CPC+ Overview
Comprehensive Primary Care Plus (CPC+) is an advanced primary care medical home model, created by Centers for Medicare and Medicaid Services and in collaboration with other Payers, that rewards value and quality by offering an innovative payment structure to support delivery of comprehensive primary care.
Arkansas
Statewide
Arkansas BlueCross BlueShield, Arkansas Health & Wellness Solutions, Arkansas Medicaid, Arkansas Superior Select, HealthSCOPE Benefits, QualChoice Health Plan Services, Inc.
Colorado
Statewide
Anthem, Colorado Choice Health Plans, Colorado Medicaid, Rocky Mountain Health Plans, UnitedHealthcare
New York
North Hudson-Capital Region
Hudson Valley Region: Capital District Physicians’ Health Plan, Empire BlueCross BlueShield, MVP Health Plan, Inc.
New Jersey
Statewide
Hudson Valley Region: Capital District Physicians’ Health Plan, Empire BlueCross BlueShield, MVP Health Plan, Inc.
Montana
Statewide
BlueCross BlueShield of Montana, Montana Medicaid, PacificSource Health Plans
Michigan
Statewide
BlueCross BlueShield of Michigan, Priority Health
Kansas and Missouri
Greater Kansas City Region
Greater Kansas City: BlueCross BlueShield of Kansas City
Hawaii
Statewide
Hawaii Medical Service Association
Ohio
Statewide and Northern Kentucky, Ohio and Northern Kentucky Region
Aetna, Anthem, Aultman Health Foundation, Buckeye Health Plan, CareSource, Gateway Health Plan of Ohio, Inc., Medical Mutual of Ohio, Molina Healthcare of Ohio, Inc., Ohio Medicaid, Paramount Health Care, SummaCare, Inc., The Health Plan, UnitedHealthcare
Oklahoma
Statewide
Advantage Medicare Plan, BlueCross BlueShield of Oklahoma, CommunityCare HMO, Inc., Oklahoma Medicaid, UnitedHealthcare
Oregon
Statewide
AllCare Health, Inc., ATRIO Health Plans, Inc., CareOregon, Eastern Oregon Coordinated Care Organization, FamilyCare Health, Moda Health Plan, Inc., Oregon Medicaid, PacificSource Health, PrimaryHealth of Josephine County, Providence Health Plan, Tuality Health Alliance, Western Oregon Advanced Health, Willamette Valley Community Health Organization, Yamhill Community Care Organization, Inc.
Pennsylvania
Greater Philadelphia Area
Aetna, Independence BlueCross/Keystone Health Plan East, Delaware Valley ACO
Rhode Island
Statewide
BlueCross BlueShield of Rhode Island, Rhode Island Medicaid, Tufts Health Plan, UnitedHealthcare
Tennessee
Statewide
Amerigroup Tennessee, Tennessee Medicaid, United Healthcare, Volunteer State Health Plan
Care Management Fee (CMF) & Per Beneficiary Per Month Payments
CPC+ practices will receive a risk-adjusted, prospective, monthly care management fee (CMF) for their attributed Medicare fee-for- service patients. Practices will use this enhanced, non-visit-based compensation to augment staffing and training in support of population health management and care coordination. Track 1 practices will receive a CMF that averages $15 per beneficiary per month (PBPM) to support their transformation efforts. Track 2 practices will receive an average of approximately $28 PBPM, including a $100 PBPM for a highest risk tier to support the enhanced services beneficiaries with complex needs require.
