The Centers for Medicare & Medicaid Services (CMS) recently announced Comprehensive Primary Care Plus (CPC+), the latest payment model for primary care practices. CPC+ is a multi-payor risk and incentive based payment model that makes notable changes to how primary care practices are paid in order to improve the quality of care and decrease excess healthcare utilization. Based on lessons learned from the Comprehensive Primary Care model, CMS claims this new payment method will reduce the overall cost of care for insurance providers while increasing the quality of care beneficiaries receive.
CPC+ is divided into two tracks, each with their own participation requirements and payment methods. Practices interested in either track must be able to demonstrate their eligibility by proving they can meet the Five Primary Care Functions, use the certified health IT required of each track, and must be geographically located within the 20 regions where CMS has managed to partner with local insurance payors. Track 2 eligibility differs from Track 1 by requiring practices to use enhanced health IT in order to achieve the higher standard of care delivery change expected of practices in this track.
Apart from being compensated under the Medicare fee-for-service method, Track 1 and Track 2 have significant differences between the amount practices are compensated. For example, a Track 1 practice with a Tier 2 risk category patient is paid a monthly $8 Care Management Fee and a Performance Based Incentive Payment (PBIP) of $2.50 per beneficiary per month prepaid at the start of the year. A Track 2 practice with a similar patient, however, receives a CMF payment of $11 per month and a PBIP of $4 per beneficiary. Additionally, Track 2 practices receive a portion of their Evaluation & Management Claims upfront under a Comprehensive Primary Care Payment (CPCP). Naturally, Track 2 practices are also held to higher standards of quality and healthcare utilization, both of which will be measured by using CMS’ Electronic Clinical Quality Measures (eCQMs) and Healthcare Effectiveness Data and Information Set (HEDIS). Practices involved with Medicare may be familiar with these quality and utilization measurement sets.
CMS has announced that only 2,500 practices will be admitted to participate in each track. Should there be an excess of eligible applicants, a lottery system will be used to select the final group of participants.
Primary care practices should keep in mind that CMS allows for its regional partners to have key payment, quality, and data sharing elements that are different from its own guidelines but must still serve to achieve the greater purpose of CPC+. Additionally, a primary care practice that has merely applied to participate in CPC+ is not legally bound to participate if its application is accepted. Additionally, the PBIP payment may be revoked by CMS at any time if the practice in question has not met the quality and utilization standards.
