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CPC Initiative FAQ
Section I: CPC initiative Overview
1. What is the Comprehensive Primary Care (CPC) initiative?
The initiative includes a monthly, per-patient care management fee and the potential to share in any savings to the Medicare program, in addition to traditional fee-for-service payments.
In April 2012 the CMMI released the names of seven geographic markets that were chosen to participate in the CPC initiative.
2. What is the CMS Center for Medicare & Medicaid Innovation and why are they leading this project announcement?
The CMS Innovation Center believes that primary care is critical to achieving the three-part aim of promoting health, improving care and reducing overall system costs. In addition to the CPC initiative, CMS has launched other initiatives focused on primary care transformation including the Multi-Payer Advanced Primary Care Practice Demonstration, Federally Qualified Health Center Advanced Primary Care Demonstration and Independence at Home Initiative.
3. What does the CPC initiative mean for me?
The Patient Protection and Affordable Care Act created new tools for CMS to test and integrate into primary care, including medical homes, health homes, Accountable Care Organizations and Medicare shared saving programs. Private sector payers have also adopted payment and practice reform tools such as the patient-centered medical home and risk-stratified payment formulas.
Primary care physicians have a unique opportunity to shape the future of health care through participation in this and other innovative initiatives that demonstrate their ability to increase quality of care while containing costs.
The CPC initiative will create an opportunity for selected primary care practices who are committed to improving the patient experience through increased access and continuity, planned care for chronic conditions and preventative care, patient and caregiver engagement, coordination of care across the medical neighborhood and risk-stratified care management to receive enhanced payments based on a per member per month formula. The success of participating practices may result in the expansion of this model to additional markets and create momentum for additional payment reform.
4. What is Comprehensive Primary Care? Don't I already provide "comprehensive primary care"?
- Managing care for patients with high health care needs
- Ensuring access to care
- Delivering preventative care
- Engaging patients and caregivers
- Coordinating care across the medical neighborhood
5. How does the CPC initiative fit with the patient-centered medical home (PCMH) model?
In terms of infrastructure, both include access and continuity of care, population and disease management through electronic health records and patient registries, quality and safety.
6. What are the seven markets selected to participate in the CPC initiative?
- New Jersey
- New York (Capital District-Hudson Valley Region)
- Ohio and Kentucky (Cincinnati-Dayton region and Northern Kentucky region)
- Oklahoma (Greater Tulsa region)
7. Now that the CPC initiative markets have been chosen, what’s next?
Spring 2012 – Payer meetings convened in Washington D.C. and Memorandums of Understanding signed.
Summer and early fall 2012 – In July 2012, practices located in selected markets completed applications to participate in the initiative. In August 2012, CMS announced that 500 practices were selected to participate in the initiative. In October 2012, the CPC initiative launched in the Arkansas and Oklahoma (Greater Tulsa region) markets, including initial quarterly PMPM fees paid to practices.
November 2012 – CPC initiative launched in the Colorado, New Jersey, New York (Capital District-Hudson Valley region), Ohio (Greater Cincinnati-Dayton and Northern Kentucky regions), and Oregon markets, including initial quarterly PMPM fees paid to practices.
End of Project Year One – Practices must meet nine CPC initiative milestones.
Years Two through Four – Future milestones must be completed by practices and CMS determines if project will be expanded to additional markets. CMS has the authority to expand the initiative across the country if it is shown to improve quality and lower costs.
8. Are there recommended data registries we should use?
The AAFP does not make specific recommendations regarding technology vendors. However, a number of resources for finding a registry to best meet your needs can be found at the on the AAFP’s web site. This includes guidance from Family Practice Management articles (e.g. Registries Made Simple), registry product overviews and instructions for setting up a registry from the ground up using tools such as Microsoft Excel.
Further information on specific products can be found at the Certification Commission for Health Information Technology (CCHIT).
9. If I am in one of the selected markets, how do I determine which payers are participating? Why is there such an emphasis on multi-stakeholder payer markets in the CPC initiative, and what does this mean for my practice?
Additionally, Medicare has laid out a common framework of quality and efficiency measures which will be shared by all participating payers in each market. This means that you and your staff will only need to keep track of one core set of metrics in order to participate in the CPC initiative.
A detailed list of payers participating in each market is available at: aafp.org/cpci.
10. What is the new reimbursement model that participating payers and Medicare are agreeing to use? Will it change how my practice generates revenue?
The CMS Innovation Center laid out the fundamental framework for reimbursement to which all participating payers must commit. This blended payment model is composed of:
- Base fee-for-service (FFS)
- Care management per-member-per-month (PMPM) fee
- Shared savings, which will be determined on an aggregate market level
The private payers participating in each market have committed to the CMS Innovation Centerthat they will also provide meaningful payment and support to practices participating in the CPC initiative. The details of their payment and compensation system will be negotiated directly between the private payers and primary care practices.
