MEDICARE TO PAY PRIMARY CARE DOCTORS UP FRONT INCENTIVE AND MONTHLY MANAGEMENT BUCKS $$$.?

 On April 11,  the Centers for Medicare & Medicaid Services (CMS)  announced its largest-ever initiative to, in its words   “transform and improve how primary care is delivered and paid for in America”. 

The effort, the Comprehensive Primary Care Plus (CPC+) model, will be implemented  on January 1, 2017 in up to 20 regions.  It will accommodate up to 5,000 practices,  20,000 doctors and  25 million patients. 

 CPC+  will  "provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care". 

Here's how:  

The model sets up  two (2)   payment “tracks” for physician practices.    

Under Track 1,   CMS will  pay practices a monthly care management fee of $15 per beneficiary in addition to the fee-for-service payments.  Practices are also eligible for a performance-based incentive payment of $2.50 per beneficiary per month.

Under Track 2, practices will receive a monthly care management fee of $28 per beneficiary and, instead of full Medicare fee-for-service payments for E&M services, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services   These  hybrid payments are  supposed to allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter. Track 2 practices are also eligible for a performance-based incentive payment of $4 per beneficiary per month.

Practices will either keep or repay incentive payments based on how they perform on various quality and utilization metrics.  Thus, says CMS,   docs will be  encouraged to focus on health outcomes, not the volume of visits or tests.

The  model is also intended to   help primary care practices: (i) support patients with serious or chronic diseases to achieve their health goals;  (ii) give patients 24-hour telephonic or electronic access to care and health information; (iii) deliver preventive care;  (iv) engage patients and their families in their own care and (v) work together with hospitals and other clinicians, including specialists, to  better coordinate care. 

Patients at highest risk  will receive proactive, relationship-based care management services to improve outcomes. For example, practices might offer telemedicine visits or simply provide longer office visits for patients with complex needs.

 Care will be  also coordinated across the health care system, including specialty care and community services, and patients  will receive timely follow-up after emergency room or hospital visits.

Quality and utilization of services will be  measured, and data will be  analyzed to identify opportunities for improvements in care and to develop new capabilities.

Medicare will enter into MOUs with selected  commercial and state health insurance plans in selected geographic regions  to participate in this so called “advanced primary care model”.     CMS is accepting  payer proposals from April 15 through June 1, 2016 and will accept practice applications in the determined regions from July 15 through September 1, 2016.

This model is part of CMS’s “ambitious goal”, arising out of Affordable Care Act,   of tying 30 percent of Medicare payments to quality and value through alternative payment models by 2016 and  tying 50 percent of Medicare payments to alternative payment models by 2018.  

Dr. Patrick Conway, CMS deputy administrator and chief medical officer claims that  “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.

Relying on private payers as a way of determining where this model will launch concerns some experts.  “The problem is that the regions with the least payer interest will be the ones that need it the most,” said Dr. Kavita Patel, a senior fellow at the Brookings Institute and a former policy director for the Obama administration. The AMA  on the other hand,  believes  that this model holds promise for patients, and looks forward to working with CMS on its continued refinement and implementation.

Stay tuned.