CMS unveils Primary Care Plus

With less than a year to go in the Obama administration's public-private push for better care management among primary-care providers, the CMS has rolled out a souped-up care-delivery model.

But getting the new five-year demonstration up and running relies on the agency's ability to persuade sufficient numbers of commercial health plans and doctors that it's worth the effort.

The CMS is now recruiting physician practices and state and commercial payers to test the new model in 20 regions of the country, encompassing up to 20,000 doctors and 25 million patients.

Its goal is nothing less than to upend how primary care is delivered and paid for. As CMS officials described the initiative in a piece published last week in JAMA, they want to make physician practices “incentive neutral” relative to the mode of care they deliver and render them no longer “tethered to the 20-minute office visit.”

But state regulatory hurdles and bad experiences with the CMS' earlier pilot program could lead to poor participation in certain parts of the country. Experts say the model also could steer providers away from other alternative payment models.

Under the Comprehensive Primary Care Plus (CPC+) initiative unveiled last week, the CMS and other payers will pay providers a monthly fee for patient care-management services.

A similar but smaller pilot program launched in 2012 that ends this year—the Comprehensive Primary Care initiative, or CPC—reduced total monthly expenditures by 2% per beneficiary in Medicare Parts A and B. Savings attributed to the enhanced care coordination were nearly enough to offset the costs of its fees, but it didn't generate any net savings.

In the new CPC+ program, providers can participate in one of two tracks. In the first track, the CMS will pay a risk-stratified monthly fee for each beneficiary's care- management services, in addition to fee-for-service Medicare payments for primary-care visits.

In the second track, physician practices will receive reduced Medicare fee-for-service payments and more generous upfront care-management payments. The CMS says this “hybrid” payment model will give providers more flexibility to provide care outside of traditional face-to-face encounters. For example, clinical practices might offer telemedicine visits or simply provide longer office visits for patients with complex needs.

In both tracks, instead of offering practices the potential reward of sharing in the savings they generate, providers will have to return incentive payments (awarded per beneficiary, per month) if they fail to meet cost and quality targets.

The agency estimated that Track 1 will be budget-neutral and that Track 2 will save about $2 billion over the initiative's five-year run, assuming physicians are willing to take the risk.

The project will launch only in those regions where there is “a critical mass of interested payers,” the CMS said, and experts say many plans will be prohibited from participating in Track 2 because of their state's insurance regulations.

Those regulations came in response to reports about poor quality of care provided by physician practices that received risk-based payments in the late 1980s and early 1990s. Many states subsequently passed laws restricting those arrangements to tightly regulated HMOs, said Dr. Peter Kongstvedt, a senior health policy faculty member at George Mason University.

But relatively few consumers are now enrolled in commercial HMO plans, although state laws may prohibit other types of plans from participating.

Regulations aside, the new program's reliance on interest from commercial payers means it may not reach certain areas of the country.

“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 Institution and a former policy director for the Obama administration.

Some private plans may be leery of the CPC+ initiative because of negative experiences with the first CPC program. For example, last year Cigna Corp. wrote to the CMS asking that the program not be expanded.

“Continuing (the program) would be a crutch for providers, and would reduce incentives for them to join more innovative and better-run provider groups who are contracting with payers for more advanced patient-centered medical homes and accountable care arrangements,” Cigna wrote.

Another potential pitfall for the CPC+ initiative is its potential to muddle other efforts to overhaul care delivery and payment. The Medical Group Management Association said last week that it was unclear how the initiative would mesh with the Medicare Access and CHIP Reauthorization Act, or MACRA, which will reward practices for participating in alternative payment models, beginning in 2019.

“It's very difficult for physician practices to make a decision to participate,” said Anders Gilberg, the MGMA's senior vice president of government affairs. “These models are being rolled out in a piecemeal fashion without any overarching understanding of where they are going to fit in with MACRA.”