CMMI’s Comprehensive Primary Care Plus (CPC+) Request for Applications:

Key points for States considering participation - April 15, 2016

On April 11, 2106, CMMI issued a Request for Applications for this new multi-payer primary care model. CPC+ builds on the Comprehensive Primary Care Practice Initiative (CPCI) and the Medicare Advanced Primary Care Practice initiative, both multi-payer patient-centered medical home programs which are concluding at the end of calendar year 2016.

Medicaid FFS programs and Medicaid MCOs are eligible to apply as Partnering Payers. States with existing CPCI, MAPCP and SIM Model Test programs where Medicaid is a participating payer will be given special consideration. CMS hopes to partner with payers in the 7 existing CPC regions as well as up to 13 new regions.

Deadline for Partnering Payers to respond to the solicitation is June 1, 2016.

Rationale:

According to CMMI: “CPC has engendered enthusiasm and loyalty among participants and stakeholders, and, based on early results, holds promise as an alternative approach to support the enhanced delivery of primary care in the United States.”

Findings from the first year of CPCI were encouraging enough that CMMI has chosen to more than double the size of the program.

“Our findings on the early effects of CPC on service utilization and costs for attributed Medicare fee-for-service (FFS) beneficiaries through September 2013 are promising and more favorable than might be expected for the first 12 months of the initiative. Across all seven regions in the first year, early results suggest that CPC has generated enough savings in Medicare health care expenditures to nearly cover the CPC care management fees paid by CMS for attributed Medicare FFS beneficiaries, although not enough to generate net savings. CPC also generated reductions in hospitalizations, outpatient ED visits, primary care physician visits, and specialist visits. … we recommend that these findings be interpreted with caution at this time.

As for effects on quality, there was a sizable (4 percent) CPC-wide decline (that was not quite statistically significant) in unplanned 30-day readmissions, but there were few other sizeable or statistically significant effects on other claims-based quality-of-care outcomes or process measures examined that reflect quality of care provided by all the patients’ providers.”

Although CPCI included approximately 2.7 million active patients as of 2015, only 78,000 of these were Medicaid beneficiaries. There is no Medicaid-specific evaluation of CPCI to date.

An evaluation of the first two years of CPCI published this month showed that Medicare expenditures and quality for participating members did not different significantly from expenditures in control practices.

Model Overview:

CPC Plus is a multi-payer model. The goal of including multiple payers in a region is to ensure adequate financial support for practices to make fundamental changes to their care delivery. The intent is for the Payer Partner models to be “aligned” with Medicare’s but not necessarily identical in all details. CMS will enter into an MOU that outlines the expectations of qualifying payers to ensure consistency in the parameters of CPC + within a region.

Applications for participation will be accepted in two phases. In the first phase, Partnering Payers apply to participate in the program by June 1, 2016. Based on the level of qualifying payer participation, CMMI will designate the participating states or regions, and then invite practices in those regions to apply. Practice applications will be accepted between July 15 and September 1, 2016.

Practices may apply in one of two Tracks:

  • In Track 1, participating practices will work for five years to implement and develop comprehensive primary care capabilities. In addition to their Medicare fee-for-service (FFS) payments, Track 1 practices will receive a care management fee (CMF) that averages $15 per beneficiary per month (PBPM) in support of this work. Track 1 is the most similar to the Original CPC Model, but CMS has refined the eligibility criteria, care delivery requirements, and incentive payment opportunities to incorporate lessons learned in the Original CPC Model.
  • Track 2 targets practices proficient in comprehensive primary care that are prepared to increase the depth, breadth, and scope of medical care delivered to their patients, particularly those with complex needs. In support of this advanced work, payment is redesigned to be a hybrid of FFS paid at the time of the visit and FFS prospectively paid through what CMS is calling Comprehensive Primary Care Payments (CPCPs). Beyond the FFS/CPCP payments, Track 2 practices will also receive an enhanced care management fee averaging $28 PBPM to support care management, enhanced to support the more stringent requirements for Track 2 practices and to enable more comprehensive care for their patients with more complex needs.

Both Tracks 1 and 2 will offer a prospective performance-based incentive payment to reward practices for performance on quality and utilization measures that lead to reductions in total costs of care.

Payer Responsibilities:

CMS will be hosting webinars for interested payers: CPC+ Interested Payer Event – open to payers only

  • Wednesday, April 27 | 2:00 – 3:00p.m. EDT | Registration is open
  • Tuesday, May 10 | 2:00 – 3:00p.m. EDT | Registration is open

Operational Responsibilities:

• Commit to pursuing private arrangements with practices participating in both Tracks 1 and 2 of CPC+ for the model’s full duration.

• Provide enhanced non-fee-for-service support to allow practices to meet the aims of the care delivery model.

• Offer an opportunity for a performance-based incentive payment that aligns with the financial model outlined in the Payment Redesign section.

• To align with Medicare in Track 2, change the cash flow mechanism from fee-for-service to at least a partial alternative, in whatever arrangement the payer favors, before the end of the first performance year.

Data Sharing:

• Share with CMS their attribution methodologies.

• Supply participating practices with practice- and patient-level data about cost and utilization for their attributed patients, either through reports or other methods of data sharing at regular intervals (e.g., quarterly).

• Provide CMS with practice and patient-level data to be used for monitoring and evaluation purposes, as required under 42 C.F.R. 403.1110.

Quality Measures:

• To the greatest extent possible, align practice quality and performance measures with those under the model, as outlined in the Quality section.

Health IT Vendors:

Health IT vendors will be invited to support practices who participate in Track 2. The care delivery CMS expects in Track 2 is reliant upon the use of advanced health IT capabilities that practices will need to attain through EHR enhancements or by adding or securing additional health IT services/tools. Thus, practices will engage their vendors to support the attainment and optimization of health IT to meet the goals and objectives of practice transformation. Vendor partnership is described further in Appendix C.

Potential Advantages to States of Participation:

  1. The CPC Medicare and multi-payer model provides significant financial support to practices to support care delivery re-design. By joining a multi-payer model, Medicaid programs can gain the advantages of significant practice advancement in primary care capacity without needing to finance the entire transformation.
  2. The CPC practice milestones and technical assistance are rigorous and have been generally seen as effective in making real, substantive delivery system change.
  3. Engagement of HIT vendors in the support of practices will likely be of assistance to Medicaid providers.
  4. In current CPC, MAPCP and SIM states, there will likely be significant pressure from providers for Medicaid participation, given the levels of funding being offered by Medicare.

Potential Challenges for States in Participation:

  1. PMPMs from Medicare likely exceed what most states are generally paying in Medical Home demonstrations. Although Medicaid PMPMs do not need to be at the same level as Medicare, there may be provider pressure to approach those levels.
  2. Medicaid member participation in CPCI v1.0 has been limited, and therefore financial justification for ROI is not solid.
  3. The blended FFS and lump sum payment models in Track 2, and incentive models in Tracks 1 and 2 will likely pose operational challenges for Medicaid agencies, particularly to operationalize them in the first year as required.
  4. Based on CPCI evaluations, states may face challenges in asking MCOs to implement the model without increasing capitation to cover at least some of the costs.