Upfront Payment Models
In Track 1, practices will also continue to receive regular Medicare fee-for- service payments for covered evaluation and management services. In Track 2 of CPC+, CMS is introducing a hybrid of fee-for- service and Comprehensive Primary Care Payment (CPCP). This hybrid payment will pay for covered evaluation and management (E&M) services, but allows flexibility for the care to be delivered both in and out of an office visit. Track 2 practices will receive a percentage of their expected Medicare E&M payment upfront in the form of a CPCP and a reduced fee-for- service payment for face-to- face E&M claims. In an effort to recognize practice diversity in readiness for this change in payment, CMS will allow practices to move to one of these final two proposed hybrid payment options (40 percent or 65 percent CPCP with 60 percent or 35 percent FFS), at their preferred pace by 2021, pursuant to the options shown in this table:
1 st Column is the 10/ 90 approach with increments made quarterly, practices receive initially receive 10% or 11% of previous years E&M coding up front and 10% of the alternative means visits like phone, text, e-visit this is CPCP, this is only for 1,000 patients
On average FFS per member for CMS averages $16.50 per member per month plus they get the PBPM average of $15 for Track 1 and $28 for Track 2, see Table 2
ASSUMPTIONS
| ASSUMPTIONS | Your Value |
|---|---|
| # of covered lives per provider | |
| # of providers per practice | |
| E&M Billing PMPM($) | |
| Multiple of procedure billing to E&M billing | |
| Care Management Fee - Track 1($) | |
| Care Management Fee - Track 2: PMPM($) | |
| ASSUMPTIONS | Your Value |
PER PROVIDER PER YEAR
| E&M Billing | E&M Up-Front | E&M Up-Front | Procedure Billing | Macra 5% | Care Management Fee | Cost/Quality Incentive | Total | |
|---|---|---|---|---|---|---|---|---|
| FFS | ||||||||
| CPC+ Track 1 | ||||||||
| CPC+ Track 2-65% |
PER PRACTICE PER YEAR
| E&M Billing PMPM | Procedure Billing | Macra 5% | Care Management Fee | Cost/Quality Incentive | Total | |
|---|---|---|---|---|---|---|
| FFS | ||||||
| CPC+ Track 1 | ||||||
| CPC+ Track 2-65% |
Sample Pro Forma Per Provider Per Year
| Per Beneficiary Per Month | Estimated Cost/Year On Your Own | Estimated Cost/Year CareVitality | |
|---|---|---|---|
| Internal Staff | |||
| Care Coordinator (Full-time RN) | |||
| Internal Project Manager (Practice Manager level, full time to manage program from scratch, 25% | |||
| Required IT | |||
| Certified Electronic Health Record (annual fee) | |||
| Certified Care Management Software | |||
| Claims Data and Practice Level Analytics | |||
| Analytics Support and Guidance | |||
| Additional HIT For Track 2 (TBD-Patient Reported Outcomes and as directed by CMS) | |||
| Interface Fees (over 5 years) | |||
| Quality Reporting Module or QCDR (annual fee) | |||
| Evidence-Based Care Plans | |||
| Services | |||
| Quality Improvement Training ( to get incentive) | |||
| Care Coordinator Training and Support | |||
| 24/7 Nurse Advice Line with access to PCP | |||
| Program Participation Consulting Services to ensure compliance, prepare budgets, help guide PFAC, etc. | |||
| CareVitality CPC+ Program | 5.00 | 60000.00 | |
| Total Recommended Services | |||
| Additional CPC+ Payments (Net of FFS) | |||
| Total Additional Income Track 1 | |||
| Total Additional Income Track 2 | |||
| Total Additional AWV/ACP Practice Income | 14625 | 73125 | |
| Net Physician Compensation (Track 1) Per Year | |||
| Net Physician Compensation (Track 2) Per Year | |||
- Care Coordinator: One FTE per provider, RN level (CareVitality experience)
- Program Manager: One FTE per practice if self-guided (CareVitality experience)
- Saas EHR: Per provider (HealthIT.gov)
- Care Management Software: Per life (RFP range: $0 .42-$2.00 PMPM)
- Claims Data Software: Per life (RFP range: $0.70 – $2.00 PMPM)
- Analytics Support: Per practice (CareVitality estimate, $5,000 per quarter)
- Additional Software: Requirements unknown, rough estimate only
- Interface Fees: Per practice (RFP range: $6,000 – $27,000 amortized over five years, does not include practice EHR fees)
- Quality reporting: QCDR survey: range from $395 – $1100 per provider, vendor survey range from $2,000 to 10,000 per
- Care Coordinator training and support: vendor survey: cost of training program, conference attendance including travel
- 24/7 Advice Nurse, Per life (RFP range: $0.25 – $2.00 PMPM)
- Quarterly on-site evaluation and advice, vendor survey $5,000 – $10,000 per practice per quarter
- Based on practice implementing fee-schedule population health programs using non-physician staff. CareVitality quarterly workshops
Patients in Care Management Programs (see Table 2)
Research the HCC coding to determine the different quartiles, the 4 different quartiles are representative of patients with multiple chronic conditions and the level of severity of the conditions. CMS assigns beneficiaries to a risk tier based on the individual’s hierarchical condition category (HCC) score. CMS-HCC scores are generated for all Medicare beneficiaries, and are updated annually based on the beneficiaries’ claims history. CMS will use the most recent HCC scores available in the CMS claims databases at the time of attribution. A beneficiary’s HCC score will determine to which risk quartile the CPC+ Practice Frequently Asked Questions beneficiary will be assigned (see CPC+ Care Management Fees table), based on comparison to the population of Medicare FFS beneficiaries in that region. In Track 2, the complex tier will be based on a combination of HCC score and beneficiaries who have a diagnosis of dementia.
