The spring 2017 issue of The Ohio Family Physician is dedicated to help better understand several new quality-based payment programs, how they impact the way we deliver care, and how we get paid for providing that care.
The following feature from the issue takes a deep dive into the Comprehensive Primary Care initiative (CPC classic) and CPC Plus (CPC+) as we learn about the practice transformation journey of Katherine “Toni” Clark, DO, FAAFP, of Beavercreek, OH. Look for other value-based payment features in upcoming editions of the Weekly Family Medicine Update, on the OAFP website, and on the Academy’s Facebook and Twitter pages.
Practice transformation and performance improvement are challenging endeavors. Though there isn’t much controversy about that statement, the process takes time and patience and is certainly not without frustration. Meaningful practice transformation is doable, successful, and rewarding…just ask Dr. Clark.
In Dr. Clark’s case, transformation came about initially through her practice’s participation in House Bill (HB) 198, Ohio’s Patient-Centered Medical Home (PCMH) Education Pilot Program, then participation in CPC classic, and now in CPC+.
HB 198 PCMH Education Pilot Program
Always enthusiastic about change, Dr. Clark saw a need for transformation when the PCMH Education Pilot Program was created with passage of Ohio’s medical home statute (HB 198 of the 128th Ohio General Assembly) in 2011. The goal of Ohio’s PCMH Education Pilot Program was to assist 50 selected practices to transform to the PCMH model of care where medical students and advanced practice nurses could learn how to practice in a PCMH environment. Her practice, Integrated Medical Group, is comprised of four family physicians who have a keen interest in teaching and were thrilled to mesh education with transformation. The practice has had many learners rotating monthly including medical students from the Wright State University Boonshoft School of Medicine, Dayton, OH, and the Ohio University Heritage College of Osteopathic Medicine, Athens, OH, as well as physician assistant and nurse practitioner students. As the practice participated in the pilot program, the physicians and staff found the PCMH transformation process challenging, but exhilarating. Then, not long after, came the opportunity to apply for CPC classic.
“We saw the need for change in our system to place emphasis on quality of care and outcomes for our patients. Previously, the incentives were to see many patients quickly concentrating on a chief complaint as opposed to having the time and resources to take care of the whole patient and be accountable for the utilization and quality metric outcomes. The old paradigm caused the often quoted complaint of primary care physicians feeling like they were running on a hamster wheel, but not getting very far,” said Dr. Clark.
Even though Integrated Medical Group hadn’t achieved PCMH recognition at the time of its selection for participation in CPC classic, the practice was chosen because of its participation in the Ohio PCMH Education Pilot Program. Dr. Clark frequently thanks her colleague, Ted Wymyslo, MD, former director of the Ohio Department of Health, the Ohio Academy of Family Physicians, and the Ohio Osteopathic Association for their leadership in advocating for HB 198 and their diligence in securing funding for the pilot program.
CPC Classic
In October 2012, the Centers for Medicare and Medicaid Services (CMS) launched CPC classic—a unique collaboration between CMS and other public and private payers including commercial insurers and Medicaid managed care. The program, now completed, aimed to improve primary care delivery and achieve better care, smarter spending, and healthier people. It also aimed to enhance clinician and staff experience.
CPC classic provided financial resources, learning support, and actionable data to help practices transform across five key care delivery functions: access and continuity, planned care for chronic conditions and preventive care, risk-stratified care management, patient and caregiver engagement, and coordination of care across the medical neighborhood.
The Cincinnati-Dayton region of Ohio was selected by CMS as one of seven geographic markets to carry out CPC classic. CPC classic was led by family physicians Barb Tobias, MD, and Richard Shonk, MD, from The Health Collaborative, Cincinnati, OH. The 75 practices, representing 261 physicians, in the Cincinnati-Dayton market selected for the initiative had impressive outcomes of decreasing emergency department and inpatient utilization and reducing overall costs while maintaining or improving quality.
