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Comprehensive Primary Care Plus (CPC+) 2018 Payer and Practice Solicitation

Date
2016-12-15
Title
Comprehensive Primary Care Plus (CPC+) 2018 Payer and Practice Solicitation
Contact
press@cms.hhs.gov

Comprehensive Primary Care Plus (CPC+) 2018 Payer and Practice Solicitation

Strengthening primary care is critical to promoting health and reducing overall health care costs in the U.S. Building on lessons learned from the Comprehensive Primary Care (CPC) initiative and input from the 2015 Request for Information on Advanced Primary Care Model Concepts, the Centers for Medicare & Medicaid Services (CMS) introduced the Comprehensive Primary Care Plus (CPC+) model on April 11, 2016. The first round of this five-year multi-payer model will begin in January 2017 and run through 2021. CMS will also offer a second round of CPC+ to begin in January 2018 and run through 2022.

CPC+ aims to enable primary care practices to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care. CPC+ is an advanced primary care medical home model that rewards value and quality by offering an innovative payment structure to support delivery of comprehensive primary care. The model will contribute to the goals set by the Administration of having 50 percent of all Medicare fee-for-service payments made via alternative payment models by 2018. The model will offer two tracks with different care delivery requirements and payment methodologies to meet the diverse needs of primary care practices.

CMS is partnering with 54 payers in the following 14 regions for CPC+ Round 1. Regions were selected based on payer alignment and market density to ensure that CPC+ practices have sufficient payer supports to make fundamental changes in their primary care delivery. Practices in these regions applied to CPC+ from August 1 to September 15, 2016, and selected practices will begin participation on January 1, 2017.

1. Arkansas: Statewide
2. Colorado: Statewide
3. Hawaii: Statewide
4. Kansas and Missouri: Greater Kansas City Region
5. Michigan: Statewide
6. Montana: Statewide
7. New Jersey: Statewide
8. New York: North Hudson-Capital Region
9. Ohio: Statewide and Northern Kentucky Region
10. Oklahoma: Statewide
11. Oregon: Statewide
12. Pennsylvania: Greater Philadelphia Region
13. Rhode Island: Statewide
14. Tennessee: Statewide

To broaden opportunities for Medicare primary care clinicians to participate in Advanced APMs under the Quality Payment Program, CMS will offer a second round of solicitations in 2017 for payers and practices to partner in CPC+ for a 2018 performance year start. In mid-February 2017, CMS will welcome proposals from payers in up to 10 new regions, as well as new payers in any of the existing 14 CPC+ regions. Existing payer partners in the 14 CPC+ regions do not need to submit new proposals in those regions. Based on payer interest and alignment, CMS will select new payer partners in both existing and new regions. Practices located within new Round 2 regions may apply in late spring or early summer 2017. In order to ensure a robust evaluation of CPC+, CMS will not accept applications for new practices in CPC+ Round 1 regions.

General Model Overview

Model Design

CPC+ is a regionally-based, multi-payer care delivery and payment model that includes two separate tracks. Depending on their experience, practices may participate in either Track 1 or Track 2 of CPC+. Track 1 is the choice for practices ready to build the capabilities to deliver comprehensive primary care. Track 2 is targeted to practices that have built these capabilities arnd are poised to increase the comprehensiveness of care and improve care for patients with complex needs. The program requirements ensure that practices in each track will be able to build capabilities and care processes to deliver better care, in order to achieve a healthier patient population. Payment redesign will offer the ability for greater cash flow and flexibility for primary care practices to deliver high quality, whole-person, patient-centered care and lower use of unnecessary services that drive total costs of care. CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data, to guide their decision making.

Practices in both tracks will be expected to make changes in the way they deliver care, centered on key Comprehensive Primary Care Functions: (1) Access and Continuity; (2) Care Management; (3) Comprehensiveness and Coordination; (4) Patient and Caregiver Engagement; and (5) Planned Care and Population Health.

Care Management Fee

CMS will provide prospective monthly care management fees (CMFs) to Track 1 and 2 practices. As highlighted in the table below, the Medicare CMFs will average $15 per-beneficiary per-month (PBPM) across 4 risk tiers in Track 1. In Track 2, the Medicare CMFs will average $28 PBPM across 5 risk tiers, which includes a $100 CMF to support care for Medicare beneficiaries with the most complex needs. Practices may use this enhanced, non-visit-based compensation to support augmented staffing and training needed to meet the model requirements according to the needs of their Medicare attributed patient population.

Risk Tier Attribution Criteria Track 1 Track 2
Tier 1 1st quartile HCC $6 $9
Tier 2 2nd quartile HCC $8 $11
Tier 3 3rd quartile HCC $16 $19
Tier 4 4th quartile HCC for Track 1;
75-89% for Track 2
$30 $33
Complex
(Track 2 only)
Top 10% HCC
OR
Demenita
N/A $100
Average PBPM $15 $28

 

CPC+ payer partners will also provide non-visit based financial supports to practices based on their own methods.

