Comprehensive Primary Care Plus expands to four new U.S. regions for practices willing to revamp operations
Lawrence Ward, MD, MPH, an internist in Philadelphia, has been practicing for more than 15 years, witnessing the alphabet soup of quality-improvement programs that have been ladled out by the Centers for Medicare & Medicaid Services (CMS).
The most recent, Comprehensive Primary Care Plus (CPC+), is not like the rest, says Ward, who’s also vice chairman for clinical practice and quality for the Thomas Jefferson University Health System.
“We’ve seen a lot of programs come that don’t lead to real change but involve a lot of extra work,” Ward says. “I think this one’s different. I think this is really what we’ve been waiting for from Medicare for primary care.”
CPC+ is an attempt by CMS to get practices to deliver comprehensive care management while embracing payment reforms. It’s trying to lure practices into the program with generous, upfront financial incentives not tied to fee-for-service revenue-incentives designed to allow them to build their care-management infrastructure.
CPC+ is an updated version of the original Comprehensive Primary Care initiative, which ended in 2016. The initial CPC was a four-year program. CPC+ will run for five years and will be implemented in two rounds.
Almost 2,900 practices in 14 regions are participating in Round 1 of CPC+, which launched in January 2017. To be eligible to participate, practices must have at least 150 fee-for-service beneficiaries recognized by Medicare.
Until July 13, CMS will allow practices in four new regions-Louisiana, Nebraska, North Dakota and Greater Buffalo, New York-to apply for a second round of CPC+, which will launch in January 2018. Only practices in the new regions will be added to the program. Practices in the initial 14 regions and those in non-selected regions cannot participate.
Like its predecessor, CPC+ offers upfront financial incentives to practices that transform their primary care by improving services, including access, continuity, care management and patient/caregiver engagement.
Practices can participate in either Track 1 of the program or a more demanding and ambitious Track 2, which offers bigger payments, but more reporting requirements and benchmarks.
Those financial incentives come in three forms:
1. Care management fees
Every participating practice receives an upfront per-patient, per-month payment that is not tied to practice visits. The amount depends on the patient’s risk score and on the payer. For Medicare beneficiaries, fees average $15 a month per patient for Track 1 and $28 for Track 2. Participating commercial payers-there are 54 in Round 1’s 14 regions-negotiate the incentive amounts with participating practices. This money also is paid prospectively, but must be used for staffing and training related to the program’s objectives.
2. Performance-based incentive payments
These payments also go to practices and reward performance on quality and utilization measures. These are also upfront payments, but practices will have to return at least some of the funds if they do not hit performance goals.
3. Comprehensive Primary Care Payments (CPCP)
These payments go only to practices in the more demanding Track 2 of the program. (To qualify for Track 2, practices must do two-step risk stratification, offer alternatives to traditional office visits, develop care plans for high-risk chronic disease patients, and integrate behavioral health, among other requirements.) With this third type of bonus, CMS is experimenting with replacing some of a practice’s expected fee-for-service billings with upfront CPCP. These new payments will include an additional 10% of expected fee-for-service payments to help a practice deliver transformed care.
Another benefit of CPC+ is that it qualifies as an advanced alternative payment model (APM). This makes small, independent practices eligible for an additional 5% lump sum Medicare payment under the Medicare Access and CHIP Reauthorization Act
(MACRA) Quality Payment Program.
For example, Ward estimates that a practice enrolled in Track 2 of CPC+ with about 500 Medicare beneficiaries would get roughly $200,000 in additional payments a year from the program’s incentives. This is separate from the 5% MACRA bonus.
“If you had $200,000 each year for five years, that can be a nurse, a medical assistant and a social worker,” Ward says. “The nurse could do your care coordination, the medical assistant can assist you either in the office or can do outreach. And the social worker can do your integrated behavioral health.”
CPC+ is a complex program with numerous rules, regulations and reporting requirements. The quality measures are ambitious, says Ward.
“It’s a colossal effort,” he adds. But the requirements didn’t stop him. “When this came across our desks as an opportunity, we jumped at it. And we jumped with both feet in.”
South Arkansas Medical Associates (SAMA), a primary care practice about 10 miles from the Louisiana border, hasn’t been shy about embracing innovations in healthcare. For example, in 2002 the practice became one of the first in the state to adopt electronic health records (EHRs).
“CPC was a good experience, and we felt like we did well,” practice administrator Pete Atkinson says. The new “plus” version, he says, offered a chance to “take care to another level.”
In 2012, the original CPC came at a perfect time for the practice. The four physician- owners sensed an inevitable transformation of primary care in America. They wanted to be proactive about being part of it.
“We felt like healthcare was going to change and change dramatically,” says Gary L. Bevill, MD, a primary care physician and one of the four owners. Led by Atkinson, the practice hatched a plan to implement care coordination.
CPC’s financial incentives allowed the plan to become reality. “They were going to give us the financial resources to hire some people to do some of the things we wanted to do. And we wanted to do care coordination,” he says.
