Medicare Compliance & Reimbursement

But CPC+ model could create dire problems for ACOs’ MSSP participation.

In a further move toward the volume-to-value migration in Medicare reimbursement, the Centers for Medicare & Medicaid Services (CMS) recently offered up yet another alternative payment model. But you can’t have it all — find out why you may soon face a difficult decision.

CMS Makes a Bold Move with New Model

On April 11, CMS’s Center for Medicare and Medicaid Innovation (CMMI) announced the new Comprehensive Primary Care Plus (CPC+) model, which is its largest-ever multi-payer initiative to improve primary care. CMS will implement the model in up to 20 regions and involve up to 5,000 primary care practices. The model will run for five years.

Background: The CPC+ model builds on the Comprehensive Primary Care Initiative (CPCI), which CMS launched in 2012. The CPCI will conclude at the end of 2016.

The CPC+ model is CMS’s “largest investment in advanced primary care to date,” stated an April 11 Journal of the American Medical Association (JAMA) article by Laura Sessums, JD, MD, Sarah McHugh, MPH, and Rahul Rajkumar, MD, JD. “CPC+ represents the next step in advanced primary care for both care delivery and payment design.”

“Primary care is central to a high-functioning healthcare system,” the JAMA article said. “Advanced primary care medical homes are practices supported by payment, health information technology, and data that transform their delivery of care while accountable for the cost and quality of care their patients receive.”

CPC+ Offers Up-Front Incentives

The model aims to improve care quality and reimbursement, providing “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,” CMS states.

The CPC+ model will require participating primary care practices to deliver preventive care, engage patients and their families in their own care, and support patients with serious or chronic diseases to achieve their health goals. Also, the model will help primary care practices provide patients with 24-hour access to care and health information, as well as to work together with hospitals and other clinicians (including specialists) to provide better coordinated care.

Participating practices will enroll in one of two tracks. In Track 1, practices must perform the functions and meet the basic criteria described above. For Track 2, practices must additionally provide more comprehensive services for patients with complex medical and behavioral health needs. If appropriate, Track 2 participants must perform a systematic assessment of such patients’ psychosocial needs and an inventory of resources and supports to meet those needs, according to CMS.

Understand the Payment Structure

Track 1 practices will receive a monthly care-management fee in addition to the fee-for-service (FFS) payments under the Medicare Physician Fee Schedule. Track 2 participants will also receive a monthly care-management fee and, instead of full Medicare FFS payments for Evaluation and Management (E/M) services, will receive a hybrid of reduced Medicare FFS payments and upfront comprehensive primary care payments for those services.

Snag: Practices participating in both tracks will receive upfront incentive payments that CMS will either allow you to keep or force you to repay, depending on your performance on quality and utilization metrics.

The prepaid incentive payment for Track 1 practices is $2.50 per beneficiary per month, and for Track 2 the payment is $4.00 per beneficiary per month, according to Martie Ross, JD, principal with Pershing Yoakley & Associates, P.C.

“The payments under this model encourage doctors to focus on health outcomes rather than the volume of visits or tests,” CMS claims. And the hybrid payment design for Track 2 practices “will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter.”

You Have a Tough Choice to Make

Problem: But CMMI won’t allow providers to participate in both CPC+ and the Medicare Shared Savings Program (MSSP). So now providers are wondering how they should decide between participating in CPC+ versus joining a MSSP accountable care organization (ACO), Ross points out.

Because providers participating in the CPCI were eligible for shared savings payments, they were not eligible to also participate in the MSSP when that program launched shortly after the CPCI’s 2011 application period, Ross notes. Even though there are no shared savings payments in the CPC+ model, participating providers still cannot dually participate in the MSSP.

ACOs will likely be the biggest losers due to the choice between participating in the CPC+ model versus the MSSP. ACOs depend on primary care providers for beneficiary attribution, Ross explains. And if providers decide that the immediate payment under the CPC+ model is more desirable than waiting several months for a potential payout under the MSSP, ACOs could lose providers.

Pitfall: If ACOs lose their current primary care participants and can’t recruit new ones, they may be forced out of the MSSP, Ross warns.

Pay Attention to Model’s Timing

CMS will base its selection of regions to participate in the CPC+ model on the amount of interest generated from multiple payers to support practices’ participation. Payers can submit proposals to partner in CPC+ through June 1, 2016.

Shortly thereafter, CMS will select the regions with “sufficient interest” and accept applications from practices in those regions from July 15 through Sept. 15, 2016. The CPC+ model will begin in January 2017.

Insight: Because providers won’t find out whether CMS selects their region for CPC+ participation until summer, they may participate in an MSSP ACO conditioned upon their selection for the CPC+ model, Ross says. This creates uncertainty that could harm the investments needed for the MSSP to be successful.

Resources: For more information on the new CPC+ model, go to http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus. Also, to access the recent article in JAMA about the CPC+ model, visit http://jama.jamanetwork.com/article.aspx?articleid=2513625.