Rural Healthcare Needs More CPC+ for Duplication and Sustainability

Comprehensive Primary Care Plus (CPC+) is a national, advanced, medical home model that aims to strengthen primary care delivered through regionally based, multi-payer arrangements.

The CPC+ model includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of such practices. The goals of the CPC+ model are to support better care, healthier people, and smarter spending – and to inform future Medicare and Medicaid policy. 

CPC+ has nearly 3,000 participating primary care physicians. More than 2.8 million patients are now receiving care being delivered in more than 440 practices, with 2,160 practitioners. CPC+ also includes 37 public and commercial payers, 800,000 commercially insured patients, and 327,000 Medicare beneficiaries and 79,000 Medicaid beneficiaries in seven regions throughout the United States.

CPC+ Round 2 Recipient Regions

Results have been so positive that in late May, a second round of participants was announced in four designated regions. These include the following:

1. Louisiana – Statewide
2. Nebraska – Statewide
3. North Dakota – Statewide
4. New York – Greater Buffalo Region (Erie and Niagara counties only)

The eligible practices located in these regions may apply to participate in CPC+ Round Two from May 18 until July 13, 2017 via an online portal. The Centers for Medicare & Medicaid Services (CMS)  expects 1,000 practices to participate in CPC+ Round 2, and only practices located in one of the selected Round 2 regions will be eligible to apply.

The CPC+ Round 2 regions were selected based on payer alignment and market density to ensure that participating practices have sufficient payer support to make fundamental changes in their primary care delivery areas.

Payer Partnerships

The payers selected to partner in CPC+ Round 2 include AmeriHealth Caritas, Americgroup Louisiana, and Blue Cross Blue Shield of Louisiana; plus, Blue Cross Blue Shield of Nebraska, Blue Cross Blue Shield of North Dakota, and HealthNow New York and the Independent Health Association, Inc. in New York.

Primary Care Focus

Key areas of focus for CPC+ Round 2 include the following:

1. Access and continuity
2. Risk-stratified care management
3. Comprehensive transformation and coordination
4. Patient and caregiver engagement
5. Planned care and population health

Payer Skin in the Game

Since many payers have continued to leave insurance exchanges, it is interesting to gauge reform participation even for the Medicare group. CPC+ is a prime focus of CMS, and the goal is to have both public and private payers sponsor the opportunity for comprehensive primary care reform. CMS is keenly focused on those partners that share Medicare’s focus of fortifying primary care in each of the Round 2 regions. To that end, there is an expectation, completely separate from Medicare fee-for-service (FFS), that private and public payers will provide their own financial support to physician practices.

Payment Mechanisms

To support these key areas in the delivery of comprehensive primary care, CPC+ includes three payment areas:

1. The Performance-Based Incentive Payment: CPC+ will prospectively pay and retrospectively reconcile a performance-based incentive focusing solely on how well each practice performs on clinical quality measures, patient experience measures, and utilization measures that drive total cost of care.
2. The Care Management Fee (CME): Both tracks of CPC+ provide a non-visit-based CME, paid per member, per month (PMPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for the specific patient population needs of each practice. Additionally, the Medicare FFS CMFs will be paid directly to each practice on a quarterly basis.
3. Payment under the Medicare FFS: Track 1 continues to bill and receive payment from Medicare FFS as usual. The Track 2 practices also will continue to bill as usual, but the FFS payment will be reduced to account for CSM shifting a CPCP, which will be paid in a lump sum on a quarterly basis, absent a claim. CMS has also noted that given its expectations that Track 2 practice participation will increase comprehensiveness of care delivered, the CPCP amounts will be larger than FFS payments (which they are supposed to replace).

Important Disclaimers

Track 1 Utilization PMPM was $1.25, quality PMPM was $1.25, for a total PMPM of $2.50.

Track 2 Utilization PMPM will be $2.00, quality PMPM will be $2.00, and the total PMPM will be $4.00.

