Time to Pay Attention to CPC-Plus—And Its Enormous Potential to Reshape Primary Care | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Time to Pay Attention to CPC-Plus—And Its Enormous Potential to Reshape Primary Care

May 22, 2017
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Participants in the CPC+ program face challenges and opportunities in working to reshape primary care delivery

The announcement on May 18 that the federal Centers for Medicare and Medicaid Services (CMS) had added four new regions of the United States in which it was encouraging participation on the part of primary care practices, was significant in several different ways.

To begin with, CMS officials, in making their announcement last Thursday, noted that 2,891 primary care practices had already been participating in Round 1 of the Comprehensive Primary Care Plus program, known informally as CPC+. What’s more, 54 payers were already involved in Round 1 of CPC+, working in nine regions, some of which were states. This map/guide lists the regions and the health insurers involved, which included Arkansas, Colorado, Hawaii, Greater Kansas City (three counties in Missouri and two in Kansas, in the Kansas City metropolitan area), Michigan, Montana, New Jersey, the North Hudson-Capital Region of New York (14 counties), the Ohio and Northern Kentucky region (all counties in Ohio, plus four counties in Kentucky), Oklahoma, Oregon, the Greater Philadelphia Area (five counties in southeastern Pennsylvania), Rhode Island, and Tennessee. Now, adding Louisiana, Nebraska, North Dakota, and the Greater Buffalo Region (Erie and Niagara Counties) in New York state, will significantly expand CPC+’s footprint nationwide.

But it’s far more than geography of significance here. To begin with, there are the program’s core payment elements, as CMS officials quote them on their website. As they explain, “To support the delivery of comprehensive primary care, CPC+ includes three payment elements:

1. Care Management Fee (CMF): Both tracks provide a non-visit-based CMF paid per-beneficiary-per month (PBPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for the practice’s specific population. The Medicare fee-for-service (FFS) CMFs will be paid to the practice on a quarterly basis.

2. Performance-Based Incentive Payment: CPC+ will prospectively pay and retrospectively reconcile a performance-based incentive based on how well the practice performs on patient experience measures, clinical quality measures, and utilization measures that drive total cost of care.

3. Payment under the Medicare Physician Fee Schedule: Track 1 continues to bill and receive payment from Medicare FFS as usual. Track 2 practices also continue to bill as usual, but the FFS payment will be reduced to account for CMS shifting a portion of Medicare FFS payments into Comprehensive Primary Care Payments (CPCP), which will be paid in a lump sum on a quarterly basis absent a claim. Given our expectations that Track 2 practices will increase the comprehensiveness of care delivered, the CPCP amounts will be larger than the FFS payment amounts they are intended to replace.”

And even though Comprehensive Primary Care Plus is still quite a new program—the Round 1 performance program began on January 1 of this year—it builds on the advances made in the original Comprehensive Primary Care program, launched in October 2012. As a report from Mathematica noted in April 2016, meaningful, if modest, gains were made through that program. A very large team of researchers, led by Deborah Peikes, sorted through what had been learned in the original CPC program, as of April of last year.

As the authors wrote in their report on CPC, “As is to be expected at this stage of the initiative, practices have experienced some challenges in changing care delivery and have more work to do during the remaining two years of the initiative. Qualitative data collected from a small number of practices show several common challenges of transformation, such as difficulties in changing workflows and procedures, incorporating new staff roles such as care managers into the primary care team, and communicating with other providers when a lack of interoperability exists. Despite being only midway through the four-year initiative,” they noted, “CPC’s care delivery improvements are generating small improvements in outcomes for Medicare FFS [fee-for-service] beneficiaries, the focus of our quantitative evaluation. Between its first and second year, CPC appears to have had small, statistically significant favorable effects on the percentage of respondents in CPC practices choosing the most favorable ratings for three of six composite measures of patient experience over time relative to respondent ratings of comparison practices: (1) getting timely appointments, care, and information (2.1 percentage points, (2) providers supporting patients in taking care of their own health (3.8 percentage points); and (3) shared decision making (3.2 percentage points). Thus, the findings suggest that the substantial changes in CPC practices’ staffing, care processes, and workflows did not worsen patient experience in the short run, and even improved it modestly.”

Those may seem like relatively small advance, but it’s also true, the Mathematica researchers found, that “CPC reduced average monthly Medicare expenditures without care management fees by a statistically significant $11 per beneficiary per month (PBPM), or 1 percent, over the initiative’s first two years, with [that] $11 per beneficiary per month translat[ing] to an estimated cumulative savings in Medicare expenditures without fees of $91.6 million. These cost reductions are driven by reductions in service use, especially hospitalizations and skilled nursing facility. While not a large component of total expenditures, there was also a 3 percent reduction in primary care visits, non-billable calls, emails, and care management interactions, supported by the CPC fees, may have supplanted or reduced the need for primary care office visits. There was no effect on visits to specialists,” the authors of the study added.

Meanwhile, a different, also large, team of researchers looked at the initial Comprehensive Primary Care program, publishing an article online on August 5, 2016, in NEJM Catalyst, a section of The New England Journal of Medicine. Led by Stacey B. Dale, the team’s article was entitled “Two-Year Costs and Quality in the Comprehensive Primary Care Initiative.”

“We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices,” the article’s authors wrote. Those researchers emphasized the small differences in utilization and costs, writing in their conclusion that, “Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience.”

Now, here’s a particularly important section in the NEJM Catalyst article: “The practice survey and site visits indicated that efforts to undertake transformation were often challenging. Common challenges included refining workflows and procedures for the purpose of implementing, documenting, and reporting initiative requirements, trying to incorporate new staff roles (such as that of care manager) into the primary care team, and trying to overcome the incompatibility of EHRs [electronic health records] when attempting to communicate with other providers,” the researchers wrote. “Initiative practices began to stratify patients according to risk systematically and hired or repurposed staff to help manage the care of high-risk patients, particularly with respect to providing patient education, monitoring the care of patients with chronic conditions, and providing follow-up after discharge from the hospital or emergency department. To improve patients’ access to care, practices worked on increasing patients’ use of patient portals, decreasing wait times for appointments, increasing telephone access to the practice, and increasing after-hours access to clinicians by means of e-mail, telephone, or in-person visits.”

All of these findings, from both articles written by both teams of researchers, about the original CPC, speak to the opportunities and challenges facing the participants in the new CPC+ program. Interoperability, communications among clinicians and patient care organizations, and refining workflows in order to perform the intensive data collection, measurement, and data reporting underpinning this program, remain huge challenges. And they speak to some of the core challenges facing all primary care practices in the United States going forward, whether they participate in CPC+ or not—the need to reengineer physician practice-patient communications, engage patients, and rework care management at some fundamental levels.

But therein lie many opportunities as well. What CPC program participants have been learning, and what CPC+ program participants will be learning going forward, could help reshape care delivery at the primary care level—the potential here is enormous. And healthcare IT leaders will need to be broadly and deeply involved at all levels, working as a team with clinician leaders and frontline clinicians to get it done. And, given the five-year framework of CPC+, you can bet we’ll be hearing about developments in this critical initiative going forward. Meanwhile, there’s not a moment to waste for the healthcare IT leaders and professionals working with the leaders of primary care practices involved in CPC+, in order to make rapid advances to show that it can be done. I’m excited by the prospects, and will be watching the forward evolution of this program very closely, in the coming months and years.


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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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