The Comprehensive Primary Care Plus initiative will be implemented in up to 20 regions and include up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians. The program would collaborate with commercial, state, and other federal insurance plans. Therefore, the CMS has yet to identify regions since it must first assess interest by payers and providers.
Provider practices will be able to participate in two ways. In Track 1, the agency will pay a monthly fee to practices that provide specific services. That fee is in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for care.
Providers currently perform a service and then submit a claim to Medicare for payment.
In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-for-service payments for evaluation and management services, they will receive reduced Medicare fee-for-service payments and up-front comprehensive primary-care payments. This hybrid payment design will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter, the agency said.
For example, practices might offer telemedicine visits or simply provide longer office visits for patients with complex needs.
Practices in both tracks will receive upfront incentive payments that they might have to repay if they do not perform well on quality and utilization metrics. The CMS initially will pay primary care practices $15 per beneficiary per month for care management under Track 1 and an average of $28 a month under Track 2 to support enhanced, coordinated services on behalf of Medicare fee-for-service beneficiaries.
Participating payers will also offer higher payments to primary care practices that are designed to support them in providing high-quality primary care on behalf of their members.
Starting April 15, the CMS will solicit payer proposals to partner in CPC. Once it gets a sense of which insurers want to partner and in which regions, the CMS will solicit applications from nearby practices. That solicitation will take place between July 15 and Sept. 1, 2016.
Relying on private payers as a way of determining where this model will launch concerns some experts.
“The problem is that the regions with the least payer interest will be the ones that need it the most,” said Dr. Kavita Patel, a senior fellow at the Brookings Institute and a former policy director for the Obama administration.
Industry reaction to the payment model reflected confusion over how this will work with forthcoming physician payment changes taking place under Medicare Access and CHIP Reauthorization Act (MACRA). MACRA eliminated the sustainable growth-rate formula physicians were once paid for in favor of two options.
The Merit-based Incentive Payment System (MIPS) takes into account quality measures and providers' implementation of electronic health records that comply with meaningful-use requirements. MIPS also incorporates the value-based payment system that was part of the Affordable Care Act. That system rewards or penalizes providers depending on how they score.
Providers can be exempt from being evaluated for quality if they participate in an alternative payment model.
Since the start of the year, the CMS has announced various quality pay model initiatives and it's unclear if any of them, including the primary care payment model could qualify as an alternative payment model said, Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association.
The CMS has yet to release guidance on what will qualify as an APM. The new payment scheme under MACRA begins Jan. 1, 2019.
“It's very difficult for physician practices to make a decision to participate," Gilberg said. “These models are being rolled out in a piecemeal fashion without any overarching understanding of where they are going to fit in with MACRA.”
Others are pleased with the primary care model because moves away from a high volume/low quality care strategy taking place under fee-for-service to one that addresses patient needs, said Dr. Wanda Filer, president of the American Academy of Family Physicians.
Currently, providers are not paid for non-face-to-face activities such as consulting with other providers to coordinate care, or answering e-mails from patients.
This model will give doctors the flexibility to spend the time needed on the sicker patients, while exploring telemedicine-based strategies for those who are healthier.
“This model makes sure patients are getting the right kind of care, at the right time,” Filer said.
To be eligible for the incentives under the programs, practices will need to ensure:
• Services are accessible, responsive to an individual's preference, and practices should offer enhanced in-person hours and 24/7 telephone or electronic access.
• Patients at highest risk receive proactive, relationship-based care-management services to improve outcomes.
• Care is comprehensive and practices can meet the majority of each individual's physical and mental healthcare needs, including prevention. Care is also coordinated across the healthcare system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits.
• It is patient-centered, recognizing that patients and family members are core members of the care team, and actively engages patients to design care that best meets their needs.
• Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements in care and to develop new capabilities.
The CMS will accept practice applications in the determined regions from July 15 through Sept. 1.