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Friday, April 15, 2016

Medicare Announces New Payment Model for Primary Care

The Medicare program yesterday unveiled an ambitious model for delivering — and paying for — primary care in medical homes that seeks to "delink" reimbursement from office-based visits.

The Centers for Medicare and Medicaid Services (CMS) expects that greater reliance on monthly capitation payments, a traditional tool of managed care, will free physicians to care for patients through secure email, telephone calls, video consults, home visits — whatever it takes to best meet the need. The government hopes to recruit up to 5000 practices with upwards of 20,000 clinicians treating 25 million patients.

These patients will not be limited to Medicare beneficiaries. CMS will partner with private insurers, state Medicaid programs, and Medicare Advantage plans that agree to adopt the same payment, data sharing, and quality metrics.

The initiative, Comprehensive Primary Care (CPC) Plus, will run from January 2017 through 2021. It builds on a current CMS program called Comprehensive Primary Care (CPC) that debuted in 2012 and expires at the end of 2016. It has roughly 500 participating practices.

CPC took a baby step in capitation by initially paying its primary-care physicians a monthly care-management fee that averaged $20 per Medicare beneficiary. The monthly fee, later reduced to $15 per beneficiary on average, covers behind-the-scenes care coordination that largely goes unpaid in traditional fee-for-service (FFS) Medicare. The practices still receive normal FFS reimbursements for covered services.

The initiative notched some notable achievements in 2014, according to CMS. Hospital readmissions fell below national benchmarks, and patients gave clinicians high scores on communication and access to care. CPC also reduced spending on physician services and hospitalizations, but not enough to recover what was spent on care-management fees and thereby break even. And some physicians grumbled that the fees were too small.

More Up-front Money for Medical Homes

CPC Plus goes further into managed-care territory than its predecessor. It offers primary-care practices two tracks to choose from, with one more challenging, but potentially more rewarding. In track one, the easier of the two, practices receive a care-management fee of $6 to $30 per beneficiary per month (PBPM), depending on the medical needs of the beneficiary, or $15 on average. For track-two practices, the care-management fee will be from $9 to $100 PBPM, or $28 on average. Their fee is higher because they will provide "more comprehensive services for patients with complex medical and behavioral needs," according to CMS.

As in the original CPC program, track-one practices will continue to receive standard FFS reimbursement for covered services. Track-two practices, in contrast, will receive an additional monthly capitation payment for the more extensive care they provide. This capitation payment is meant to cover evaluation and management (E/M) services, but not necessarily in the confines of a 15-minute office visit. Practices can use the money to hire a visiting nurse, purchase telemedicine technology, or justify a 2-hour office visit, for example.

This Comprehensive Primary Care Payment (CPCP) is essentially a down payment on what a practice would normally receive under FFS for its likely E/M services in a given month. The practice will bill Medicare as usual for face-to-face E/M services, but the claims would be reimbursed at a commensurately lower rate in light of the CPCP payment. In the first year of CPC Plus, practices in track two can elect to receive from 10% to 65% of their estimated E/M reimbursement in the form of the CPCP, and the rest through reduced FFS payments. By 2021, however, practices will have to receive either 40% or 65% of this E/M revenue up front.

Both track-one and track-two practices will vie for a bonus under CPC Plus based on their performance on quality-of-care and cost metrics. The potential bonus is $2.50 PBPM in track one and $4 PBPM in track two. Medicare and other participating third-party payers will dole out these bonuses in advance, just like capitation. Practices keep this at-risk money if they measure up. If they perform poorly, they return their bonus.

CMS considers these advance bonuses an improvement on the original CPC program, which paid out incentives in the form of shared savings. Practices that came under a spending target for their Medicare patients kept some of the savings, whereas those that exceeded the target owed CMS money. In an article published online in the Journal of the American Medical Association on April 11, CMS officials conceded that a time lag from performance to payment and other weaknesses of this method "diminished the incentive" for practices.

In a "request for applications" document published on its website, CMS said that some physicians might worry that they will forgo patient out-of-pocket payments — such as the 20% coinsurance in Medicare — for an in-person visit that is replaced by remote care or monitoring in CPC Plus. However, practices switching to more streamlined methods of delivering care are better able to earn a bonus and take on more patients, balancing out the revenue picture, CMS said. The track-two financial model "empowers practices" and "delinks a substantial portion of payment from visit-based claims," according to the agency.

A Possible Morale Booster for Primary Care

The CPC Plus program has already received positive preliminary reviews from two major medical societies oriented toward primary care.

Wayne Riley, MD, MPH, the president of the American College of Physicians, said in a release that the new program has the potential of "greatly strengthening" the ability of internists to deliver high-quality, accessible care. Dr Riley also said it's encouraging that CMS will offer medical practices "robust" educational resources to get up to speed on CPC Plus.

Wanda Filer, MD, the president of the American Academy of Family Physicians, told Medscape Medical News that CPC Plus "looks promising."

"I think this kind of initiative may help physicians keep the lights on and the doors open," Dr Filer said.

The new program, she said, not only substantially increases the amount of capitated payments but also gives physicians flexibility on how to address the needs of patients outside of an office appointment, whether it's hiring someone to make home visits or work with an immigrant community that doesn't speak English. And by not having to depend exclusively on office visits for revenue, primary care physicians can get off their deadening hamster-wheel schedules.

Dr Filer recalls one veteran physician on the verge of retirement who felt a second professional wind after signing up for the original CPC program. "She told me, 'I can love practicing medicine again. I don't have to run people through the door to get paid,' " she said. That colleague didn't retire after all.

Dr Filer said she hopes CPC Plus turns out to be an even bigger morale booster.

CMS will begin to formally solicit applications from practices interested in CPC Plus on July 15. More information on the initiative is available on the CMS website.


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