On Aug. 1, CMS announced 14 regions selected for a five-year medical home model, Comprehensive Primary Care Plus (CPC+). The aim is to give doctors the freedom to decide what types of care will deliver the best outcomes for their patients and then reward them for achieving those results.

CMS unveiled the CPC+ initiative in April, billing it as the “largest-ever” push to transform the way primary care is delivered and paid for in the U.S. The focus is on preventive patient-centered care and is part of the agency’s broader thrust toward rewarding quality over quantity. Last year, CMS set a goal of achieving 50% of traditional Medicare reimbursements through alternative payment models by 2018. Currently, 30% of such payments meet that goal.

Under the CPC+ model, Medicare will collaborate with commercial and state health insurance plans to support primary care practices in delivering advanced primary care. Key components enhanced in-person hours and 24/7 access, comprehensive care that is coordinated across the healthcare system, data analytics to identify opportunities for improvement in care quality and utilization, and care management for high-risk patients.

What the model is supposed to do

CMS is offering two tracks for CPC+, one that pays doctors $180 a year for some type of care management (averaging about 30 minutes a year of the doctor’s time). The other track is a risk model, where fee-for-service is reduced and doctors are rewarded or penalized for quality of care and cost savings.

Eligible practices statewide may apply to participate in CPC+ in Arkansas, Colorado, Hawaii, Michigan, Montana, New Jersey, Oklahoma, Oregon, Rhode Island and Tennessee. In addition, practices may apply in the following regions: Kansas and Missouri (Greater Kansas City region); New York (Hudson-Capital region); Ohio (statewide and Northern Kentucky region); and the greater Pennsylvania area.

CMS has estimated up to 5,000 primary care practices could participate in the model, encompassing roughly 3.5 million beneficiaries. The deadline for applications is Sept. 15.

Intended results

“The overarching goal [of CPC+] is improving health outcomes at lower cost,” and to do that, doctors must be able to function as the “quarterback” in the patient’s game plan, says Mark Hefner, CEO of Infina Connect Healthcare Systems.

“The increased emphasis on building capabilities to coordinate care across the community, including interactions with specialists, addresses a key ingredient that was missing in the first CPC program,” he says. He notes, for example, a single primary care doctor makes around a thousand referrals a year, influencing 10 million dollars in downstream healthcare spending.

“Imagine the impact on cost and quality if primary care physicians could achieve greater control, visibility and coordination of that care and effectively control the downstream spend,” Hefner says. “With the care management payments under CPC+ primary care can make the investments necessary to effectively manage the total cost of care outside of their offices, provider better care in between office visits and transition [patients] to wellness and prevention.”

The ultimate goal of CPC+ is demonstrating models of care that achieve these goals, he adds. 

But not everybody is convinced that CPC+ will save money. “It may deliver better care … [but] in the end the details of payment, reporting and effectiveness will be very challenging to support its roll out to the remainder of the country,” says Wayne Lipton, founder and CEO of Concierge Choice Physicians.

On the other hand, it could increase compensation for select populations of primary care physicians in all sizes of practices in areas that need it the most, such as rural and otherwise underserved communities, and improve compensation for complex cases, he says.

François de Brantes, executive director for the Health Care Incentives Improvement Institute, says CPC+ attempts to resurrect a private sector model — patient-centered medical home (PCMH) — that has been tried and largely discarded over the past decade.

The basic premise of PCMH is to pay practices a fixed fee for adopting the model and offer other incentives based on certain quality measures, he explains. CPC+ has a couple of options, one of which provides a management fee, but then reduces ongoing fee-for-service payments.

“Most of the private sector initiatives around primary care practices — and many Medicaid ones — have shifted from these fixed ‘care management’ fee payment programs to tying the provider to total costs of care targets,” de Brantes says. “What’s interesting in the selection of the [CPC+] sites is that many of them are states or regions in states in which Medicaid reform had been aligned to the CPC model and had already been in the original CPC program. There isn’t really any expansion per se, and I don’t expect to see any … [because] pretty much everyone has moved off of these models in which there’s a fixed fee paid, pretty much irrespective to actual results.”

Scarcity of West Coast regions

Interestingly is that there is scant representation from West Coast regions in CMS’ five-year pilot. California, for example, is completely left out. Evan Pankey, product manager and solution architect for Amazing Charts’ InLight EHR, says it’s likely that areas not selected for CPC+ will continue to pilot other value-based models like Direct Primary Care.

“This model has been gaining traction in regions such as Washington state where Qliance is the pioneer network,” he tells Healthcare Dive. “However, there is also a large IMPACT grant by CMS to support providers piloting the DPC model nationwide under the Consortium for Southeastern Hypertension Control. Since there is funding for DPC nationwide, this model might gain more traction compared to CPC+,” he adds.

Then, too, payers in western regions generally have more experience with integrated models of primary care delivery and may already be in a position to test various care management incentives, says Julie Simer, special counsel in Buchalter Nemer’s healthcare practice group. “I expect commercial and Medicaid payers in the western region to carefully watch the experience of this demonstration project and use that experience to inform their own development of new primary care management incentives.”

Scaling out

To expand the initiative, CMS will need to offer incentives that attract payers and providers in other parts of the country, particularly in areas where there are large at-risk populations, says Simer. “CMS had some success with the original CPC model, but initial results showed that savings were not sufficient to cover the incentives,” she points out.

The biggest challenges will be resistance to change in care delivery models, lack of interoperability between disparate EHRs and motivating patients to participate in their own care, says Hefner. But with MACRA making downside risk inescapable for providers, he believes the country has reached a “tipping point” in healthcare reform.

“The previous CPC program appeared to decrease unnecessary hospitalizations and [emergency department] visits, so we know these types of activities can have an impact,” Hefner says. “We think that CPC+ offers significant opportunity to redesign care and deliver higher value coordinated care at a lower cost.”

Still, Pankey says scaling out CPC+ to a national level could be a slow process, given the program’s complexity, and this could cause providers to drop out. And there are already other value-based programs — like PCMH and DPC — that are showing positive results. With more than a thousand DPC physicians offering fully capitated primary care services, getting them to switch could be difficult, he says.

“In contrast, providers who participate in CPC+ will have less pressure around maximizing insurance-based billing,” Pankey adds. “This should give them time to offer other avenues of care, which could be less expensive and more valuable to patients, such as telemedicine services.”