The CMS Innovation Center encourages all primary care practices interested in taking part in the CPC initiative to contact the private payers participating in the CPC initiative to ensure clarity on the commitment of those plans for financial and technical support.
11. When will participating practices see the new payment model go into effect?
12. What do physicians and practices need to know about risk-stratified care management?
13. Will CMS, the participating payers, or the convener provide any resources to help facilitate my practice's participation? What kind of investments will my practice need to make to participate?
Section II: Practice Eligibility
14. Is my practice eligible to participate? What practice characteristics are the most desirable as practices apply?*
- Provide comprehensive primary care to all patients
- Serve at least 150 Medicare fee-for-service beneficiaries
- Submit Medicare claims using the standard Medicare Physician/Supplier claims form (CMS-1500)
- Be geographically located in selected regions
- Declare a willingness to transform in all five comprehensive primary care functional areas
- Agree to provide comprehensive primary care and evaluation activities
- Have a robust HIT systems infrastructure. Meaningful Use – Stage 1 serves as the benchmark for HIT utilization for the application review process. This includes the use EHRs and patient registries.
- Have received some form of PCMH recognition will be given some form of priority over those that have not in the application review process.
- Completed transformational activities in the last two years.
- Most importantly, though, the CMS Innovation Center has made clear that practices can use the first year of the CPC initiative to adopt the underlying components of the comprehensive primary care model.
- The best resource for assessing your eligibility can be found on the CMMI web site at cms.gov/cmmi/cpci. Posted on the website is a short eligibility questionnaire.
- What is the definition of a practice? Practices will be defined on the basis of physical sites. Practice sites will be determined using a combination of Tax Identification Number (TIN) and the individual National Provider Identifiers (NPI) of the physicians that provide care at the practice site. This means that multiple practices that are part of the same health care system can apply as separate physical sites.
- Can residency programs participate in the CPC initiative? While challenging, a residency program may qualify if it meets all criteria set forth by CMMI.
- Can Federally Qualified Health Centers (FQHC) participate in the CPC initiative? No.
- What if I am already participating as in an ACO, shared savings project or other CMMI project, can I still participate? If you are already participating in another CMS shared savings program or demonstration you will not be eligible to participate in the CPC initiative.
15. Are there going to be any sliding scales for eligibility?
16. Which of my patients are eligible to participate, and how are patients assigned to the project? Can they opt in/out?
- Be enrolled in Part A and Part B Medicare;
- Be using Medicare coverage as their primary insurer;
- Not be enrolled in a Part C Medicare Advantage, Medicare cost or PACE Plan;
- Not be institutionalized; and
- Not diagnosed with end-stage renal disease (ESRD).
Section III: Critical Follow Up
17. What if my market wasn't chosen? Should I wait to see the outcomes of this four-year project?
CMS and many private payers are developing initiatives similar to the CPC initiative that you may qualify to participate in. It is critical that you continue to work toward conversion to an electronic health record system that meets meaningful use criteria and patient-centered medical home recognition so that you are positioned to take advantage of future initiatives.
18. There is a PCMH/ACO program up and running in my market. Would my participation in that program make my practice ineligible for the CPC initiative?
If your practice is currently participating, or has plans to participate, in a Medicare initiative that involves shared savings, including the Medicare Shared Savings Program (MSSP, also known as the Medicare ACO Program), Pioneer ACO model, or Independence at Home, you will not qualify to participate in the CPC initiative.
19. How can I determine if I should participate in the CPC initiative, PCMH or ACO program?
20. The CMS Innovation Center will require that nine milestones are met by the end of the first year of the project. What are the milestones?
- Create a budget forecast using a TBD CMS template to show where CPC initiative money is reinvested.
- Demonstrate how the practice provided case management for high risk patients with metrics, plan, and implementation methodology. Practices could utilize a global health risk score but method used probably TBD by the practice.
- Providers must have access to patient data even when the office is closed so they can continue to participate in care decisions with their patients. Patients should have access to the care team 24/7.
- Demonstrate improvement in patient experiences via completion of CAHPS survey or alternatively by demonstrating evidence of patient advisory council that meets at least once per quarter.
- Demonstrate that data was used to guide patient care at provider/team level via utilization of quality management projects.
- Demonstrate active engagement across the medical neighborhood utilizing measures of choice.
- Improve patient shared decision making capacity.
- Participate in regular learning sessions and market based collaboratives.
- Meet requirements for Meaningful Use Stage 1.