CPC+ Laying Groundwork for Value-Based Payment

Source: American Academy of Family Physicians Leader Voices Blog, Michael Munger, MD, AAFP President-Elect

Too often in primary care, our practices don’t get paid for all of the work we do.

For example, the average medical practice wastes roughly 16 hours of staff and physician time each week — per physician — on prior authorizations. And we know that for every hour we spend with patients, physicians spend two hours on documentation.

Although the American Academy of Family Physicians is working to reduce these types of administrative burdens,  there are still other examples of vital work, returning patient phone calls, telehealth, etc., that aren’t reimbursed adequately, if at all.

This year, my practice is one of nearly 3,000 primary care practices working with more than 50 payers to change that. The Comprehensive Primary Care Plus (CPC+) program,  launched in January, is a five-year pilot that aims to move practices away from the volume-driven, fee-for-service payment system. It will do so by providing a new payment structure that encourages flexibility in engaging patients with methods beyond the traditional office visit. Improved payment is expected to allow practices to improve infrastructure, integrate behavioral health, and essentially lay the groundwork for the value-based payment systems of the future.

Shawn Martin, the AAFP’s senior vice president of advocacy, practice advancement, and policy, outlined the specifics of how CPC+ will pay better and differently in a blog post published during the application period last summer.

The short version is that CPC+ offers a payment model with three components that de-emphasize fee-for-service payments and provide prospective payments to support practices as they provide advanced primary care to meet the needs of their patients.

The CPC+ model includes two tracks with slightly different payment components to support practices: track one for those that are building capabilities or track two for practices that are already delivering advanced primary care. Each track has three payment components:
  • Care management fee (CMF): Practices will receive a per-beneficiary-per-month (PBPM) CMF. The fee will be paid prospectively on a quarterly basis and will be based on the complexity of the patient population. The average PBPM CMF will be $15 for track one and $28 for track two. Track two practices will receive a $100 PBPM CMF for the most complex cases, such as patients with dementia.
  • Performance-based incentive payment (PBIP): All CPC+ practices receive their PBIP as a prospective payment at the beginning of each program year so they can meet patient needs and build capacity. At the end of the program year, practices that do not meet quality and utilization benchmarks will repay some or all of this payment. The PBIP will be equivalent to $2.50 PBPM for track one and $4 PBPM for track two.
  • Payment under Medicare physician fee schedule: All CPC+ practices will continue to bill and receive fee-for-service (FFS) payments. Track one practices will continue to receive standard FFS payments. Track two practices will receive a hybrid payment with a prospective portion paid quarterly, the Comprehensive Primary Care Payment (CPCP), coupled with reduced fee-for-service payments. The CPCP plus FFS payments together will be larger than the practice’s historical FFS payment.

The advance payments in this structure will allow practices to invest in the capabilities they need to be successful in transforming care. These capabilities may include care managers, clinical social workers, licensed counselors or other resources needed to deliver robust population health, chronic disease management, and care coordination. We will be able to better identify our high-risk populations, more closely monitor utilization, and reduce emergency room visits, and recurrent hospitalizations.

Once we identify patients in those high-risk groups, we can ensure they are linked to resources within our health care system as well as to external resources and work with them to improve their overall health. We also will work to close gaps in care, improve transitions in care, and proactively manage chronic diseases.

As a level three patient-centered medical home, we already are doing many of the things we will be judged on in this pilot. Now we will be able to do them even better and get paid accordingly.

This month, the Centers for Medicare and Medicaid Services (CMS) is expected to begin accepting applications from payers for an expansion of this concept. CMS will select up to 10 new regions that have sufficient payer commitment to support practices in adopting the CPC+ model. The agency then plans another application period this spring or summer for practices in those new regions.

The AAFP will notify members about opportunities and provide support and resources for those interested in applying. I urge you to consider how your practice, and your patients, might benefit from the experience.

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Disclaimer: The views and opinions expressed in comments published in Weekly Family Medicine Update (WFMU) are those of the writers alone. They do not represent the views or opinions of Ohio Academy of Family Physicians (OAFP) or its staff. Comments are automatically posted live; however, OAFP reserves the right to take down comments at any time.

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