirements.

Although practices in both tracks have to adopt certified health IT, those applying for Track Two have to include a letter from an IT vendor that commits to supporting the practice. Each vendor has to sign a memorandum of understanding with the CMS.

This won't come without challenges for smaller practices.

Although Anthem's Owen said that she's aware of a solo practitioner who did well in the classic program, many “don't have the broad infrastructure and capital resources to do very costly technology changes” like data analytics.

Office Visit Alternatives

Track Two practices also have to offer at least one alternative to office visits and can be reimbursed for non-office communications.

Providers, for example, may bill for patient interaction by phone, e-mail, text, home video and other methods.

The CMS's Sessums, an internist and lawyer, said a patient could send in photos of a rash via Facetime, and communicate with a physician during a vacation or on a weekend.

“There's so much our primary care doctors are doing today that's uncompensated and this will pay them for that work,” Lynn Barr, Caravan's chief executive officer, said during a July 18 company webinar.

Getting Word Out

In the meantime, the CMS has doing the ground work, prepping its learning systems to be ready to go when regions are announced, Sessums said.

The CMS, through its national and regional offices, will work with professional organizations, such as the ACP and the American Academy of Family Physicians.

Erickson said each state has one or more ACP chapters and will be sending out material if the program is in their area.

Alternative Payment Model Bonus

Practices, however, could have their appetite whetted for participation once they realize that CPC+ is a possible way to qualify to be an advanced alternative payment model (APM) under the Medicare Access and CHIP Reauthorization Act of 2015 (82 HCDR, 4/28/16).

“It actually adds a whole new incentive for practices that want to be involved,” Erickson said.

The CMS named CPC+ as one of six advanced APMs under the MACRA regulation that was proposed in April (88 HCDR, 5/6/16).

Eligibility for advanced APMs has been the focus of attention because clinicians who get substantial revenue through one are entitled to receive a 5 percent bonus for their 2019 through 2024 Medicare payments.

Interest in CPC+ was already high before the MACRA proposed rule was released, but the prospect of the extra 5 percent bonus will only heighten that interest, Sessums said.

Push Toward P4P

CPC+ represents one more step in Medicare's move away from away fee- for-service to pay for performance and boosting primary care.

The 2017 physician fee schedule rulemaking, proposed in July, had, at its core, increases in primary care resources (131 HCDR, 7/8/16).

MACRA's alternative payment models and quality grading system, which replaced the sustainable growth rate formula as the doctor payment methodology, is another step.

“Moving from a system that's focused on volume to one that rewards high quality care takes commitment from a lot of people,” Sessums said. CPC+ “comes at a time when the health-care market is in a time of great transition in terms of organization and that comes with challenges,” she said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

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