As it relates to care management, PMPM Track 1 was $15.00, and for Track 2 it will be $28 for general care and $100 for complex care.

Successes Support the Need

Given the specific programmatic expectations of Round 1 of CPC+, the results have been impressive. In the areas of care management, 424 (96 percent) of practices implemented care plans for patients under care. Ninety-nine percent of all active patients were attributed/assigned/empaneled to a physician/provider/care team; 20 percent were under care management; and 93 percent were risk stratified – up 3 percent from 2015. 

In patient access, 99 percent  expanded availability of same- or next-day appointments; 64 percent extended hours in the morning, evenings, and weekends; 68 percent adopted a flexible appointment schedule system; 91 percent included family in caregivers’ plan development and goal setting; 59 percent documented patient confidence areas and potential barriers;  and 81 percent conducted between-visit coaching. 

In the area of patient engagement, 80 percent of practices allocated time for quality improvement; 91 percent integrated quality improvement in daily staff activities; and 99 percent used data on utilization patient experience and cost. Additional quality improvement successes included the fact that one in five practices included pharmacists participating in CPC+, and one in two physician practices included IT teams working on CPC+.

Participation

CMS expects that practices will participate in CPC+ for a full five years, but participation is voluntary, and practices may choose to withdraw from the model without penalty as long as they notify CMS at least 90 calendar days before the planned day of withdrawal. Practices should note that the departure from the model before the completion of a performance year (PY) would put the practice participants at risk for recouping any CPC+ payments. Also, new practices cannot join after the selection date. The Round 2 service date begins January 2018. 

CPC+ practices that leave an Accountable Care Organization (ACO) during CPC+ determination regarding the advanced alternative payment model (APM) incentive payment will be evaluated on their participation in the Shared Savings Program, not the CPC+, including those practices that terminate their respective relationship/participation in an ACO.

The Confusing World of CPC+ and APMs

With all of these CMS innovation models being created, it is difficult to know where one begins and ends – and how each can be applied toward another model. For example, CPC+ is on the list of advanced APMs, and this determination was based on the “medical home model specific requirement” noted in the qualifiers. The fine print of qualifying information reads that (for payment years 2019-2024) for clinicians participating who meet the threshold for a sufficient participation in advanced APMs applicable in the eligibility requirements of 2018 and beyond, the parent (lead) organization’s size is excluded from the Merit-Based Incentive Payment System (MIPS) reporting requirements and payment adjustments and will qualify for the 5-percent APM incentive. For additional insight about QPPs and Advanced APMs, participants should visit https://qpp.cms.gov.

The ACO Question

Primary care practices that choose to participate in both the CPC+ and Shared Savings Program ACO must adhere to the ACO required care processes and implement the CPC+ care delivery requirements. Additionally, those practices must also adhere to quality reporting requirements for both CPC+ and the Shared Savings Program.

Decoding the Codes

Billing codes for chronic care management (CCM) will be 99487 and 99489. CPC+ practices may not bill for attributed beneficiaries. For the G codes of G0502-G0504, the collaborative model, CPC+ practices may bill for attributed beneficiaries. Regarding the G code, G0505, for cognition and functional assessment for patient with cognitive impairment, CPC+ practices are permitted to bill attributed beneficiaries. For GO506, assessment/care planning for patients requiring CCM services, there is no allowable billing for attributed beneficiaries. For G0507, care management for behavioral health conditions, CPC+ practices cannot bill for beneficiaries. Finally, codes 99358-99359, for prolonged non face-to-face evaluation and management services, there is no allowable CPC+ practice billing for attributed beneficiaries. 

We all know that primary care has historically been underfunded and underappreciated. This new model highlights the incredible work those in primary care provide for their patients every day. 

In those states in which payers are leaving exchanges, collaboration and comprehensive participation in models such as CPC+ could be a pathway towards how to put the best foot forward to patients (as recipients) and physicians (for delivery of care) to build a better, healthier future. 

The sustainability of rural healthcare is more uncertain than ever before, so the CPC+ model marks a great leap forward.