EDITOR’S NOTE: The U.S. House of Representatives’ Energy and Commerce Committee and Ways and Means Committee recently sent a letter to U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell, urging the successful implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) so that “doctors and other healthcare providers can deliver quality care their patients deserve.” This article speaks to this development.
About this time each year, consumers get the opportunity to see what goods and services various entities are introducing into the national marketplace – and the Centers for Medicare & Medicaid Services (CMS) is no different, as it is currently showcasing a new wave of innovation in delivery of primary care.
This was first announced in April, when CMS noted that it was building on the Comprehensive Primary Care initiative launched in 2012. The newest development is the new CPC+, a five-year, primary care, medical home model being launched in January 2017.
This model will enable primary care practices to provide care for their patients in the manner they feel will deliver the best outcomes, and then pay them for achieving results and improving care. In August, CMS announced the 14 regions where practices will be eligible to apply for participation.
“We see CPC+ as the future of primary care in the U.S.,” CMS Administrator Dr. Patrick Conway said. “By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists, we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars.”
With the clock already ticking, these are the all-important 14 regions where eligible practices may apply between Aug. 1 and Sept. 15, 2016 to participate in CPC+:
1. Arkansas: Statewide
2. Colorado: Statewide
3. Hawaii: Statewide
4. Kansas and Missouri: Greater Kansas City
5. Michigan: Statewide
6. Montana: Statewide
7. New Jersey: Statewide
8. New York: North Hudson-Capital Region
9. Ohio: Statewide and Northern Kentucky
10. Oklahoma: Statewide
11. Oregon: Statewide
12. Pennsylvania: Greater Philadelphia
13. Rhode Island: Statewide
14. Tennessee: Statewide
With a need for this program in every state, how did the aforementioned regions become eligible?
- CMS selected regions based on payor interest and coverage, with the aim of ensuring that selected regions exhibit the best opportunity incorporating state Medicaid agencies, Medicare, and private insurance companies supporting primary care practices.
- There are no more one-size-fits-all, fee-for-service systems – this model purely supports physicians in their focus and engagement to best deliver patient care and improve health outcomes.
- A. Transformation: CPC+ marks a transformational opportunity for practices in diverse sizes, ownership, and structure that are interested in qualifying for the incentive payment for advanced alternative payment models (APMs) through the proposed Quality Payment Program, CMS says.
- B. Outreach and Impact: According to CMS, up to 5,000 primary care practices serving an estimated 3.5 million beneficiaries could participate in the advanced model.
- C. Participation: Primary care practices will be able to participate in one of two tracks. In Track 1, CMS will pay practices a monthly fee in addition to regular Medicare fee-for-service payments.
- D. Participation (continued): To allow and encourage greater flexibility in how primary care practices will deliver patient care, Track 2 will allow practices to receive the monthly fee plus a hybrid of reduced Medicare fee-for-service payments as well as up-front comprehensive primary care payments.
- E. Information/Data: Participating practices will receive necessary cost and utilization data, allowing them to be cognizant of the total program need for a robust IT and learning support system – this will allow these providers to synthesize care delivery changes and use data to track and improve care.
- F. MOU for Track 2: It is imperative in the CPC+ program that vendors sign an MOU outlining true deliverables in their respective commitment to support and advance their IT capabilities, ensuring that physicians and patients have access to information when they need it.
- G. Alignment: Partnerships must align with the Office of the National Coordinator for Healthcare IT.
Collapse of ACO Structure
With primary care physicians (PCPs) being pressured in a financial results-oriented world; with accountable care organizations (ACOs) being shut out despite being an enormous piece of innovation/payment reform; and with the new era of healthcare delivery moving toward fee-for-value instead of fee-for-service, there were fears that all of this could have brought a near collapse to the system. So with all this risk in play, CMS readjusted its strategy:
- Back in May there was great concern that ACOs wouldn’t be able to participate in the CPC+ program, leaving primary care practices in a stop-and-start mode, both financially and programmatically. This would have ultimately jeopardized program success in establishing true patient results and risked the very existence of the ACO structures/memberships – especially the MMSP model, incentives, and benchmarking standards.
- CMS’s 360 on the issue now allows 1,500 eligible practices to engage in the MSSP program and participate.