The top 10 percent of the HCC risk pool will represent patients who are the “sickest of the sick,” with multiple conditions and high expected costs. The exact range of HCC scores and number of beneficiaries assigned to the complex tier will vary based on region, due to different populations and variations in coding practices. For a more detailed description of the HCC methodology, as well as detailed information on what diagnoses are included in the HCC scores, please refer to this independent evaluation report. In addition to beneficiaries in the top 10 percent HCC, beneficiaries who have a diagnosis of dementia will also be assigned to the complex tier. Dementia diagnosis is assigned based on a chronic condition flag generated annually based on a set of diagnoses codes present in the prior three years. For detailed information, please refer to the Chronic Conditions Warehouse.
The estimates for Care Management Fees (CMF) on average are as follows Track 1 $180,000 and Track 2 $336,000.
Suggested Cost/ Ratios for Practices
- Suggest 1 nurse per FT provider (care coordination/care management) average of $65,000 cost
- Suggest 1 Project Manager to oversee progress and meeting requirements/ working part time $25,000-$40,000 (dependent on practice size)
- Must use Certified Care Plan Software (if their EHR has it if not additional cost)
- Suggest use of Population Health/Care Management software of $0.42-$2.00 PMPM (per patient per month)
Incentive Payments for Performance
CMS will prospectively pay a performance-based incentive payment, which practices may keep if they meet annual performance thresholds. Practices that do not meet the annual thresholds would be required to repay all or a portion of the prepaid amount. Practices will thus be “at risk” for the amounts prepaid. The payment will be broken into two distinct components, both paid prospectively: incentives for performance on clinical quality/patient experience measures and incentives for performance on utilization measures that drive total cost of care. The quality/experience component will be based on performance on electronic clinical quality measures (eCQM) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) metrics. The utilization component will be based on claims-based measures that are commonly used to measure total cost of care and measurable at the practice level, such as: inpatient admissions and emergency department visits that are available in the Healthcare Effectiveness Data and Information Set (HEDIS).
CMS will provide larger performance-based incentive payments in Track 2 than in Track 1, as outlined in the following table. However, all practices are at risk for repaying all or a portion of the prepaid amount to CMS depending on their performance. The final methodology for calculating the prepaid amounts and repayment amounts will be outlined in a methodology paper, so practices understand the payment mechanism prior to the start of the model.
CPC+ Performance Based Incentive Payment
Three Payment Paths
- Care Management Fee (CMF): Both tracks provide a non-visit based CMF paid 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. The 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 payment based on 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:
- a. Track 1 continues to bill and receive payment from Medicare FFS as usual.
- b. Track 2 practices also continue to bill as usual, but the FFS payment for evaluation and management services will be reduced to account for CMS shifting a portion of Medicare FFS payments into Comprehensive Primary Care Payments (CPCP), which will be paid in a lump sum on a quarterly basis without a claim. Given our expectations that Track 2 practices will increase the comprehensiveness of care delivered, the CPCP amounts will be larger than the FFS payment amounts they are intended to replace.
Reporting to CMS
This model aims to improve the quality and experience of care that beneficiaries receive and decrease the total cost of care. To assess quality performance and eligibility for the CPC+ performance-based incentive payment, CMS will require Track 1 and 2 practices to annually report electronic clinical quality measures (eCQMs) and patient experience of care measures (Consumer Assessment of Healthcare Providers & Systems [CAHPS]). eCQMs must be reported at the practice-site level and are specified to include all practice population patients, regardless of payer or insurance status. CAHPS surveys will be administered by CMS or its contractors to patients in practices in Track 1 and Track 2. In future years, Track 2 practices may also use a patient reported outcome measure survey. The provisional Quality and Utilization Measure Set for CPC+ is available in Appendix D of the Request for Applications. The quality reporting requirements may undergo changes prior to the start of CPC+, after the final list of the MIPS measures are published in the Quality Payment Program final rule.
