Earlier this month, the Comprehensive Primary Care Plus (CPC+) model launched in 14 regions across the country. The goal of this multi-payer payment program is to strengthen primary care delivery within five key functions: 1) access and continuity; 2) care management; 3) comprehensiveness and coordination; 4) patient and caregiver engagement; and 5) planned care and population health.
Within each of the 14 regions participating in Round 1, the Centers for Medicare and Medicaid Services (CMS) has engaged with state and commercial payer partners to provide greater economies of scale and further support participating primary care practices with increased financial resources for their efforts to transform care delivery. CMS chose the initial regions based on a high concentration of willing participants, both payers and providers, and on market density. In February 2017, additional payers and providers in up to 10 new regions will have the opportunity to apply for Round 2 of the program.
Selected practices will apply to participate in one of two tracks, in which they will stay for all five years. Although all primary care practices were invited to participate under Track 1, Track 2 is designed for practices that focus, or wish to enhance their focus, on patients with complex medical, behavioral, and psychosocial needs. Practices participating in both tracks will receive three payment elements:
1. A monthly, capitated care management fee, which is risk-adjusted to reflect the intensity of care management services the practice provides, and is higher for practices participating in Track 2;
2. A prospective performance-based incentive payment, reconciled retrospectively based on the practice’s performance on patient experience, quality, and utilization measures. This incentive payment is calculated on a per-beneficiary per-month basis, and practices will keep a percentage of the prospective payment based on their performance; and
3. Medicare fee-for-service (FFS) payments.
Under Track 1, fee-for-service payments continue as usual.
Under Track 2, CMS will reduce fee-for-service payments for evaluation and management services as it shifts some of these funds into Comprehensive Primary Care Payments, which will not be tied to claims and will be paid in a lump sum each quarter. CMS anticipates that these Comprehensive Primary Care Payments will be larger than the fee-for-service payments they are intended to replace, as Track 2 practices are expected to increase the comprehensiveness of the care they deliver.
The incentives for primary care practices to participate are fairly straightforward—their incentives are aligned more closely with value rather than volume. In addition, CPC+ qualifies as an Advanced Alternative Payment Model (APM) under the Quality Payment Program, Medicare’s new physician payment program. Participating practices may qualify for a 5% bonus payment and escape the potential downside of the Merit-based Incentive Payment System (MIPS).
But why should payers participate in the model? Medicare and individual payer efforts to strengthen primary care have had a limited impact at the individual practice level. However, by bringing together multiple payers and forging a primary care medical home, we believe CMS will finally have the necessary momentum to change care patterns and enact value-based primary care.
There are five major reasons individual payers should participate:
- Value-based payment models are the future. Medical homes, bundled or episodic payments, accountable care organizations, and other value-based payment models are the future of health care payment. Payers must learn to operate and succeed in these models.
- Increased prospects of success. Joining a multi-payer model helps increase the likelihood that participating payers will experience improved quality and reduced total cost of care among their enrollees. CMS chose the initial regions based on payer alignment and market density, incentivizing practices to participate and make the kind of investments needed to improve population health.
- Drive market change. The deployment of an aligned value-based payment model by multiple public and private payers within a market helps push providers over the value “tipping point.” With more patient volume and revenue received through a value-based model, practices are more likely to fully transition into a clinical model based on value.
- No experience required. Payers can gain experience and learn how to operate performance-based payments using a pre-constructed template.
- Flexibility. Payers participating in the CPC+ do not have to replicate the CPC+ payment model identically. Instead, they are granted the flexibility to design a model where practice incentives and goals align with Medicare’s new model -- this is where Aver can help payers make this model their own.
How Aver can help:
For individual payers considering participation in CPC+ or other medical home models, Aver’s suite of solutions gives payers the flexibility to design and implement a primary care medical home model either within or outside the CPC+ framework. Aver offers payer clients next-generation analytics to help them identify provider partners and gain insights into what their particular medical home would look like, including total cost of care, pay-for-performance contract elements, population health measures, and contract modeling. Finally, Aver can operationalize risk-based payments and simplify complex contractual arrangements between payers and providers to streamline care across the continuum.
Contact us to learn more today.
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