Original story posted on: April 27, 2016

CMS Makes Key Move on Primary Care

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The Centers for Medicare & Medicaid Services (CMS) has unveiled and launched a major expansion of its Comprehensive Primary Care (CPC) Plus model initiative for primary care physicians.

It is the agency's largest-ever plan to transform and improve how primary care is delivered and reimbursed, with Medicare working with commercial payors and state Medicaid programs.

The expansion of the CPC model, as released on April 11, would pay a monthly fee to manage care and could impact as many as 20 regions, 5,000 practices, 20,000 physicians, and 25 million patients. 

According to CMS, the initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care.

Piloted in 2012, the program to date has included Medicare, 38 insurers, 2,200 physicians, 500 practices, and 2.7 million patients in seven markets. It was originally designed to change the volume incentives of a fee-for-service program by giving each physicians a monthly fee to coordinate care.

In the program, primary-care physicians risk-stratified their patients and provided care management plans for those with two or more chronic diseases. It didn’t, however, include telehealth and home health as a part of the model. 

Initially, the program was found to have reduced total monthly expenditures by 2 percent per beneficiary in Medicare Parts A and B, with hope moving forward for dramatically better costs, savings, and results.

Additionally, CMS estimated that it met the ambitious goal – 11 months ahead of schedule – of tying 30 percent of Medicare payments to quality and value through alternative payment models by the end of 2016. The agency’s next goal is tying 50 percent of Medicare payments to alternative payment models by 2018.

Within CPC Plus, primary care physicians can participate in two ways called tracks. Practices in both tracks will receive upfront incentive payments that might have to be repaid if the physicians do not perform well on quality and utilization metrics. 

In the first track, CMS will pay a monthly fee for specific services in addition to using the Medicare Physician Fee Schedule for care. Physicians currently perform a service, then submit a claim to Medicare for payment; under this track they would receive an additional $15 per beneficiary.

In the second track, physician practices also will receive a monthly care-management fee, but instead of full Medicare fee-for-service payments for primary care, they will receive reduced Medicare fee-for-service payments and upfront payments – typically $28 a month in order to support enhanced, coordinated services.  

This hybrid model allows practices to provide care outside of the traditional face-to-face encounter and offer telemedicine visits or longer office visits for patients with complex needs.

CMS hopes that there is more interest in the second track, which the agency estimates will save about $2 billion over the course of the five-year program. The first track was tagged as budget-neutral.

There are five key concerns about the program shared by rural healthcare providers:

  1. Is the CPC Plus model strategically inclusive of “rural” physicians and patients? It seems that the program only launches in regions where there is a “critical mass of interested payors,” and a result, patients who are the most chronically ill and could benefit most from the program might not be represented. The Brookings Institute has noted that the Southeast and Mid-Atlantic regions might be vulnerable, given prior program participation in other innovation/payment models such as accountable care organizations (ACOs).
  2. Will second-track plans receive greater scrutiny of participation due to state insurance regulations?
  3. How does CPC fit within the Medicare Access and CHIP Reauthorization Act (MACRA)?
  4. Within the first track of CPC Plus, will physicians avoid taking responsibility for lowering their total cost of care and improving their performance on quality metrics?
  5. Do the details of the CPC program dissuade physicians from participating in better-run programs such as patient-centered medical homes, or more robust alternative payment models such as the ACOs or Medicare shared savings programs? 

But there also five key opportunities for rural healthcare providers:

  1. Some primary care physicians are pleased, as this model moves away from a high-volume/low-quality care strategy under a fee-for-service model to address patient needs with the “right care at the right time.”
  2. This model will provide doctors the flexibility to spend the time needed on sicker patients while exploring telemedicine-based strategies for those who are healthier.
  3. As it relates to the second track, lemons could be made into lemonade. Those regulatory laws might not stand in the way, as there are positive opportunities for program communication via messaging and education to dispel problems within systems, payors, and states.
  4. More physicians and patients might elect to participate within the Patient Protection and Affordable Care Act (PPACA)-accepted and growing DPC, thus eliminating the burden of programmatic activities within the CPC Plus model.
  5. This model actually opens the rural marketplace to optimize a non-face-to-face paradigm via chronic care management-based rural service solutions for clinical reimbursement.

There are also five criteria for eligibility:

  1. Services must be accessible, responsive to an individual's preference, and offered along with enhanced in-person hours and 24/7 telephone or electronic access.
  2. Patients at the highest risk levels must receive proactive, relationship-based care management services to improve outcomes.
  3. Care must be comprehensive, and practices must meet the majority of each individual's physical and mental healthcare needs, including prevention. Additionally, care must be coordinated across the healthcare system, with patients receiving timely follow-up after emergency room or hospital visits.
  4. Care must be patient-centered, recognizing that patients and family members are core members of the care team and must be actively engaged.
  5. Quality and utilization of services must be measured, and data analyzed, to identify opportunities for improvements in care. 

CMS began soliciting payor proposals to partners in CPC on April 15, and once it gets a sense of which insurers in which regions want to partner, the agency will solicit applications from practices within those locations. CMS will accept practice applications in the determined regions from July 15 through Sept. 1.

I still believe there is a prime opportunity for rural providers to position themselves within the CPC Plus model. We are a critical mass of more than 70 million, and rural, local care delivery, better health outcomes, and more prevention and lifestyle intervention are crucial for our communities.

We also make an immense difference in Medicare beneficiary value/spending versus more urban areas. On a final note, rural healthcare faces a deficit of up to 30,000 rural primary physicians within the next 15 years, so we need to be included in payment models that engage and incentivize physicians now (this also acts as a positive recruitment and retention method) so patients can benefit from a sustainable healthcare delivery system involving programs and services.

About the Author

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill.  A former hospital CEO and regional rural strategy executive, Janelle is a past National Rural Health Association Rural Fellow, Rural Congress member Nebraska Rural Health Association President.  She is currently the Nebraska DHHS Chair of The Office of Minority Health Statewide Council addressing needs of rural, public, minority, tribal and refugee health and is serves on the Regional Health Equity Region VII council as Co-Chair of Rural Health and Partnerships.  Janelle holds a masters and doctorate in communications and recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGENTEX. 

Contact the Author 

drjalidinar@yahoo.com

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