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.”