On August 1, the Center for Medicare & Medicaid Innovation (CMMI) announced the 14 regions that will be part of the Comprehensive Primary Care Plus (CPC+) program. These include the 7 regions now participating in the Comprehensive Primary Care Initiative (now known as “CPC Classic”) and 7 new regions.
Primary care practices located in the 14 regions have until September 15 to submit an application to participate in CPC+ beginning January 1, 2017, and ending December 31, 2021.
Each practice’s decision of whether to apply for CPC+ requires careful consideration of several factors in light of its specific facts and circumstances. Here, we summarize the key factors and offer some direction for eligible practices’ decision-making.
Number of participating practices. CMMI will select up to 5,000 practices to participate in CPC+, with preference given to current CPC Classic practices (of which there are approximately 450).
For purposes of CPC+, CMMI defines “practice” as a physical delivery site at which primary care practitioners (defined as physicians, advanced practice registered nurses, clinical nurse specialists, and physician assistants with a specialty designation of general, family, internal, or geriatric medicine) furnish services. A group practice with multiple practice locations, therefore, will need to submit a separate application for each location wanting to participate in CPC+ (even if all locations bill under the same TIN). If a practitioner provides services at more than one such location, the group practice must elect which location under which he or she will be listed for purposes of CPC+.
A multi-specialty group practice is eligible to participate in CPC+, but only the group’s primary care physicians will be considered for purposes of patient attribution (more on the how and why of patient attribution below).
CMMI makes no guarantee that all applicants with the same TIN will be accepted into the program. If CMMI receives more qualified applicants than available slots, it will select participants based on its desire to test the model in multiple practice settings, e.g., geographic location, population served.
Track 1 vs. Track 2. A practice may apply to participate in Track 1 or Track 2. Track 2 is intended for practices with greater experience with practice transformation activities. These practices will receive additional payments in exchange for meeting more demanding program requirements. CMMI intends to accept 2,500 practices into each track. A practice applying for Track 2 must indicate whether it is willing to participate in Track 1 if CMMI determines the practice does not meet the requirements for Track 2.
Practice eligibility. To be considered for CPC+, a practice must meet the following requirements: (1) presently utilize a certified electronic health record (CEHRT); (2) have experience with specified practice transformation activities; (3) have at least 150 attributed traditional Medicare beneficiaries; (4) not charge any sort of concierge fees to Medicare beneficiaries; and (5) not be a present participant in certain other CMMI initiatives (i.e., Accountable Care Organization [ACO] Investment Model, Next Generation ACO Model, and Comprehensive ESRD Care Model).
Practice transformation experience. To qualify for Track 1, a practice must certify that it has experience (1) assigning patients to provider panels; (2) providing 24/7 access for patients; and (3) supporting quality improvement activities.
For Track 2, a practice must also have experience (4) developing and recording care plans; (5) engaging in post-discharge follow-up for emergency room visits and hospital discharges; and (6) maintaining processes to link patients to community-based resources.
Beneficiary attribution. CMMI will attribute to a CPC+ practice those traditional Medicare beneficiaries for whom its practitioners either (a) provided the plurality of primary care services in the most recently available 24-month period (based on allowed charges), or (b) are the most recent provider of chronic care management services. For practices participating in the Medicare Shared Savings Program (MSSP), its CPC+ attributed beneficiaries likely will be different from its MSSP attributed beneficiaries, given minor differences in the attribution models.
CMMI will provide a participating practice with a list of attributed beneficiaries near the beginning of the performance period. That list then will be updated quarterly based on billings for the then-most-recent 24-month period. CMMI attributes beneficiaries by practice, not by individual practitioner. Thus, the departure of a practitioner from a practice will not immediately impact that practice’s beneficiary attribution.
The number of beneficiaries attributed to a practice determines the amount the practice will receive in care management fees and performance-based incentive payments (discussed in the following section).
While a multi-specialty practice is eligible to participate in CPC+, CMMI will only consider the practice’s primary care physicians in determining attribution, and thus the amount of funding received by the practice.
Care Management Fee. A CPC+ practice will receive a per-beneficiary-per-month (PBPM) care management fee. The fee is not subject to beneficiary cost-sharing requirements.
