Advanced Alternative Payment Models Part III: Understanding Comprehensive Primary Care Plus

This article is the third of four parts.

In May 2016, the CMS formally announced the six Advanced Alternative Payment Models (APMs) that they will consider as fully qualifying APMs under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) in a proposed rule.(1) Although this may seem insignificant to the uninitiated, this is a major step toward moving the entire national system toward a “fee-for-performance” setup. This is of note for all physicians practicing within the country, due to the fact that if an APM is not embraced by any given practice, it could readily result in said practice being forced to “compete” for reimbursements against predetermined peer groups through the non-APM Merit-Based Incentive Payment System (MIPS), which replaces the former Sustainable Growth Rate (SGR)-driven conversion factor in determining how RVUs are altered for specific practices under the former “fee-for-service” system. For some, MIPS may represent an unacceptable risk to practice viability, as changes in reimbursement levels can vary from ±4% to ±9% past 2019. Although some may “win” and receive bonuses through MIPS, just as many may see significant losses through not meeting CMS performance targets.

We have chosen to highlight the most critical aspects of the Advanced APMs listed as acceptable alternatives to the MIPS-driven reimbursement structures to help foster understanding of these programs (Table 1). This article, the third in the series, focuses on the most critical aspects of the Comprehensive Primary Care Plus (CPC+) model. The APMs not discussed in this article are covered in their respective parts of the series.

What is the CPC+ Model?

CPC+ is a primary care–centered initiative being rolled out for deployment for a five-year test period from 2017 through 2022 for applying practices and organizations. Based on feedback from payers and participants in the previous Comprehensive Primary Care (CPC) initiative, CPC+ is an attempt at further propelling the ideals of the Patient-Centered Medical Home (PCMH) and care coordination exclusively in the primary care setting. CPC+ offers two distinct tracks for primary care practices to participate in the program, with both tracks qualifying for Advanced APM status (Table 2). Available to a total of 5000 practices (2500 in each track) in up to 20 possible regions, this initiative has a limited number of slots available for participation and is the only PCMH model currently listed as an Advanced APM.

This model focuses on five core areas of operational improvement:

• Access and continuity for patients;

• Improved care management;

• Maximal comprehensiveness and coordination of care;

• Better patient and caregiver engagement; and

• Consideration to planned care and population health.

Specific requirements to meet these goals are listed on the CMS website(2) (Table 3). Although these requirements are preliminarily set for the 2017 performance year, CMS explicitly states that these requirements may change, deepen, or be removed over time, depending on feedback.

More than the ACO models discussed previously in this series, this PCMH model focuses on practice partnerships with vendors and payers alongside those necessary to facilitate delivery of coordinated care. In fact, the first step for CMS in deploying CPC+ has been to solicit payer agreements in the various potential rollout regions across the country.(3) As is standard for Advanced APMs, minimum threshold performance in the current CMS quality and value initiatives, such as the Electronic Health Record (EHR) Incentive Program, Physician Value Modifier, and the Physician Quality Reporting System, will be pertinent to maintaining the ability for practices to participate in the program. For Track 2 participants, EHR requirements are so intensive as to require a Memorandum of Understanding from a practice’s vendor prior to acceptance into the program.

Who Can Qualify for Participation in CPC+?

By design, and emphasized explicitly in the name, this advanced APM is only available to practices that are particularly designed to deliver primary care to Medicare beneficiaries and other patient populations. Although this is a CMS initiative, the program specifically requires participation from other payers and insurers to help create consensus in the reimbursement structure for a practice, thus presumably minimizing the chances that conflicts in practice and management incentives will emerge from varying payer requirements. Thus only practices and eligible providers in areas that have payer agreements sufficient to CMS standards will be able to participate in this advanced APM model. Although participation in only one APM, be it advanced or not, is often the standard for both Part A and Part B reimbursements, the ability for an eligible practice to participate in both the Shared Savings Program and CPC+ has been explicitly acknowledged by CMS.(4)

How Do I Apply for CPC+?

Applying for CPC+ is contingent upon the results CMS received from payers during the payer solicitation for partnership period between April 15, 2016, and June 8, 2016. From July 15, 2016, through September 1, 2016, CMS began accepting applications for either track of the initiative for participation in the 2017 performance year. Although it is currently uncertain if CMS will allow new applicants for the 2018 performance year, this initiative will likely be another stepping stone toward new programs and initiatives targeting the primary care setting. It is worth reiterating that for practices wishing to participate in Track 2, a letter of support from their EHR vendor will be required for participation, with templates available on the primary CMS website.(5)

Further information can be obtained through the CMS website using the links provided in the references at the end of this article. Publications such as this one and those distributed by the AMA and other primary care–oriented professional organizations also are invaluable tools in further understanding the suitability of each advanced APM, given the unique clinical space that a physician or other clinical provider may occupy.

References

1. Medicare Access and CHIP Reauthorization Act (MACRA), Pub. L. No. 114-10, 129 Stat. 87 (codified at 42 U.S.C. 1305 (2015)).

2. CPC+ Practice Care Delivery Requirements. CMS.gov. https://innovation.cms.gov/Files/x/cpcplus-practicecaredlvreqs.pdf . Accessed July 20, 2016.

3. Comprehensive Primary Care Plus (CPC+) Fact Sheet. CMS.gov. April 11, 2016. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-11.html . Accessed July 20, 2016.

4. Comprehensive Primary Care Plus. CMS.gov. July 18, 2016. https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus . Accessed July 20, 2016.

5. Instructions for submitting health IT vendor letter(s) of support for Track 2 CPC+ practice applicants. CMS Innovation Center. https://innovation.cms.gov/Files/x/cpcplus-hitvndrsupportltrinstr.pdf. Accessed July 20, 2016.