CMS is offering no-risk risk contracts to primary-care physicians in its efforts to drum up insurer interest in administering a far-reaching experiment designed to change the way primary care is delivered to as many as 25 million Americans.
The latest wrinkle in the CMS' Comprehensive Primary Care Plus initiative, announced last month, has left many of the insurers the agency wants to see participating in the program scratching their heads.
“CMS leaves many unanswered questions, not the least of which is how you can have capitation without downside,” said Ceci Connolly, CEO of the Alliance of Community Health Plans, which represents 22 not-for-profit insurers with their own provider networks.
Under CPC Plus, the CMS and other insurers would pay physicians a monthly fee for patient primary-care visits. The new model aims to improve health outcomes and lower cost not only for Medicare beneficiaries, but also consumers enrolled in commercial plans and other coverage options such as insurer-managed Medicaid plans.
The model will be implemented in up to 20 regions and could include up to 5,000 practices with 20,000 doctors and clinicians.
As originally proposed, CPC Plus will have two tracks. Under track one, the CMS will pay a monthly fee for specific services in addition to the fee-for-service Medicare payments.
But in track two, practices will receive an upfront monthly care-management fee and reduced fee-for-service payments. This hybrid model is designed to let practices provide care outside of the traditional face-to-face encounter, the agency said.
Companies offering preferred provider organization (PPO) and high-deductible plans told the CMS they could not participate in the program because of legal restrictions in many states. Specifically, many states passed laws in the late 1980s and early 1990s that prohibited non-HMO plans from offering capitated or risk-based payments to physicians as outlined in track two.
HMOs were allowed to continue offering such payments as they were more tightly regulated than other private health plans, said Dr. Peter Kongstvedt, a senior health policy faculty member at George Mason University.
The conflict led plans to ask the CMS if it would be OK to participate only under track one. The CMS responded in a newly released frequently asked questions document that plans are strongly encouraged to partner in both tracks of CPC+. If they don't get enough interest from plans in a region willing to do both tracks, they may not launch the model in those places, the CMS said.
The agency has said in the past it is hopeful that there would be strong commercial plan interest in track two, which is estimated to save about $2 billion over the five-year program. Track one was tagged as budget-neutral.
To address the concerns around non-HMO private plans offering capitated or risk-based payments to physicians, the CMS offered plans some potential alternatives that may be allowable in their states. The CMS said plans in track 2 could do partial capitation without downside risk, full capitation without downside risk, sub-capitation without downside risk, and episodic payment.
Payer industry were skeptical that there could be capitation without risk. “Capitation with no downside is a euphemism,” Kongstvedt said. However, it may allow states with restrictions on non-HMO plans to participate in the model, he said.
Payers interested in the model must submit proposals by June 8. The CMS is slated to announce the selected CPC+ regions by July 15. The initiative will formally launch on Jan.1, 2017.