CMS picks markets for primary care reforms

CMS picks markets for primary care reforms
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The Centers for Medicare & Medicaid Services (CMS) on Monday announced the regional participants in its largest initiative to reform primary care.

The five-year Comprehensive Primary Care Plus (CPC+) aims to shift payers and primary care doctors to what's being called a value system based on patient outcomes.


The model expands the practice areas included in a pilot program and will launch in January in the following regions in 16 states:

Arkansas: statewide
Colorado: statewide
Hawaii: statewide
Kansas: greater Kansas City region
Kentucky: northern region
Michigan: statewide
Missouri: greater Kansas City region
Montana: statewide
New Jersey: statewide
New York: North Hudson-Capital region
Ohio: statewide
Oklahoma: statewide
Oregon: statewide
Pennsylvania: greater Philadelphia region
Rhode Island: statewide
Tennessee: statewide

CPC+ builds on the agency’s previous Comprehensive Primary Care pilot, a four-year initiative from the CMS Innovation Center set to end Dec. 31. That model enlisted 441 payers, which included commercial insurance plans as well as state Medicaid agencies, 2,200 practices and 2.7 million patients.

Payers were tasked with developing value-based payment structures with a variety of healthcare providers to promote core components of primary care, like access, patient engagement and preventive care for chronically ill patients. The CMS considers the level of insurer interest and market share when selecting regions.

The new program offers participating providers two payment tracks. The first pays an average $15 per beneficiary per month (PBPM) care management fee, in addition to traditional fee-for-service payments, for newer practices still building up infrastructure and resources. The second track pays an average $28 PBPM fee for practices with enhanced IT capabilities, and includes a $100 PBPM fee for patients with complex needs.

The second track also relies on a “hybrid” model that incorporates some fee-for-service payments, allowing doctors to provide care in a variety of ways, including through telemedicine. Providers in both tracks are eligible for incentive payments, with Track 1 providers receiving a smaller payment than Track 2 providers.  

The American Medical Association applauded the model when the CMS revealed the payment structure in April, saying that the agency had adopted several of its recommendations.

“At first glance, the new Comprehensive Primary Plus payment model includes several advances over the current primary care model, particularly because it emphasizes improvements in care that are achievable by primary care physicians instead of cost reductions that are beyond their control,” former AMA President Dr. Steven J. Stack said in a statement.

The original model launched in 2011 in seven regions: Arkansas, Colorado, New Jersey, New York’s Capital District-Hudson Valley region, Ohio and Kentucky’s Cincinnati-Dayton region, Oklahoma’s greater Tulsa region and Oregon. Participating practices received a monthly fee of $20 per Medicare or Medicaid fee-for-service beneficiary for the first two years of the program, then a $15 monthly payment for the second two years. They also received additional payments through participating payers, and a slice of any savings to Medicare and Medicaid.

A report issued by the CMS in April determined that participating practices in year two of the pilot received median payments of $203,949, or 14 percent of total practice revenue, and saved the Medicare program $91.6 million, before factoring in monthly care management fees.

The program has yet to produce net savings.