Comprehensive Primary Care Plus (CPC+)

A CMS Center for Medicare & Medicaid

Innovation (CMMI) care delivery and

payment redesign model

Donna M. Daniel, PhD

Senior Program Director

Continuum of Care

July 28, 2016

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© Copyright International Business Machines Corporation 2016

All Rights Reserved

Printed in the United States of America (07/28/2016)

The following are trademarks of International Business Machines Corporation in the United States, or other countries,

or both.

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Polling Question

Q: Are you or your organization planning to submit an application for

the Comprehensive Primary Care Plus (CPC+)?

Responses:

Definitely

Possibly

Probably Not

I Don’t Know

Not Applicable (e.g., not a member of a practice)

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MACRA (QPP)Providers Have Choices Regarding Medicare Payment Under MACRA

MIPSMerit-Based Incentive Payment System

System• APMs (not advanced)

• Not First Year Medicare Part B participation

• >$10K charges to Medicare per year

• >100 empaneled Medicare pts per year

ADVANCED Alternative Payment Models

•Medicare Shared Savings Program, Tracks 2&3 (MSSP)

•Next Generation ACO Model

•Comprehensive ESRD Care (CEC)

•Comprehensive Primary Care Plus (CPC+)

•Oncology Care Model (OCM)

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On April 11, 2016, CMS announced the

latest and largest investment in Advanced Primary Care:

Comprehensive Primary Care Plus (CPC+)

50% of all Medicare fee-for-service payments to be made via alternative

payment methods by 2018

Improved care coordination and management for Medicare beneficiaries

Predicted to save up to $2 Billion in healthcare

expenditures by 2022 (Diamond, 2016).

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New Advanced Primary Care Medical Home Model

5 year initiative

Regionally-based

Multi-payer

Comprehensive Primary Care Delivery

What is Comprehensive Primary Care Plus

(CPC+)?

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CPC+ Timeline to Launch

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Differences between CPC & CPC+

Comparison of the Design Features of CPC and CPC+ Tracks 1 and 2 (2016). Medicare’s Vision for Advanced Primary Care: New Directions for Care Delivery and Payment. JAMA.

Published online April 11, 2016. doi:10.1001/jama.2016.4472

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Goals of CPC+

CMS Center for Medicare & Medicaid Innovation (2016b).CPC+ Advancing the delivery of and payment for primary care. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-modeloverviewslides.pdf.

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Framework for Payer Partnership

CMS Center for Medicare & Medicaid Innovation (2016b).CPC+ Advancing the delivery of and payment for primary care. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-modeloverviewslides.pdf.

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Practices Apply to Participate in 1 of 2 Tracks

CMS Center for Medicare & Medicaid Innovation (2016b).CPC+ Advancing the delivery of and payment for primary care. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-modeloverviewslides.pdf.

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CPC+ Practice Eligibility Criteria

CMS Center for Medicare & Medicaid Innovation (2016b).CPC+ Advancing the delivery of and payment for primary care. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-modeloverviewslides.pdf.

CMS will accept practice applications from

July 15 through September 1 August 1 through September 15, 2016.

Practices should apply for the Track they believe they are eligible.*

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Practices will Engage Health IT Vendors

CMS Center for Medicare & Medicaid Innovation (2016b).CPC+ Advancing the delivery of and payment for primary care. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-modeloverviewslides.pdf.

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CPC+ Functions Guide Transformation towards

Comprehensive Primary Care

CMS Center for Medicare & Medicaid Innovation (2016b).CPC+ Advancing the delivery of and payment for primary care. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-modeloverviewslides.pdf.

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Comprehensive Primary Care Functions -

Enhanced

CMS Center for Medicare & Medicaid Innovation (2016b).CPC+ Advancing the delivery of and payment for primary care. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-modeloverviewslides.pdf.

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Comprehensive Primary Care Functions -

Enhanced

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• Office or other Outpatient visit for Evaluation & Management of a new patient:

99201-99205

• Office or other Outpatient visit for Evaluation & Management of an established patient

99211-99215

• Welcome to Medicare and Annual Wellness Visits:

G0402, G0438, G0439

• Complex Chronic Care Coordination services:

99487-99489

• Transitional care management services:

99495-99496

• Home visit for the Evaluation & Management of a New Patient:

99341-99350

• Chronic Care Management services:

99490

Who are Your Attributed Patients?

CMS Center for Medicare & Medicaid Innovation (2016b). Comprehensive Primary Care Plus (CPC+) Request for Applications. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-rfa.pdf.

