Comprehensive Primary Care Initiative

CMS Announces New CPC Model

The Comprehensive Primary Care Plus (CPC+) is an advanced primary care model built on learnings from the original CPC initiative.

The CPC Initiative

Led by the CMS Centers for Medicare and Medicaid Innovation (CMMI), the Comprehensive Primary Care initiative (CPC initiative) is a four-year, multi-payer initiative designed to test practice redesign models and a supportive multi-payer payment model.

Under the CPC initiative, CMS pays selected primary care practices in seven geographic markets a care management fee (initially set at an average of $20 per beneficiary per month) to support enhanced, coordinated services for Medicare beneficiaries in addition to fee-for-service payments. In 2015, CMS decreases the care management fee to $15 per beneficiary per month with the opportunity for shared savings for practices that can demonstrate decreased cost and improved quality of care.

Simultaneously, participating commercial, state, and other federal insurance plans are offering enhanced payment to primary care practices designed to support them in providing high-quality primary care on behalf of their members. At this time, there are a total of 38 public and private payers participating in the CPC initiative.

Implementing the CPC Initiative

On October 1, 2012, the CPC initiative launched with participating practices in the Arkansas and Oklahoma (Greater Tulsa region) markets with the Oregon, Colorado, Ohio (Cincinnati-Dayton region and Northern Kentucky region), New Jersey, and New York (Hudson-Valley region) markets following on November 1, 2012. This included receipt of initial care management fee payments based on an attribution formula for qualified patients as well as participation in national and local learning collaboratives designed to assist practices in achieving practice redesign. As of January 2015, there are 479 practices with 2,652 providers serving 2.56 million patients.

Five Comprehensive Primary Care Functions and Nine Key Milestones

The framework for the CPC initiative set by CMS is designed to achieve the Institute for Health Improvement's Triple Aim of better health, better care, at lower costs.

CMS believes this can be achieved through the provision of comprehensive primary care, including Enhanced Accountable Payment, Continuous Improvement Driven by Data, Optimal Use of Health IT, and implementation of five Comprehensive Primary Care Functions:

  1. Risk-stratified care management
  2. Access and continuity
  3. Planned care for chronic conditions and preventive care
  4. Patient and caregiver engagement
  5. Coordination of care across the medical neighborhood

Current Findings

In early 2015, CMS released the first evaluation report( of the CPC initiative that reported favorable findings from the first program year (2013). CMS is pleased with the first year findings, but anticipates it will take 18 months to three years for practices to truly transform and to see efforts on cost, service use, and quality. Here’s what the first report has found:

  • The CPC initiative reduced total monthly Medicare expenditures without care management fees during the first program year by $14 per beneficiary, or two percent.
  • Impacts were large enough to offset most of CPC initiative’s monthly care management fees, which average $20 per patient per month among participating CPC practices. This implies that the CPC initiative as a whole was close to cost neutral during the first year.  An update to the evaluation report indicates the same reductions in cost through March 2014.
  • More specifically, results show a reduction in high cost areas such as hospitalizations, emergency department visits, and specialist visits (all per 1,000 beneficiaries):
    • Annual Hospitalizations decreased by two percent.
    • Annual emergency department visits fell by three percent.
    • Annual specialist visits declined by two percent. 
    • Annual primary care visits in all settings fell by two percent.
    • There was a four percent CPC-wide decline (not quite statistically significant) in unplanned 30-day readmissions.

CPC Practice’s Self-Reported Progress on Key Milestones


By the end of 2013, CPC practices reported having increased their care management staff from 1.35 to 2.5 FTE. Most CPC practices used the care management fees to hire staff to help provide care management services and self-management support for patients. Practices reported care management staff as pivotal to improving care success in the program.


For the purposes of CPC, empanelment allows the provider to identify and manage patients based on risk status to determine who needs care management services. CPC practices reported empanelling 95.2% of patients to a provider or care team.

Risk Stratification and Care Management (RCSM)

CPC practices reported 73% of patients have been assigned a risk category, with 20% of those patients assigned to the top-two highest risk categories. Of those patients identified as “high-risk,” 11% have received care management services.

While practices reported RSCM was challenging to implement, they believe it improved patient care and communication among care team members. This proved to be a challenging, but very meaningful milestone for CPC practices. 

Advance Primary Care Strategies

Out of the three advanced primary care strategies, 57% chose to provide self-management support, 35% elected to integrate behavioral health into their practice, and 17% chose to provide comprehensive medication management and review services.

Access and Continuity

Almost all CPC practices offered patients 27/7 access to a care team provider who had real-time access to their EHR. Modes of enhanced access included patient portal messages, email, text messaging, and structured phone visits.

Improved Patient Experience

CPC practices were required to conduct a patient experience survey or convene regular patient-family advisory councils (PFAC).

From the practices that selected PFACs, most actions emphasized improving front desk processes or patient access and improving communication and engagement with patients. The average PFAC is composed of eight patients or family members that help guide improvement in the system of care and create an active culture of improvement.

Data to Guide Improvement

CPC practices were asked to report nine clinical quality measures and to select three of these measures on which to focus their quality improvement activities.

Practices most commonly chose diabetes HA1c poor control, controlling high blood pressure, and colorectal cancer screening measures to focus their quality improvement efforts. Most practices reviewed clinical quality data on a monthly or quarterly basis with a variety of staff.

Care Coordination

CPC practices reported following up with 80% of patients discharged from the hospital within 72 hours (meeting the target goal of 75%). Additionally, 80% of practices followed up with patients discharged from the emergency department with in one week.

Shared Decision-making

CPC practices were asked to implement shared decision-making tools or aids to engage patients and families in decision-making in all aspects of care.

Common conditions chosen with preference-sensitive decisions or tests include: colon cancer screening, PSA for prostate cancer screening, and tobacco cessation.   

Source: CPC Fast Facts Mid-Year Update, 2014(

CMS Announces New CPC Model

The Comprehensive Primary Care Plus (CPC+) is an advanced primary care model built on learnings from the original CPC initiative.

Leading the Way to
Patient-focused Care

Learn about how St. John Clinic in Tulsa, Oklahoma, is participating in the CPC initiative to deliver better health care.

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