The amount of the fee depends on the degree of risk in the practice’s attributed beneficiaries measured by hierarchical condition categories, or HCCs:
CMMI will establish the range of HCC scores for each tier based on regional data.
Participating practices will be required to report on their spending of care management fees, which are to be used to fund required practice transformation activities (e.g., technology, staff, training). Track 2 practices receive higher PBPM payments due to the additional requirements for these practices.
While a CPC+ practice may bill for transitional care management, it cannot bill for chronic care management for those beneficiaries for which the practice receives a CPC+ care management fee. Subsequent to the announcement of CPC+, CMMI proposed expanded reimbursement for care management services under the Medicare Physician Fee Schedule, including complex chronic care management and care plan development. At present, CMMI has not stated whether CPC+ practices will be precluded from billing under these new codes.
Performance-Based Incentive Payment. CPC Classic practices had an opportunity to earn shared savings if they were successful in reducing the total cost of care for their attributed beneficiaries. CPC+ replaces shared savings with performance-based incentive payments.
In addition to the care management fee, a CPC+ practice will receive a second PBPM payment to incentivize improved quality and efficiency. Again, Track 2 practices will receive higher payments:
However, a CPC+ practice may be required to refund all or a portion of this payment to CMMI depending on the practice’s score on specified performance measures. Thus, CMMI considers this payment to be “at risk,” given this repayment requirement.
Initially, CMMI had proposed that practices participating in the Medicare Shared Savings Program would not be eligible to participate in CPC+. In response to harsh criticism, CMMI moderated its position, deciding to allow up to 1,500 MSSP-participating practices into CPC+. However, these practices will not receive the performance-based incentive payment.
CMMI has proposed the following performance metrics for CPC+ practices, although these metrics are subject to change. CMMI has not specified the scores a practice must attain on these metrics to avoid repayment of the performance-based incentive payment, and it likely will not do so prior to the application deadline.
Track 2 Practices Only: Comprehensive Primary Care Payments. Track 1 practices will continue to bill and collect fee-for-service (FFS) payments for evaluation and management (E/M) services as usual. Track 2 practices also will continue to bill as usual, but the FFS payment will be reduced to account for shifting a portion of the payment into Comprehensive Primary Care Payments (CPCPs) to be paid in a lump sum to participating practices on a quarterly basis.
With the hybrid payment, CMMI hopes to find the “sweet spot” between reduced FFS payments and “upfront” payments to incentivize site-of-service neutrality. A practice’s CPCP will be calculated based on its historical revenue. In making this calculation for 2017, CMMI will inflate the practice’s historical revenue by 10% to account for the increased depth and breadth of primary care services required under Track 2.
Taken together, the CPCP and reduced FFS payments are designed to increase participating Track 2 practices’ revenues by 4% to 6.5% over historical revenues. Practices that elect to receive 40% of payments upfront will see a 4% bonus, while those electing 65% upfront (and thus receiving lower FFS payments) will receive a 6.5% bonus. These bonuses are in addition to the care management and performance-based incentive payments.
Track 2 practices will have the option of easing into CPCP payments during the first two years, according to the following schedule from CMMI’s CPC+ Request for Applications:
The CPCP payments have some strings attached. CMMI will monitor whether a practice’s attributed beneficiaries receive primary care services from other practices, using this information as a marker that the CPC+ practice is not providing adequate care. If CMMI identifies an issue, it will recoup all or a portion of the CPCP from the practice.
Practice Transformation Activities. During its five years of CPC+ participation, a practice will be required to improve its functionality in five areas: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver experience; and (5) planned care and population health. CMMI will regularly update practice requirements in each area, with Track 2 practices expected to perform at a higher level.
In the CPC+ Request for Applications, CMMI offers the following examples of the types of practice requirements to which CPC+ practices may be subject; the initial list will be finalized by the time practices are required to sign formal participation agreements. Again, CMMI intends to increase the complexity and intensity of these requirements over time.
