Another Quality Measure is Being Proposed by CMS But this Focuses on PMPM Payments up Front.

According to CMS, the Original Comprehensive Primary Care (Original CPC) Model, is being replaced with the Comprehensive Primary Care Plus (CPC+) which is intended to allow health care provider practices to apply for one of two program tracks, with increasing payment and care redesign expectations from Tracks 1 to 2.

  1. Track 1 targets practices with multi-payer support that have the health information technology and other basic infrastructure necessary to deliver comprehensive primary care. In Track 1, participating practices will work for five years to implement and develop comprehensive primary care capabilities. In addition to their Medicare fee-for-service (FFS) payments, Track 1 practices will receive a care management fee (CMF) that averages $15 per beneficiary per month (PBPM) in support of this work. Track 1 is the most similar to the Original CPC Model, but CMS has refined the eligibility criteria, care delivery requirements, and incentive payment opportunities to incorporate lessons learned in the Original CPC Model.
  2. Track 2 targets practices proficient in comprehensive primary care that are prepared to increase the depth, breadth, and scope of medical care delivered to their patients, particularly those with complex needs. In support of this advanced work, payment is redesigned to be a hybrid of FFS paid at the time of the visit and FFS prospectively paid through what CMS is calling Comprehensive Primary Care Payments (CPCPs). Beyond the FFS/CPCP payments, Track 2 practices will also receive an enhanced care management fee averaging $28 PBPM to support care management, enhanced to support the more stringent requirements for Track 2 practices and to enable more comprehensive care for their patients with more complex needs.

According to CMS, Tracks 1 and 2 will offer a prospective performance-based incentive payment to reward practices for performance on quality and utilization measures that lead to reductions in total costs of care. The goals of CPC+ are (1) accommodating practices at different levels of readiness for and interest in transformation, and (2) innovating care delivery and payment to empower primary care practices to provide more comprehensive care that meets the needs of all their patients, particularly those with complex needs.

Authority for CPC+ : Social Security Act Section 1115A

Section 1115A of the Social Security Act provides authority for CMS to create CPC+, a redesign to include different care delivery requirements and payment options for different U.S. primary care practices. Also, CMS states that multi-payer involvement is essential to CPC+, since the goal is to ensures financial support for practices to make changes to care delivery. Further, when payers share cost, utilization, and quality data1 with practices at regular intervals, it facilitates practices’ ability to manage their patient population’s health, leading to smarter spending, better care, and healthier people. CPC+ will be regionally based and there will be a staged application process (payer solicitation period April 15, 2016 to June 8, 2016; practice application period August 1, 2016 to September 15, 2016). The selection of payers will inform the selection of regions; the practice application will be open in only these to-be-determined regions. Payers must support practices in both tracks. Practices will apply for the track (1 or 2) for which they are eligible.

1 All data sharing and data analytics in the CPC+ will comply with applicable law, including the privacy and security requirements promulgated under the Health Insurance Portability and Accountability Act (HIPAA)

CMS Application Policies and Impacted Medicare Beneficiaries

CMS will accept up to 2,500 practices into each Track. In aggregate, up to 3.5 million Medicare FFS beneficiaries, as well as millions of other Medicare Advantage, Medicaid, and commercial patients, could be impacted over the course of this model.

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