Software Requirements & Explanation
Practices in both Tracks 1 and 2 are required to adopt the following health IT to participate in CPC+
- Practices should adopt the certified health IT modules that meet the definition of CEHRT according to the timeline and requirements finalized for use in CMS programs supporting CPC+ Practice Frequently Asked Questions certified EHR use (e.g., EHR Incentive Programs. Consistent with these programs, practices can use either 2015 Edition or 2014 Edition technology in 2017, but must use only 2015 Edition technology starting in 2018.
Practices in both Tracks 1 and 2 also need to meet certain technology requirements in order to report on required electronic clinical quality measures (eCQMs) under the program
- Practices will need to adopt health IT certified to the (c)(1) – (c)(3) certification criteria for all of the electronic clinical quality measures in the CPC+ measure set. As with the overall CEHRT requirements, practices should follow the requirements and timeline of the EHR Incentive Program (i.e., practices can use either 2015 Edition or 2014 Edition technology in 2017, but must use only 2015 Edition technology starting in 2018).
- For the CPC+ measures, practices must use the latest annual measure update. For instance, for the 2017 performance period, practices must use the eCQM specifications contained in the 2016 annual update, released in April 2016 (https://www.cms.gov/regulations-andguidance/legislation/ehrincentiveprograms/ecqm_library.html ).
- Practices must be able to filter their electronic clinical quality measure data by practice site location and TIN/NPI beginning in 2017. Beginning in 2018, practices will demonstrate their ability to conduct this filtering by adopting 2105 Edition health IT certified to the criterion found at 45 CFR 170.315(c)(4).
To support specific Track 2 enhanced health IT functions, Track 2 practices will also be expected to meet two additional certified technology requirements:
- Adopt health IT certified to the 2015 Edition “Care Plan” criterion found at 45 CFR 170.315(b)(9) by January 1, 2019 (the beginning of performance year (PY) 3 of CPC+).
- Adopt health IT certified to the 2015 Edition “Social, Behavioral, and Psychosocial Data” criterion found at 45 CFR 170.315(a)(15) by January 1, 2019 (the beginning of performance year 3 of CPC+).
- PARTICIPANTS
-
Arkansas
StatewideArkansas BlueCross BlueShield, Arkansas Health & Wellness Solutions, Arkansas Medicaid, Arkansas Superior Select, HealthSCOPE Benefits, QualChoice Health Plan Services, Inc.
Colorado
StatewideAnthem, Colorado Choice Health Plans, Colorado Medicaid, Rocky Mountain Health Plans, UnitedHealthcare
New York
North Hudson-Capital RegionHudson Valley Region: Capital District Physicians’ Health Plan, Empire BlueCross BlueShield, MVP Health Plan, Inc.
New Jersey
StatewideHudson Valley Region: Capital District Physicians’ Health Plan, Empire BlueCross BlueShield, MVP Health Plan, Inc.
Montana
StatewideBlueCross BlueShield of Montana, Montana Medicaid, PacificSource Health Plans
Michigan
StatewideBlueCross BlueShield of Michigan, Priority Health
Kansas and Missouri
Greater Kansas City RegionGreater Kansas City: BlueCross BlueShield of Kansas City
Hawaii
StatewideHawaii Medical Service Association
Ohio
Statewide and Northern Kentucky, Ohio and Northern Kentucky RegionAetna, Anthem, Aultman Health Foundation, Buckeye Health Plan, CareSource, Gateway Health Plan of Ohio, Inc., Medical Mutual of Ohio, Molina Healthcare of Ohio, Inc., Ohio Medicaid, Paramount Health Care, SummaCare, Inc., The Health Plan, UnitedHealthcare
Oklahoma
StatewideAdvantage Medicare Plan, BlueCross BlueShield of Oklahoma, CommunityCare HMO, Inc., Oklahoma Medicaid, UnitedHealthcare
Oregon
StatewideAllCare Health, Inc., ATRIO Health Plans, Inc., CareOregon, Eastern Oregon Coordinated Care Organization, FamilyCare Health, Moda Health Plan, Inc., Oregon Medicaid, PacificSource Health, PrimaryHealth of Josephine County, Providence Health Plan, Tuality Health Alliance, Western Oregon Advanced Health, Willamette Valley Community Health Organization, Yamhill Community Care Organization, Inc.
