by Tiffany Lauria, Project Coordinator, Researcher, and Practice Consultant
CMS is now soliciting applications from primary care practices that wish to enroll in Comprehensive Primary Care Plus (CPC+), their five-year advanced payment model program. The application period ends September 15, 2016 and is accepting a total of 5,000 practices split across two tracks- 2,500 into track 1 and 2,500 into track 2.
The CPC+ program offers a financially sound opportunity for practices in a select 14 regions to increase their revenues while continuing to work on transitions that improve quality and care management, and the use of certified technology in patient care and reporting. Primary practices who have already transitioned into Patient Centered Medial Homes, should definitely consider applying, as the program goals align well and many of your PCMH functions have essentially prepared you for CPC+, with a higher probability of qualifying for the higher reimbursed track 2 program.
In order to qualify, your eligible primary care practitioners must bill under one tax identification number, have a minimum of 150 Medicare beneficiaries, and ideally, 50% of the practice’s patients would be covered under Medicare and the participating payer umbrellas. Let’s take a look at some of the financial benefits if you qualify.
Medicare intends to pay a Per Beneficiary Per Month Care Management Fee that is risk-adjusted per the diagnosed Hierarchal Condition Codes (HCC). For track 1 practices, this averages $15 per beneficiary per month, and track 2 practices average $28 per beneficiary per month, with your most complex Medicare patients warranting a $100.00 per month. These are the “sickest of the sick” in your practice.
In addition, practices will be rewarded for meeting quality measures, such as patient experience and utilization measures, with an additional performance based incentive payment for each Medicare beneficiary, per month, as high as $4.00 monthly per Medicare patient for those practices qualifying for track 2.
How does this all add up? Let’s say your practice has 150 Medicare beneficiaries, and you have been accepted into track 2 for the five-year term of the program. If you continue to meet all quality and utilization measures each year, using the average monthly payments of $28.00 PBPM for Care Management and $4.00 PBPM Incentive payments, your take away looks something like $57,600 annually for participation. That equals $288,000 over the five-year program, for 150 patients.
Plus, your practice will still continue to bill Medicare fee-for-service for track 1 practices. Track 2 practices will slowly decrease your fee-for-service billing in lieu of a percentage of Comprehensive Primary Care Payments, that are intended to reimburse for the more total care you are providing your patients, even encompassing at home visits and other alternative means of patient care.
CMS has not outlined a specific payment model to be used by the private payers that are participating in CPC+. It is expected however that payment incentives will be similar, with them paying per member per month payments for covered members and an increased revenue to cover the additional care management functions that are expected. Without specific direction from CMS, there is of course no guarantee that payers will be providing an adequate reimbursement model. However, with the number of payers putting forward PCMH incentives and looking for ways to improve their satisfaction ratings, we just may see a worthwhile investment on their part.
CMS will be asking practices to report on practice use of these incentive funds. The goal being to ensure that these funds are being re-invested into the practice, with enhanced staff training and care management procedures. And ultimately, as these payments are going to be paid prospectively, if your practice fails to meet certain benchmarks, be prepared to pay back a percentage to CMS. This is where the ’risk’ to your practice comes in.
Are you already providing team-based care? Following up on Emergency Room and specialist visits? Using your EMR to provide recall reports and stratify patients by diagnosis and procedure? Then aim for track 2 approval, with the understanding that CMS reserves the right to offer you track 1 instead. I would encourage you to create a log-in through the CMS Application Portal and review the application questions to get a sense of what is being asked of applicant practices. This is a no-obligation way to determine if your practice meets base requirements. The CMS CPC+ page contains a number of resources. Scroll to the bottom of the page to review multiple links and FAQs to help you make your determination about applying. And of course, contact The Verden Group team if you have specific questions or would like help in applying and implementing the transitions necessary in practice.