CPC+ Model Offers Payers Insight into Population Health Management

September 05, 2018 - CMS’s Comprehensive Primary Care Plus (CPC+) model may offer lessons and strategies for payers that want to increase primary care efficiency with population health management strategies.

The CPC+ model is the nation’s largest comprehensive primary care model. The initiative began in 2016 and is expected to run until 2022. Currently, the CPC+ model operates in 18 regions across the US.

The CPC+ has the potential to generate significant cost savings, improve the quality of primary care practices, and integrate value-based care more deeply into the PCP environment.

What is the CPC+ model?

In 2012, CMS launched the initial Comprehensive Primary Care Initiative to offer a value-based population health management framework for primary care providers (PCPs).

CPCI participants were responsible for five core functions including risk-stratified care management, access and continuity, planned care for chronic conditions and preventive care, patient engagement, and care coordination.

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CMS recruited payers across the country to participate in the CPCI. CMS then invited provider organizations to the CPCI based on the organization’s ability to use health information technology, earn national accreditation in primary care best practices, and deliver high quality care.

Participating providers received monthly payments for services and shared savings for treating Medicare patients.

In 2016, CMS revamped the CPCI and renamed it. The CPC+ initiative now occupies the same space in CMS’s value-based care portfolio.

CPC+ reimburses providers based on the same core principles as the CPCI. The CPC+ model also gives practices educational resources and professional development opportunities to improve comprehensive care capabilities.

Currently, 2188 primary care providers serving 2.7 million patients are participating in the CPC+ program. CPC+ providers serve Medicare and Medicaid beneficiaries as well as commercially insured beneficiaries.

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CPC+ is divided into two tracks. Track 1 providers have qualified for the CPC+ model, but are still developing their comprehensive care capabilities. Track 2 providers have the capabilities to take on greater accountability for quality and costs.

A mix of 61 public and private payer organizations participate in the CPC+ model.

Large commercial payers such as Aetna, BlueCross BlueShield, Molina Healthcare, and UnitedHealthcare are just a few payers that are active in the CPC+ model.

What does CPC+  payment look like?

The CPC+ payment methodology uses three types of reimbursement: care management fees (CMFs), performance-based incentive payments (PBIPs), and Medicare FFS payments.

The program uses beneficiary risk scores and a five-tier risk system to calculate per member per month (PMPM) CMF payments.  

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Patients with the lowest risk scores are placed into tier 1 and patients with the highest scores are placed into tier 5. A beneficiary’s risk score increases based on clinical conditions and other risk factors.

Track 1 providers receive $6 PMPM for tier 1 patients, while Track 2 providers receive $9 PMPM for beneficiaries in the lowest risk category. Track 2 providers can earn as much as $100 PMPM for tier 5 beneficiaries.

Provider organizations can earn additional performance incentives if they meet quality benchmarks.

PBIPs range between $1.25 and $2 PMPM if providers are able to reduce high-cost utilization of emergency departments and inpatient facilities. PBIPs are prospective payments that are then subtracted if providers fail to keep up with performance measures.  

“To encourage and reward accountability for clinical quality, patient experience of care, and utilization measures that impact total cost of care, practices will receive a prospective incentive payment annually and will be allowed to keep all or a portion of these funds if they meet annual performance targets,” CMS explained. “Practices will thus be ‘at risk’ for the amounts prepaid, and CMS will recoup unearned payments.”

Track 1 providers also receive standard Medicare FFS payments while Track 2 providers receive a hybrid payment that combines a retrospective comprehensive primary care payment and (CPCPs) a reduced FFS payment.

The CPCP is an upfront payment for a percentage of expected Medicare costs for evaluation and management (E&M) services. Track 2 providers then receive a hybrid payment that uses both CPCPs and FFS rates for treating Medicare beneficiaries.  

For example, Track 2 providers in 2018 can choose to receive a hybrid payment of 10 percent CPCP reimbursements and 90 percent traditional FFS payments.

How can CPC+ contribute to the value-based care ecosystem?

The CPC+ model has produced encouraging early results.

In 2017, CMS found that 96 percent of CPC+ providers performed care coordination tasks and 76 percent of all participating providers implemented new programs to improve risk stratification capabilities.

Eighty-five percent of Track 2 providers implemented screenings for unmet social needs and 65 percent provided care outside of traditional primary care facilities.

However, it remains to be seen if comprehensive primary care can create equally significant cost reductions.

The CPCI program did not produce measurable financial savings, the Mathematica Policy Research found. While CPCI participants slowed Medicare spending more than non-comprehensive care practices, the first year of the CPCI did not create enough savings to offset general spending rates.

“The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices,” the researchers said. “However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures.”

The revamped payment design of the CPC+ model has produced more impactful results in its first years of operation, CMS said.

CMS estimates that the average CPC+ Medicare payment for Track 2 practices was $23.90 PMPM over the first nine months of the model, and CMS paid over $28.5 million in CPC+ Medicare payments in 2017. In comparison, Medicare PMPM payments in the CPCI averaged $15 PMPM, which is only $8.90 less than providers participating in the more extensive CPC+ program.

Track 2 practices could become more cost effective as they transition from FFS to CPC+ payments, but may need more time to transition from FFS payments to CPC+ payments.

With time, the CPC+ models may help payers contain the high costs of primary care for multiple beneficiaries and improve the quality of healthcare services.