Dr. Clark’s family medicine practice, Integrated Medical Group, and its CPC classic partner practice, South Dayton Internal Medicine led by Bihu Sandhir, MD, are part of the Kettering Health Physician Network. Both practices had larger than average high risk panels, and are in suburban locations. The practices differed in that the Integrated Medical Group patient-payer mix was 25% Medicaid and 50% Medicare while South Dayton Internal Medicine patients were older and had fewer social determinants negatively affecting their health.
“When it comes to CPC classic, patience is a virtue; you are actually redesigning the metaphorical airplane while you are flying it,” said Dr. Clark.
CPC Classic Payments
According to CMS, Medicare fee-for-service (FFS) and most other payers used per member, per month (PMPM) payments for their enhanced CPC classic payments to practices. Across payers, practices received a median of $8.02 per attributed patient per month, or $3.27 per active patient per month. This translated to a median of $175,775 per practice ($51,286 per clinician) over the course of 2015, which averaged 12.5% of 2015 total practice revenue for CPC classic practices. Practices reported that CPC classic care management fees from all payers totaled $372 million from the start of the initiative through December 2015. Total payments ranged from $38 million in Oklahoma to $75 million in Ohio. More statistics and details are available by reading the Evaluation of the Comprehensive Primary Care Initiative: Third Annual Report.
“The CPC classic payment model included a monthly, non-visit-based care management fee, and the opportunity to share in any net savings. We received up to $40 per patient per month for care management, as well as quality and prepaid fee-for-service payments through our participation in CPC classic,” said Dr. Clark.
With only two Kettering Health Network practices selected for CPC classic, network leaders were somewhat skeptical in the beginning. Once received, the PMPM dollars became a catalyst for transformation of the whole system’s infrastructure.
“Once the care management payments came in, the system realized the program’s value. Today, there are 35 PCMH practices in the Kettering Health Network. Our practices compete in the community to have the best staff in order to have the best outcomes for patients. We revamped our compensation plan to significantly reflect on quality metrics,” said Dr. Clark.
Both Integrated Medical Group and South Dayton Internal Medicine were consistently in the top 10 most improved practices across the entire region each quarter. Changing the infrastructure of the practice took about two years.
Based on the achievements of CPC classic, CMS announced, on April 11, 2016, the launch of the CPC+ program—a five-year, multi-payer program that began January 1, 2017. CMS expanded the reach of CPC+ from the original Cincinnati-Dayton region to the entire state of Ohio.
CPC+
“The process is a huge culture shift relative to teamwork and care management, but well worth it. Some physicians resisted the PCMH model, CPC classic, and CPC+, but many were open to it. It takes time to gain physician trust that the benefits of the program are for patients, staff, and physicians. In the end, Kettering had 29 practices that were accepted into CPC+,” said Dr. Clark.
- Practice readiness
- Aligned payment reform
- Actionable performance-based incentives
- Robust data sharing.
- Care management fee (CMF): Non-visit-based CMF paid per beneficiary, per month (PBPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for the practice’s specific population. Medicare FFS CMFs will be paid to the practice on a quarterly basis.
- Performance-Based Incentive Payment: CPC+ will prospectively pay and retrospectively reconcile a performance-based incentive depending upon how well the practice performs on patient experience measures, clinical quality measures, and utilization measures that drive total cost of care.
- Payment Under the Medicare Physician Fee Schedule: Track 1 continues to bill and receive payment from Medicare FFS as usual. Track 2 practices also continue to bill as usual, but the FFS payment will be reduced to account for CMS shifting a portion of Medicare FFS payments into CPC payments, which will be paid in a lump sum on a quarterly basis absent a claim. Given the expectations that Track 2 practices will increase the comprehensiveness of care delivered, the CPC+ amounts will be larger than the FFS payment amounts they are intended to replace.
Dr. Clark is thrilled to participate in CPC+ and looks forward to continuing her practice transformation and performance improvement journey.
“I am enthusiastic about change. My success has been measured by maintaining and improving quality. I am highly motivated because in my old age I am accomplishing what I have always wanted to do—work with our team to improve the quality of care provided for our patients,” said Dr. Clark.