With ACOs involved, there is the potential for the program to reach totals of 5,000 practices, 20,000 providers, and 25 million patients.
Power of Adjustments for PCs and ACOs
- With open ears, CMS listened to the multitude of comments calling for ACO inclusion and allowing physicians to participate in both CPC+ and ACOs; this has the power to actually boost both initiatives/models. Hence, CMS announced in May that 1,500 (of the 5,000) CPC+ practices would also be allowed to participate in MSSP ACOs.
- PCPs likely will be engaging with a secondary avenue to be financially rewarded while doing the right thing and delivering high-quality patient care.
The Big Gain and Possible Bottom-Line Impact
- This greatly helps the delayed nature of shared savings distribution; participating CPC+ and ACO physicians will likely gain an infusion of cash flow to pay for services that shared savings incentivized, but never provided immediate access to, due to the nature of how funds within the ACO system are distributed.
- Given the specific model of CPC+, Medicare patients would be key to success as the innovation model focuses on high-quality care (lower costs), access to preventive services, increased coordination, and increased access to services.
For Track 1, practices receive risk-adjusted care management payments, averaging probably around $15 per Medicare beneficiary, per month.
- For Track 2, in the name of supporting innovation within the care delivery spectrum, physicians will likely receive, on average, a risk-adjusted $28-per-Medicare beneficiary, and most also will receive some monetary coverage for projected fee-for-service payments.
- For Track 1 of CPC+ (according to research), the average practice likely will receive $126,000 annually, plus $21,000 in performance payments.
- For Track 2, practices likely will receive $235,000 and $33,600, respectively.
- This is contingent upon the track chosen and the number of physicians’ beneficiaries’ numbers.
A Losing Proposition
- As noted so many times before by rural, small, and independent practices when innovation isn’t emphasized, the result is that those physicians don’t have as many resources to effectively manage their respective populations for providing the best care and outcomes; they can’t advance strategically for new care delivery paths, they can’t perform in technology arenas, and there is insufficient training and opportunities for internal teams to advance.
- Additionally, the gap widens in types of practices and overall strategic sustainability, putting even greater pressure on rural access and delivery.
- They also risk being financially penalized for threshold expectations in their track.
- Vendors and other suppliers then lose the ability to help physicians advance, making for a losing business proposition.
- Via the CPC+ model, either monthly payments or advance payments to incentivize certain primary care approaches, such as:
a. Comprehensive practices to meet care and goal metrics, including preventive care;
b. Enhanced 24-hour access to care and health information, including telephone or electronic access;
c. Coordinated care with hospitals and other clinical services;
d. Quality and utilization of services measured and data analytics for improvements, opportunities, and new capabilities;
e. Supporting patients with the highest risk/chronic diseases, ensuring that they receive proactive relationship care management services; and
f. Patient-centered care, with family members at the core in the care of the patient.
Lasting Impact Implications
- Will all of these additional innovation models of the future create more bulk and confusion in the system, with so many programs, layers, deliverables, and expectations within them?
- Will it impact enrollment numbers and growth of physician-led ACOs in 2017, both inside and outside of awarded regions?
- Could CPC+ pull physicians away from ACOs?
- Will it disengage physicians to join or stay with an ACO, with added bulk in the innovation models?
- Would physicians become disengaged and not move from Track 1 to ACO tiers with the downside risk because they are still grappling with the mechanisms of the CPC+ model?
- Will this drive more PCPs to the market? There is great angst that the MACRA rule won’t allow the MSSP Track 1 ACOs (which comprise 95 percent of the nearly 450 MSSP ACOs) to qualify as designated APMs, which would most likely provide their respective physicians an additional 5-percent annual bonus under Medicare.
- Could a fee restructuring within CPC + be a pathway for physician-led ACOs?
- Could an enhanced per-member, per-month fee be allowable to achieve and advance health goals while lowering Medicare spending?
- Could CMS redefine and align parameters so that there is more PCP opportunity for current practices, allowing Medicare ACOs to emerge into the CPC+ initiative?
End is Just the Beginning
The season of rapid transformation in the marketplace is upon us, with many an individual and collective voice being heard. Let’s see what the final result is.
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 also a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and 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 she serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx.
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