Advanced HIT. All CPC+ practices must meet the following minimum requirements for the use of health information technology: (1) adopt certified health IT modules to meet CEHRT (including upgrading to the 2015 edition by January 1, 2018); (2) use the latest eCQM specifications for all CPC+ measures (including all annual updates); and (3) adopt technology that allows filtering of data by practice site location and by individual NPI/TIN.
Track 2 practices also must complete the following health IT enhancements by no later than January 1, 2019, (more fully detailed in Appendix C of CMMI’s CPC+ Request for Applications):
- Risk stratify practice site population; identify and flag patients with complex needs
- Produce/display eCQM results at practice level
- Systematically access patients’ psychological needs and inventory resources and support to meet those needs (requiring the adoption of certified health IT that meets the 2015 “Social, Behavioral, and Psychological Data” criterion)
- Document/track patient reported outcomes
- Empanel patients to practice/site care team needs
- Establish patient-focused care plan (requiring the adoption of certified health IT that meets the 2015 “Care Plan” criterion)
To demonstrate its ability to meet these requirements, a practice applying for Track 2 must submit a signed letter of support from its HIT vendor(s) that the vendor will work with the practice to satisfy the requirements in a timely manner by either optimizing the practice’s electronic health record or providing other health IT solutions.
Merit-Based Incentive Payment System. In the proposed rule implementing the Merit-Based Incentive Payment System (MIPS), CPC+ is identified as an Advanced Alternative Payment Model (APM), meaning a practitioner participating in the program may qualify for an exception from the MIPS composite performance score and its corresponding adjustment to Medicare Physician Fee Schedule payments in favor of a 5% bonus on such payments.
In two circumstances, however, a practitioner’s participation in CPC+ does not qualify as participation in an Advanced APM:
- A practitioner who is part of an ACO that participates in the Medicare Shared Savings Program (including an ACO in Track 1 of that program) still will be subject to MIPS.
- Beginning in 2018, a CPC+ practitioner whose practice is operated through an organization with more than 50 MIPS-Eligible Clinicians (physicians and non-physician practitioners) will not be considered part of an Advanced APM.
Even if these circumstances do not apply, a CPC+ practitioner will avoid MIPS only if a specified percentage of the Part B patients for whom the practitioner furnishes services are in fact attributed to the practitioner’s practice. The required percentage goes up each year:
- Volume: 20% of all Part B patients are CPC+ attributed beneficiaries in 2017 and 2018; 35% in 2019 and 2020; 50% thereafter
- Value: 25% of all Part B billing is for services furnished to CPC+ attributed beneficiaries in 2017 and 2018; 50% in 2019 and 2020; 75% thereafter
As a result, it becomes more difficult over time for a CPC+ practitioner to benefit from participating in an Advanced APM for purposes of MIPS.
Other Payers. One key feature of CPC+, as compared to other Medicare programs, is multi-payer participation. In all 14 regions, at least one commercial payer has agreed to make available similar payments to participating practices. However, a practice’s acceptance into CPC+ does not automatically qualify that practice for these commercial payer programs; a practice will have to sign separate agreements with these payers. Nor are these programs unique to CPC+ practices; a payer may elect to make its program available to other providers.
CMMI will not provide any detail regarding any commercial payer program, as it considers this information confidential. Thus, a practice must communicate directly with the payer(s) regarding requirements and rewards of that payer’s program.
So Now What? CPC+ is not without its downsides, especially given the monitoring and reporting requirements. Also, CMMI has been less-than-transparent regarding the repayment of the performance-based incentive payment. If, however, one believes primary care practices will need to transform their operations to succeed in the future, CPC+ offers a reasonably well-funded and well-structured opportunity to support these efforts meriting serious consideration.
While a practice may generate more FFS revenue through a formal ambulatory care management program (billing for those services for which CPC+ practices cannot bill), launching such a program requires a significant upfront investment and ongoing self-discipline. Many CPC Classic participants credit the program’s structure and accountability as driving forces in their practice transformation efforts.
PYA consultants can assist your organization in evaluating the pros and cons of CPC+ based on your unique circumstances, including specific financial modeling. Also, our experienced team can help your clinicians understand the program’s impact on their daily work. And, finally, we can support the completion of the CPC+ application to ensure compliance with all requirements. For more information, please contact Martie Ross or Aaron Elias.