Comprehensive Primary Care Payments

Track 1 practices will continue to receive Medicare fee-for-service payments. In Track 2 of CPC+, CMS is introducing a hybrid of Medicare fee-for-service and “Comprehensive Primary Care Payment” (CPCP). The CPCP changes the cash flow mechanism for Track 2 practices, promotes flexibility in how practices deliver care traditionally provided face-to-face, and requires practices to increase the depth and breadth of primary care they deliver. For attributed Medicare beneficiaries, Track 2 practices will receive a percentage of their expected Medicare reimbursement for Evaluation & Management (E&M) claims payment upfront in the form of a quarterly CPCP. Track 2 practices also receive a reduction in Medicare fee-for-service payments for their billed E&M claims.

CPC+ payer partners are expected to make changes to their underlying payment structures in ways that align with the goal of the CPCP and allow practices to deliver care in more flexible ways to their entire population of patients.

Performance-Based Incentive Payment

CPC+ will reward practices using incentive payments based on their performance on patient experience, clinical quality, and utilization measures. The CPC+ performance-based incentive payments paid by Medicare will be up to $2.50 PBPM for Track 1 and up to $4 PBPM for Track 2. Performance-based incentive payments will be prospectively paid at the beginning of a performance year, but CMS will recoup payments made to the practices if they do not meet thresholds for quality and utilization performance.

CPC+ payer partners are expected to provide practices with their own incentives based on quality, patient experience, utilization, and/or cost of care.

Partners and Participants

Multi-Payer Partnership

CPC+ will bring together Medicare and other payers, including commercial insurance plans and state Medicaid agencies, in 14 regions in CPC+ Round 1 to provide the necessary financial support for practices to make significant changes in their care delivery. In Round 1, CMS is partnering with 54 payers that will align on payment, data sharing, and quality metrics. Eligible practices within the 14 existing regions applied for CPC+ Round 1 between August 1-September 15, 2016. Selected practices will begin participating in CPC+ Round 1 on January 1, 2017.

CMS expects to release the CPC+ Round 2 Solicitation for Payer Partnership in mid-February 2017. CMS welcomes proposals from payers in up to 10 new regions, as well as new payers in any of the existing 14 CPC+ regions. Existing payer partners in the 14 CPC+ regions do not need to submit new proposals in those regions. CMS will select new payer partners in existing and new regions for CPC+ Round 2 in spring 2017, based on payer density and alignment with CMS’ approach to payment, data sharing, and quality measurement.

Primary Care Practices

Beginning in late spring or early summer 2017, practices located within the new CPC+ Round 2 regions may apply to participate in CPC+ Track 1 or 2. CMS will randomly assign the eligible applicants to CPC+ Round 2 into an intervention or comparison group. Practices randomized into the comparison group will not receive the CPC+ payments or participate in the learning communities. Practices in the 14 CPC+ Round 1 regions are not eligible to apply for Round 2. CMS will accept a maximum of 5,500 practices into CPC+ across both rounds. Once CMS announces selected Round 1 practices for 2017, CMS will also release the number of the eligible Round 2 practices.

CPC+ targets primary care practices with varying capabilities to deliver comprehensive primary care. In order to participate, all CPC+ practices must demonstrate multi-payer support, use Certified Electronic Health Record (EHR) Technology, and have other capabilities. Track 1 practices will work for five years to more fully develop the capabilities necessary to deliver comprehensive primary care. Track 2 practices must demonstrate Track 1 clinical capabilities and commitment to enhanced health IT at the time they apply, and commit to increasing the depth, breadth, and scope of care offered, with particular focus on patients with complex needs.

Health Information Technology (Health IT) Vendors

Comprehensive primary care requires efficient, advanced health IT to support its population-health focus and team-based structure. Practices in both tracks will qualify for the model based, in part, on having met certain Certified EHR Technology requirements, and will be expected to report electronic clinical quality measures at the practice-level. CMS also expects Track 2 practices to work with vendors to develop and optimize a set of advanced health IT functions. CMS will ask interested health IT vendors to memorialize their commitment to supporting Track 2 practices and participating in model activities in a Memorandum of Understanding (MOU) with CMS.

Quality Payment Program and CPC+

Tracks 1 and 2 of CPC+ are included on the list of Advanced Alternative Payment Models (APMs) under the Quality Payment Program (QPP), and this determination was based on medical home model-specific requirements. For payment years 2019 through 2024, clinicians who meet the threshold for sufficient participation in Advanced APMs and who meet requirements, as applicable for 2018 onward, regarding parent organization size are excluded from the Merit-based Incentive Payment System (MIPS) reporting requirements and payment adjustments and qualify for a five percent APM incentive payment. More information about the QPP and Advanced APMs can be found on the QPP website: https://qpp.cms.gov.

Further Information

For questions about the model or the application process, visit http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus or email CPCplus@cms.hhs.gov

Innovation Center

CPC+ was developed by the Center for Medicare and Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). Congress created the Innovation Center to test innovative payment and service delivery models – including primary care payment and care delivery reform – to reduce Medicare, Medicaid, and the Children’s Health Insurance Program expenditures and improve quality for beneficiaries.

In January 2015, the Administration announced its goals to help drive Medicare and the health care system at large towards rewarding the quality of care as opposed to the quantity of care provided to beneficiaries. The goals include tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements, by the end of 2016 and tying 50 percent of payments to these models by the end of 2018. Alignment between HHS, private sector payers, employers, providers, and consumers will help health care payments transition more quickly from pure fee-for-service payments to alternative payment models – a critical step toward better care, smarter spending, and healthier people. 

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