Using CPC’s care management fees, the practice hired care coordinators and reorganized the office into care teams. Over the next four years, the practice went from six providers and 30 employees to 14 providers and 70 employees. By following CPC’s core set of functions, Atkinson says, the practice didn’t just change the way it delivered care. The culture of the organization has undergone a transformation.
And the doctors?
“They’re enjoying practicing medicine today more than they have in the last 30 years,” Atkinson says.
Not all practices were as eager as SAMA to jump into CPC+.
Philadelphia internist Ward assists independent practices that fall under the Jefferson Health umbrella. Only four, including his, applied for CPC+. The rest-more than 20-did not.
“I think it was because it was too overwhelming,” he says, “[The practices] knew it was going to be a lot of money, so they knew that there would be a lot of oversight and a lot of reporting.”
Despite the financial incentives, practices weren’t sure what the reporting requirements would be, Ward adds. “A lot of practices were careful not to get involved in a program with the government that did not have every duck in a row and clearly set-out expectations.”
Some of those concerns have been realized. For example, the launch of CPC+ was rocky at Radnor Family Practice, an independent two-physician, two-nurse-practitioner office in suburban Philadelphia, which provides a range of primary care services.
“It was difficult at first because the program was just rolling out, and the government was a little behind in having information out there,” says practice administrator Debbie Brown, RN, BSN.
She says the delays have caused headaches with the practice’s EHR. CPC+’s risk stratification scoring system, which requires patients to be scored and placed into four risk tiers, didn’t match the system in the practice’s EHR, which scored from zero to 100. And when the practice faced a Friday deadline in April to submit a batch of first-quarter reports, the dashboard to submit wasn’t up and working until the Wednesday before.
Ward says his practice has been surprised by metrics and reporting requirements that CMS hadn’t disclosed earlier.
Both Ward and Brown say the government has been hands-on in helping fix problems during the rollout. Representatives have been available to answer questions after business hours, and weekly webinars and other events update the participants.
CMS hosts a robust social media platform. CPC Connect, for participants to share their experiences and knowledge online.
Despite the problems, CPC+ holds great promise, especially for small independent practices, says Tracey Allen-Ehrhart, manager of the American Academy of Family Physicians' Center for Quality, who works with medical practices nationwide on practice improvements.
“This is a payment model truly designed for primary care,” she says.
CPC+ was created for family medicine, internal medicine and geriatrics, which means the program’s technical support as well as payments are designed for them, she adds.
Michael L. Munger, MD, a primary care physician with Saint Luke’s Medical Group in Overland Park, Kansas, lauds these investments but says the benefits of CPC+ go beyond just the cash.
“For me, the CPC+ program is taking that first step to really putting the value on what we deliver,” he says. “Through care coordination fees, it’s really placing value on the non-face-to-face care that we all do on a daily basis to coordinate care.”
Finally, he adds, physicians are getting paid for the work-the emails, the calls, the extras-they do for patients beyond the exam table, the work that doesn’t have a CPT code.
After four years in CPC and more than four months in CPC+, Bevill is seeing the transformation in his Arkansas practice, and he’s thrilled. The work of the practice’s care coordinators and support staff has given him more time to face patients rather than a computer screen.
“I have a luxury now of if I’m going in to see a diabetic that’s, say, 65 with high blood pressure and maybe even with coronary disease, thanks to the care coordinator, everything is already available for me to see in the EHR before I walk in,” says Bevill. “I’m not having to click 14, 15, 20 screens to look at any lab testing or specialist reports.
“I can focus on the important stuff and spend the whole time being very productive with that patient instead of-and you hear so much griping nowadays about it-being a doctor with his nose in the computer screen the whole time.”
Brown and the other nurses at her practice have seen an unexpected benefit from CPC+’s care management requirements that direct practices to follow up with patients after they’ve been discharged.
“We’ve really enjoyed getting to know our patients a lot better than we ever would have,” Brown says. “I feel like we’ve developed a nice relationship with people like, ‘Hi, it’s me again. How are you feeling today?’ That’s why we became nurses.”
Ward encourages practices in the four new regions to apply for the second round of CPC+ before the July 13 deadline.
“For a smaller practice, you really don’t have a lot to lose by applying for it,” he says. Practices can always not sign the contract or drop out of the program without penalty.
Practices eyeing CPC+ should be thinking strategically, Munger says. “My advice is to start thinking about the blueprint of what you want your practice to transform into,” he says. “Think about whether you want to embed behavioral health as part of your practice or whether you need to ramp up your care coordination.”
Practices might not get a chance to participate, even if they work in one of the selected regions. Since CPC+ is essentially an experiment, CMS wants to be able to evaluate its effectiveness. So some practices that apply for Round 2 will be randomly placed in a control group. That means they won’t be eligible for payments.
For practices that are selected, Allen-Ehrhart expects the second round of CPC+ to go much smoother. By then, she says, health information technology vendors will have figured out what CMS and practices need and will have built the systems to match.
“There is going to be some growing pains,” says Bevill, “but the payoff is going to be worth every dime.”