Pennsylvania
Greater Philadelphia AreaAetna, Independence BlueCross/Keystone Health Plan East, Delaware Valley ACO
Rhode Island
StatewideBlueCross BlueShield of Rhode Island, Rhode Island Medicaid, Tufts Health Plan, UnitedHealthcare
Tennessee
StatewideAmerigroup Tennessee, Tennessee Medicaid, United Healthcare, Volunteer State Health Plan
- PAYMENT STRUCTURE
-
Care Management Fee (CMF) & Per Beneficiary Per Month Payments
CPC+ practices will receive a risk-adjusted, prospective, monthly care management fee (CMF) for their attributed Medicare fee-for- service patients. Practices will use this enhanced, non-visit-based compensation to augment staffing and training in support of population health management and care coordination. Track 1 practices will receive a CMF that averages $15 per beneficiary per month (PBPM) to support their transformation efforts. Track 2 practices will receive an average of approximately $28 PBPM, including a $100 PBPM for a highest risk tier to support the enhanced services beneficiaries with complex needs require.Upfront Payment Models
In Track 1, practices will also continue to receive regular Medicare fee-for- service payments for covered evaluation and management services. In Track 2 of CPC+, CMS is introducing a hybrid of fee-for- service and Comprehensive Primary Care Payment (CPCP). This hybrid payment will pay for covered evaluation and management (E&M) services, but allows flexibility for the care to be delivered both in and out of an office visit. Track 2 practices will receive a percentage of their expected Medicare E&M payment upfront in the form of a CPCP and a reduced fee-for- service payment for face-to- face E&M claims. In an effort to recognize practice diversity in readiness for this change in payment, CMS will allow practices to move to one of these final two proposed hybrid payment options (40 percent or 65 percent CPCP with 60 percent or 35 percent FFS), at their preferred pace by 2021, pursuant to the options shown in this table:1 st Column is the 10/ 90 approach with increments made quarterly, practices receive initially receive 10% or 11% of previous years E&M coding up front and 10% of the alternative means visits like phone, text, e-visit this is CPCP, this is only for 1,000 patients
On average FFS per member for CMS averages $16.50 per member per month plus they get the PBPM average of $15 for Track 1 and $28 for Track 2, see Table 2
- CPC+ REVENUE CALCULATOR
-
ASSUMPTIONS
Calculator ASSUMPTIONS Your Value # of covered lives per provider # of providers per practice E&M Billing PMPM($) Multiple of procedure billing to E&M billing Care Management Fee - Track 1($) Care Management Fee - Track 2: PMPM($) ASSUMPTIONS Your Value
PER PROVIDER PER YEAR
E&M Billing E&M Up-Front E&M Up-Front Procedure Billing Macra 5% Care Management Fee Cost/Quality Incentive Total FFS CPC+ Track 1 CPC+ Track 2-65%
PER PRACTICE PER YEAR
E&M Billing PMPM Procedure Billing Macra 5% Care Management Fee Cost/Quality Incentive Total FFS CPC+ Track 1 CPC+ Track 2-65%
Sample Pro Forma Per Provider Per Year
Per Beneficiary Per Month Estimated Cost/Year On Your Own Estimated Cost/Year CareVitality Internal Staff Care Coordinator (Full-time RN) Internal Project Manager (Practice Manager level, full time to manage program from scratch, 25% Required IT Certified Electronic Health Record (annual fee) Certified Care Management Software Claims Data and Practice Level Analytics Analytics Support and Guidance Additional HIT For Track 2 (TBD-Patient Reported Outcomes and as directed by CMS) Interface Fees (over 5 years) Quality Reporting Module or QCDR (annual fee) Evidence-Based Care Plans Services Quality Improvement Training ( to get incentive) Care Coordinator Training and Support 24/7 Nurse Advice Line with access to PCP Program Participation Consulting Services to ensure compliance, prepare budgets, help guide PFAC, etc. CareVitality CPC+ Program 5.00 60000.00 Total Recommended Services Additional CPC+ Payments (Net of FFS) Total Additional Income Track 1 Total Additional Income Track 2 Total Additional AWV/ACP Practice Income 14625 73125 Net Physician Compensation (Track 1) Per Year Net Physician Compensation (Track 2) Per Year - Care Coordinator: One FTE per provider, RN level (CareVitality experience)
- Program Manager: One FTE per practice if self-guided (CareVitality experience)
- Saas EHR: Per provider (HealthIT.gov)
- Care Management Software: Per life (RFP range: $0 .42-$2.00 PMPM)
- Claims Data Software: Per life (RFP range: $0.70 – $2.00 PMPM)
- Analytics Support: Per practice (CareVitality estimate, $5,000 per quarter)
- Additional Software: Requirements unknown, rough estimate only