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Three Payment Innovations Support Practice

Transformation

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Care Management Fees Determined by Risk Tier

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Two Performance-Based Incentive Payment

Opportunities

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Track 2 Payment Offers More Flexibility in Care

Delivery

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Example of CPC+ Total Payments

1000 Medicare Covered Lives, per Provider

ProviderProcedure Billing makes up 50% of Total Billing

Average E&M Billing Yr.4 in CPCI = $15.00 PBPM

Per Provider Per Year*

E&M BillingProcedure

Billing

MACRA

5%**

Care

Management Fee

(CMF)

Performance-

based

Incentive

Payment

TOTAL

Potential $$Upfront $$

FFS $180,000 $180,000 $0 $0 $0$360,000

(average)$0

CPC+ Track 1 $180,000 $180,000 $18,000$180,000

(avg= $15 pbpm)

$30,000

($2.50 pbpm)

$588,000

(average)

$180,000

(CMF)

CPC+ Track 2

(@65%/35%)~$198,000 $180,000 $18,900***

$336,000

(avg=$28 pbpm)

$48,000

($4.00 pbpm)

$780,900

(average)

$464,700

(65% CPCP

+ CMF)

Let’s assume:

23CMS Center for Medicare & Medicaid Innovation (2016b). Comprehensive Primary Care Plus (CPC+) Request for Applications. Baltimore, MD: CMS. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-rfa.pdf.

*Subject to change based on release of technical methodology anticipated to be released late 2016.

**Subject to change based on the final rule.

***It is unclear if the 5% bonus from MACRA will include the 10% increase in historical E&M billing.

Proposed CPC+ Quality Measure Set

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CMS knows that practices are

the primary drivers of change

CMS will provide online learning tools

so ensure:

Practice ownership and

management of CPC+

implementation

Practices are able to make

Assessments and give feedback

Support from CMS staff

Alignment with national and regional

health care reform efforts

CPC+ Learning System Strategy

CPC

Connect

Learning

communitiesNational and Regional

CPC Report

Tool

Data

Sharing

CMS Center for Medicare & Medicaid Innovation (2016b). Comprehensive Primary Care Plus (CPC+) Request for Applications. Baltimore, MD: CMS. Retrieved from

https://innovation.cms.gov/Files/x/cpcplus-rfa.pdf.

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Practices Rely upon Frequent Data Feedback from

CMS, Payer Partners and IBM Watson Health

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How IBM Watson Health Solutions support CPC+

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https://innovation.cms.gov/initiatives/ Comprehensive-Primary-Care-Plus

or email:

CPCplus@cms.hhs.gov

or call the CPC+ Help Desk:1-844.442.26728:30a.m. – 7:30p.m. ET

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Questions?

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CMS Center for Medicare & Medicaid Innovation (2016a). Comprehensive Primary Care Plus

(CPC+) Fact Sheet. Baltimore, MD: CMS Retrieved from

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-

items/2016-04-11.html.

CMS Center for Medicare & Medicaid Innovation (2016b). Comprehensive Primary Care Plus

(CPC+) Request for Applications. Baltimore, MD: CMS. Retrieved from

https://innovation.cms.gov/Files/x/cpcplus-rfa.pdf.

CMS Center for Medicare & Medicaid Innovation. (2016c). CPC+ Frequently Asked Questions.

Baltimore, MD: CMS Retrieved from https://innovation.cms.gov/Files/x/cpcplus-faqs.pdf.

Diamond, D. (2016). How to think about medicare’s new primary care plan. Politico. Retrieved

from http://www.politico.com/tipsheets/politico-pulse/2016/04/how-to-think-about-medicares-

new-primary-care-plan-213715.

Dickson, V. (2016). New CMS primary-care payment model would affect 20K doctors. Modern

Healthcare. Retrieved from

http://www.modernhealthcare.com/article/20160411/NEWS/160419999?template=print

Heath, S. (2016). CMS unveils value-based patient-centered primary care model. Health IT

Analytics. Retrieved from HealthITAnalytics.com website: http://healthitanalytics.com/news/cms-

unveils-value-based-patient-centered-primary-care-model

Sessums, L. L., McHugh, S. J., & Rajkumar, R. (2016). Medicare's vision for advanced primary

care; New directions for care delivery and payment. Journal of American Medical Association,

E1-E2. doi:10.1001/jama.2016.4472

References

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