CMS Moves forward with CPC+ that Includes PMPM to PCPs

July 19th, 2016

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. 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

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)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.

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.


Expert Witness for Future Medical Costs : Personal Injury, Medical Malpractice, Product Liablity, under ACA

July 7th, 2016

In my work as an Expert Witness, attorneys in personal injury, product liability, and medical malpractice cases sometimes retain our services to opine on the cost of future care under the Patient Protection and Affordable Care Act (ACA).

Several factors must be evaluated including age, life expectancy, and potential eligibility for Medicaid Expansion in those states that elected to expand.  Different levels of care, out of pocket expenses and maximum out of pocket assumptions must be considered.  Some types of care are also treated differently under the Affordable Care Act. Disability and waivers may come into play.

As an expert witness in personal injury cases, depending on whether past or future costs are a factor, we may ask for medical records and other data.   Life care plans or supplemental data from a different medical expert or life care planner expert may also be considered. The same holds true of expert witness work in this context for medical malpractice cases.


This proposed rule would update the Medicaid Eligibility Quality Control (MEQC) and Payment Error Rate Measurement (PERM) programs based on the changes to Medicaid and the Children’s Health Insurance Program (CHIP) eligibility under the Patient Protection and Affordable Care Act. This proposed rule would also implement various other improvements to the PERM program. Source: Federal Register / CMS

An expert witness may be required to opine regarding diagnostic imaging, evaluation and management (E&M) primary care doctor visits, and visits to specialists for pain management, orthopedic surgery, physical therapy, home health care, cardiology or other episodic or ongoing modalities of care.

In our experience, one strategy is to work within the Superior Court or State Court and then appeal to a higher court. Some courts have elected not to hear testimony regarding future care costs under the Affordable Care Act, only to potentially find that it is the law of the land and now has an impact.  This is being tested now in several states.

There are also unintended consequences in product liability cases. Third party liability and subrogation may also be affected in motor vehicle / automobile accidents where auto insurance and health insurance are factors, depending on the State.

An expert witness may also be needed to opine on regional variances in the cost of care.  The cost of medical care in San Francisco will likely be far higher than the cost of care for the same medical procedure in Akron Ohio.   To provide a valid market study, national rates compared to both charges and possibly net reimbursement may also be relevant in testimony and affect the expert witness opinion regarding the Affordable Care Act and regional medical costs.

Building on the foundation of the ACA, Meaningful Use of Electronic Health Records, and PQRS quality measures we have a new 900 page regulation which will again re-factor calculations for healthcare costs: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  Expert witness work will, I predict require re-factoring to allow for MACRA and the Affordable Care Act in the future. More on this new regulation which was posted for public comment in May 2016 in future posts.

Michael Arrigo  serves as an expert witness regarding the Affordable Care Act for personal injury, medical malpractice, and product liability cases.  He has given opinions in Superior, State, and Federal Court for cases in several venues across the U.S.  You may reach him for his Expert Witness CV, Case List, fee schedule and retainer agreement by clicking this link.

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