- Interface Fees: Per practice (RFP range: $6,000 – $27,000 amortized over five years, does not include practice EHR fees)
- Quality reporting: QCDR survey: range from $395 – $1100 per provider, vendor survey range from $2,000 to 10,000 per
- Care Coordinator training and support: vendor survey: cost of training program, conference attendance including travel
- 24/7 Advice Nurse, Per life (RFP range: $0.25 – $2.00 PMPM)
- Quarterly on-site evaluation and advice, vendor survey $5,000 – $10,000 per practice per quarter
- Based on practice implementing fee-schedule population health programs using non-physician staff. CareVitality quarterly workshops
- PATIENTS IN CARE MANAGEMENT PROGRAMS
-
Patients in Care Management Programs (see Table 2)
Research the HCC coding to determine the different quartiles, the 4 different quartiles are representative of patients with multiple chronic conditions and the level of severity of the conditions. CMS assigns beneficiaries to a risk tier based on the individual’s hierarchical condition category (HCC) score. CMS-HCC scores are generated for all Medicare beneficiaries, and are updated annually based on the beneficiaries’ claims history. CMS will use the most recent HCC scores available in the CMS claims databases at the time of attribution. A beneficiary’s HCC score will determine to which risk quartile the CPC+ Practice Frequently Asked Questions beneficiary will be assigned (see CPC+ Care Management Fees table), based on comparison to the population of Medicare FFS beneficiaries in that region. In Track 2, the complex tier will be based on a combination of HCC score and beneficiaries who have a diagnosis of dementia.The top 10 percent of the HCC risk pool will represent patients who are the “sickest of the sick,” with multiple conditions and high expected costs. The exact range of HCC scores and number of beneficiaries assigned to the complex tier will vary based on region, due to different populations and variations in coding practices. For a more detailed description of the HCC methodology, as well as detailed information on what diagnoses are included in the HCC scores, please refer to this independent evaluation report. In addition to beneficiaries in the top 10 percent HCC, beneficiaries who have a diagnosis of dementia will also be assigned to the complex tier. Dementia diagnosis is assigned based on a chronic condition flag generated annually based on a set of diagnoses codes present in the prior three years. For detailed information, please refer to the Chronic Conditions Warehouse.
The estimates for Care Management Fees (CMF) on average are as follows Track 1 $180,000 and Track 2 $336,000.
- SUGGESTED COST RATIOS
-
Suggested Cost/ Ratios for Practices
- Suggest 1 nurse per FT provider (care coordination/care management) average of $65,000 cost
- Suggest 1 Project Manager to oversee progress and meeting requirements/ working part time $25,000-$40,000 (dependent on practice size)
- Must use Certified Care Plan Software (if their EHR has it if not additional cost)
- Suggest use of Population Health/Care Management software of $0.42-$2.00 PMPM (per patient per month)
- INCENTIVE PAYMENTS FOR PERFORMANCE
-
Incentive Payments for Performance
CMS will prospectively pay a performance-based incentive payment, which practices may keep if they meet annual performance thresholds. Practices that do not meet the annual thresholds would be required to repay all or a portion of the prepaid amount. Practices will thus be “at risk” for the amounts prepaid. The payment will be broken into two distinct components, both paid prospectively: incentives for performance on clinical quality/patient experience measures and incentives for performance on utilization measures that drive total cost of care. The quality/experience component will be based on performance on electronic clinical quality measures (eCQM) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) metrics. The utilization component will be based on claims-based measures that are commonly used to measure total cost of care and measurable at the practice level, such as: inpatient admissions and emergency department visits that are available in the Healthcare Effectiveness Data and Information Set (HEDIS).CMS will provide larger performance-based incentive payments in Track 2 than in Track 1, as outlined in the following table. However, all practices are at risk for repaying all or a portion of the prepaid amount to CMS depending on their performance. The final methodology for calculating the prepaid amounts and repayment amounts will be outlined in a methodology paper, so practices understand the payment mechanism prior to the start of the model.
