April 15, 2016

CMMI Implements Sweeping Primary Care Payment Reforms

The Centers for Medicare and Medicaid Innovation (CMMI) outlined in-depth plans April 11, 2016, to launch the largest-ever policy to transform primary care reimbursement.

Scheduled to begin in January 2017, the voluntary, five-year Comprehensive Primary Care Plus (CPC+) model seeks to provide interested primary care physicians with the option of receiving care management fees, essentially prospective per-beneficiary, per-month payments, in lieu of traditional fee-for-service reimbursement. Monthly care management fees will be provided independently from reimbursement traditionally provided to primary care physicians after a patient schedules an appointment for treatment or an evaluation.

The launch of this comprehensive primary care policy further illustrates CMS’ preference to move physician reimbursement towards capitation as an alternative to traditional fee-for-service payments. ACR will continue to monitor the implementation of this comprehensive policy and its potential implications on radiology.

CMMI believes this major initiative will help the Department of Health and Human Services (HHS) reach its ambitious goal of having 50 percent of all Medicare fee-for-service payments made via alternative payment models by 2018. The agency also estimates that 20,000 doctors who treat 25 million patients will ultimately participate in the CPC+ model.

The announcement of this advanced primary care policy is timely because in the coming weeks the Centers for Medicare and Medicaid Services (CMS) is expected to unveil the first in a series of regulations to implement the Medicare Access and CHIP Reauthorization Act (MACRA). Enacted in 2015, MACRA repealed the Sustainable Growth Rate (SGR) and seeks to institute a new system that reimburses physicians for the value of their delivered care instead of the volume of their services.

Although the agency hasn’t yet released the implementing regulation, it is expected that physicians who join the CPC+ model will be deemed to be participating in an alternative payment model and, as a result, will be exempt from MACRA’s Merit-Based Incentive Payment System (MIPS). The MIPS is a modified fee-for-service program that provides doctors the opportunity to earn additional reimbursement or be subjected to penalties depending upon their performance measured by rigid quality measurement standards.

CPC+ is a regionally-based, multi-payer care delivery and payment model that includes two separate tracks. Up to 5,000 eligible practices in no more than 20 regions of the U.S. may apply for participation. To remain eligible for the prospective per-beneficiary, per-month payments, all participating primary care physicians, regardless of the selected track, must meet five key comprehensive primary care functions, specifically access and continuity, care management, comprehensiveness and coordination, patient and caregiver management, as well as planned care and population health. In addition, all CPC+ practices must use Certified Electronic Health Record Technology (CEHRT) and report on electronic clinical quality measures.

Primary care physicians who elect to participate in Track 1 will receive per-beneficiary, per-month payments averaging $15 across four risk tiers. In addition, Track 1 primary care physicians will continue to receive traditional Medicare fee-for-service payments for regular patient office visits.

Primary care physicians who participate in Track 2 will receive per-beneficiary, per-month payments averaging $28 across five risk tiers along with an additional $100 prospective care management fee to support treating patients with the most complex needs. In exchange for the higher monthly care management fees, primary care doctors in Track 2 will receive reduced fee-for-service reimbursement for patient office visits.

CPC+ also offers practices participating in either Tracks 1 or 2 the opportunity to earn additional financial rewards based on measures related to patient experience, clinical quality and utilization. The prospective per-beneficiary, per-month performance-based incentive payment is $2.50 for Track 1 and $4 for Track 2 practices. CMS, however, is permitted to recoup the performance-based incentive payments when practices do not meet quality measurement thresholds.

For additional information or to pose questions about this new advanced primary care reimbursement model, please contact Chris Sherin (Csherin@acr.org), director, Congressional Affairs, or Laura Pattie (Lpattie@acr.org), assistant director, Economics and Health Policy.