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CMS’s New Comprehensive Primary Care Plus Program: Another Signal to Healthcare IT Leaders to Step It Up

June 16, 2016
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A recent analysis of CMS’s new Comprehensive Primary Care Plus initiative reinforces the reality that we’ve reached a tipping point on value-based reimbursement in healthcare

A recent analysis published by healthcare experts at the Brookings Institution was one that I found very compelling. Paul Ginsburg, Margaret Darling, and Kavita Patel of Brookings on May 31 published their analysis, “CMMI’s New Comprehensive Primary Care Plus: Its Promise and Missed Opportunities,” which looked at the Comprehensive Primary Care Plus (CPC+) initiative, announced on April 11 by the Center for Medicare and Medicaid Innovation (CMMI), a division of the federal Centers for Medicare & Medicaid Services (CMS).

Let’s begin by providing some background on the CPC+ initiative, as many readers may not yet be familiar with it. When it was announced on Apr. 11, the CMS announcement included a statement by Patrick Conway, M.D., CMS deputy administrator and chief medical officer. In the statement, Dr. Conway said that “Strengthening primary care is critical to an effective health care system. By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists, we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars. The Comprehensive Primary Care Plus model represents the future of health care that we’re striving towards.”

Among the key elements of the initiative, which itself is built on the Comprehensive Primary Care initiative launched in late 2012, the five-year CPC+ model will, among other things, “support patients with serious or chronic diseases to achieve their health goals; give patients 24-hour access to care and health information; deliver preventive care; engage patients and their families in their own care; work together with hospitals and other clinicians, including specialists, to provide better coordinated care,” according to the Apr. 11 press release. Primary care practices will participate in one of two tracks, with both tracks requiring those practices to perform the functions and meet the criteria for the program, but those practices in Track 2 will also “provide more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs,” according to the CMS announcement.

What’s more, there is a major health IT element to the program. As CMMI noted, “To promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. The payments under this model encourage doctors to focus on health outcomes rather than the volume of visits or tests.” In that context, “Practices in both tracks also will receive data on cost and utilization. Optimal use of Health IT and a robust learning system will support them in making the necessary care delivery changes and using the data to improve their care of patients. Track 2 practices’ vendors will sign a Memorandum of Understanding (MOU) with CMS that outlines their commitment to supporting practices’ enhancement of health IT capabilities. These partnerships will be vital to practices’ success in the care delivery work and align with the Office of the National Coordinator for Health IT priority to ensure electronic health information is available when and where it matters to consumers and clinicians.”

Now, onto the Brookings Institution analysis. As Ginsburg, Darling, and Patel write, “Track 2, the more interesting part of the initiative, is for practices that are already capable of carrying out the primary care functions and are ready to increase their comprehensiveness. In addition to a higher monthly care management fee ($28), practices receive Comprehensive Primary Care Payments. These include a portion of the expected reimbursements for Evaluation and Management services, paid in advance, and reduced regular fee-for-service payments. Track 2 also includes larger rewards than does Track 1 for meeting performance thresholds. The combination of larger per beneficiary monthly payments and lower payments for services is the most important part of the initiative,” they write. “By blending capitation (monthly payments not tied to service volume) and FFS (fee-for-service), this approach might achieve the best of both worlds.”