CPC+ Performance Based Incentive Payment
- THREE PAYMENT PATHS
-
Three Payment Paths
- Care Management Fee (CMF): Both tracks provide a non-visit based CMF paid 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. The 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 payment based on 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:
- a. Track 1 continues to bill and receive payment from Medicare FFS as usual.
- b. Track 2 practices also continue to bill as usual, but the FFS payment for evaluation and management services will be reduced to account for CMS shifting a portion of Medicare FFS payments into Comprehensive Primary Care Payments (CPCP), which will be paid in a lump sum on a quarterly basis without a claim. Given our expectations that Track 2 practices will increase the comprehensiveness of care delivered, the CPCP amounts will be larger than the FFS payment amounts they are intended to replace.
- REPORTING TO CMS
-
Reporting to CMS
This model aims to improve the quality and experience of care that beneficiaries receive and decrease the total cost of care. To assess quality performance and eligibility for the CPC+ performance-based incentive payment, CMS will require Track 1 and 2 practices to annually report electronic clinical quality measures (eCQMs) and patient experience of care measures (Consumer Assessment of Healthcare Providers & Systems [CAHPS]). eCQMs must be reported at the practice-site level and are specified to include all practice population patients, regardless of payer or insurance status. CAHPS surveys will be administered by CMS or its contractors to patients in practices in Track 1 and Track 2. In future years, Track 2 practices may also use a patient reported outcome measure survey. The provisional Quality and Utilization Measure Set for CPC+ is available in Appendix D of the Request for Applications. The quality reporting requirements may undergo changes prior to the start of CPC+, after the final list of the MIPS measures are published in the Quality Payment Program final rule. - SOFTWARE REQUIREMENTS AND EXPLANATION
-
Software Requirements & Explanation
Practices in both Tracks 1 and 2 are required to adopt the following health IT to participate in CPC+- Practices should adopt the certified health IT modules that meet the definition of CEHRT according to the timeline and requirements finalized for use in CMS programs supporting CPC+ Practice Frequently Asked Questions certified EHR use (e.g., EHR Incentive Programs. Consistent with these programs, practices can use either 2015 Edition or 2014 Edition technology in 2017, but must use only 2015 Edition technology starting in 2018.
Practices in both Tracks 1 and 2 also need to meet certain technology requirements in order to report on required electronic clinical quality measures (eCQMs) under the program- Practices will need to adopt health IT certified to the (c)(1) – (c)(3) certification criteria for all of the electronic clinical quality measures in the CPC+ measure set. As with the overall CEHRT requirements, practices should follow the requirements and timeline of the EHR Incentive Program (i.e., practices can use either 2015 Edition or 2014 Edition technology in 2017, but must use only 2015 Edition technology starting in 2018).
- For the CPC+ measures, practices must use the latest annual measure update. For instance, for the 2017 performance period, practices must use the eCQM specifications contained in the 2016 annual update, released in April 2016 (https://www.cms.gov/regulations-andguidance/legislation/ehrincentiveprograms/ecqm_library.html ).
- Practices must be able to filter their electronic clinical quality measure data by practice site location and TIN/NPI beginning in 2017. Beginning in 2018, practices will demonstrate their ability to conduct this filtering by adopting 2105 Edition health IT certified to the criterion found at 45 CFR 170.315(c)(4).
To support specific Track 2 enhanced health IT functions, Track 2 practices will also be expected to meet two additional certified technology requirements:- Adopt health IT certified to the 2015 Edition “Care Plan” criterion found at 45 CFR 170.315(b)(9) by January 1, 2019 (the beginning of performance year (PY) 3 of CPC+).
- Adopt health IT certified to the 2015 Edition “Social, Behavioral, and Psychosocial Data” criterion found at 45 CFR 170.315(a)(15) by January 1, 2019 (the beginning of performance year 3 of CPC+).
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