FAQ on the CPC Initiative
Frequently Asked Questions About the Comprehensive Primary Care Initiative
Section I: CPC initiative Overview
The CPC initiative is a four-year, multi-payer initiative led by the Centers for Medicare and Medicaid Services (CMS) Center for Medicare & Medicaid Innovation to test a service delivery model of comprehensive and accountable primary care.
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. In mid-2012, practices were selected through a competitive application process in each selected region. The initiative began in 2012 and is scheduled to conclude at the end of 2016.
2. What is the CMS Center for Medicare & Medicaid Innovation and why are they leading this initiative?
According to the CMS Innovation Center web site, "The Center for Medicare & Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) fosters health care transformation by finding new ways to pay for and deliver care that improve care and health while lowering costs. The Center identifies, develops, supports, and evaluates innovative models of payment and care service delivery for Medicare, Medicaid and CHIP beneficiaries."
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. The CMS Innovation Center is using the finding of the CPC initiative, as well as other programs, to inform future payment reform and care delivery models.
The primary care system is evolving at a rapid pace with changes in the payment environment and increasing expectations related to value, service and outcomes for patients.
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 has created 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.
Most family physicians already have some of the components of comprehensive primary care in place. The CMS Innovation Center will provide resources to help primary care physician’s work with patients in a comprehensive way to achieve better health, better care and lower costs by:
- 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
The CPC initiative aligns with the patient-centered medical home model. Both models of care include a personal physician, physician directed medical practice, whole-person orientation and coordinated care.
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.
In April 2012 the CMS Innovation Center released the names of seven geographic markets that were chosen to participate in the CPC initiative. They include both statewide and partial-state markets.
- New Jersey
- New York (Capital District-Hudson Valley Region)
- Ohio and Kentucky (Cincinnati-Dayton region and Northern Kentucky region)
- Oklahoma (Greater Tulsa region)
The CMS Innovation Center planned a tiered approach toward project implementation including market, payer, and practice selection to meet project start date of Fall 2012.
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.
December 2013 (End of Project Year One) – Practices must meet nine CPC initiative milestones.
December 2014 (End of Project Year 2) – Practices must continue to meet the nine CPC initiative milestones.
January 2015 – CPC care management fees are reduced to an average of $15 (from $20) and the opportunity for shared savings for practices that can demonstrate decreased cost and improved quality of care. The first CPC evaluation report was released citing favorable findings from the first year of the initiative.
December 2015 (End of Project Year 3) – Practices must continue to meet the nine CPC initiative milestones.
January 2016 – Practices continue to receive reduced care management fees and the opportunity for shared savings for practices that can demonstrate decreased cost and improved quality of care.
8. What is the new reimbursement model that participating payers and Medicare are agreeing to use? Will it change how my practice generates revenue?
The central principle of the entire CPC initiative, as well as the larger industry trends, is to pay primary care providers for the quality of their health care outcomes as opposed to the current system of paying for the volume of patients seen and procedures conducted.
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 CMS Innovation Center has openly stated that they will provide a risk-adjusted Care Management fee ranging from $8 to $40, with an average of $20 PMPM for each Medicare patient in the first two years of the initiative. For the third and fourth years the PMPM will average $15 for Medicare patients with the opportunity for shared savings for practices that can demonstrate decreased cost and improved quality of care.
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.
According to the CMS Innovation Center, risk-stratified care management includes the ability to assess the health risk for each patient, engaging patients to create a plan of care that addresses individual health risks, circumstances and values, providing intensive care management for the sickest patients with the highest needs and using evidence-based pathways for care and decision aids to support clinical decision-making. Typically, care providers can easily identify complex and fragile patients and compare their intrinsic knowledge of their patient population against a simple list from each participating payer of the most expensive patients in that practice's panel.
10. 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?
The CMS Innovation Center has started that one of the central expectations of the CPC initiative is that participating practices will receive technical assistance and broader education as a core component of the initiative in each market. Learning collaboratives will be used to provide technical assistance, education, and peer-to-peer learning opportunities to expand the capacity of practices.
Section II: Practice Selected
It has been made clear by the CMS Innovation Center that they were only interested in recruiting high-functioning practices which will most likely be successful over the four year program. The minimum requirements for participation have been established. The selected practices have met the following qualifications:
- 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
In addition, The CMS Innovation Center gave preference to practices that:
- 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.
12. Which patients are eligible to participate, and how are patients assigned to the project? Can they opt in/out?
According to the CMS Innovation Center, to be eligible for participation, beneficiaries must:
- 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).
Patients do not need to enroll in the CPC initiative and physicians do not need to recruit patients for participation. Additionally, any patients that have coverage from a participating private payer are included in the initiative.
Section III: Critical Follow Up
An important feature of the CPC initiative is the built in ability for the Secretary of Health and Human Services to expand the CPC initiative to additional markets without congressional approval if the project shows promise in its first two years. Even if your practice was not chosen to participate in this initial project, you may be selected if the project is expanded. The general payment environment is changing to favor these same capabilities so moving toward the PCMH is a good strategy.
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.
14. 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?
Practices currently participating in either a private payer or Medicaid PCMH project were also eligible to apply to the CPC initiative. Participation in these projects did not disqualify a practice from participating in the CPC initiative.
Practices participating in 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, will not qualify to participate in the CPC initiative.
In essence, the transformation work in each practice serves all three. Moving toward the PCMH capabilities will make the practice better positioned for: 1) PCMH recognition if there is some financial advantage in your market, 2) ACO participation if there is one forming in your community, 3) CPC initiative if you are in one of the seven chosen markets, and 4) Value-based payment models.
16. The CMS Innovation Center will require that nine milestones are met by the end of each project year. What are the milestones for the current program year (2015)?
The CMS Innovation Center discussed the nine milestones participating practices must achieve be the end of each project year. The nine milestones include:
- Create a budget forecast using a CMS template to show where CPC initiative money is reinvested.
- Demonstrate how the practice empanels and provides case management for high risk patients with metrics, plan, and implementation methodology. An advanced primary care strategy (behavioral health integration, self-management support, and medication management and review) is implemented for patients in higher risk categories. .
- 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 a patient experience survey or alternatively by demonstrating evidence of patient and family advisory council (PFAC) that meets at least once per quarter. Practices must specify the changes to the practice that have occurred during each reporting period as a result of, or influenced by, patient survey PFAC activities.
- Demonstrate that data was used on a continuous basis to guide patient care at provider/team level via utilization of quality management projects. Review payer data to identify a high cost area and a practice strategy to reduce cost while maintaining or improving quality.
- Demonstrate active engagement across the medical neighborhood by measures of choice. Measures include: emergency room follow-up within one week, hospital follow-up within 72 hours, and care compacts with at least two specialists.
- Improve patient shared decision making capacity by using and tracking at least three decision aids.
- Participate in regular learning sessions and market based collaboratives.