CMS Expands Alternate Payment Model for Primary Care Doctors

The expansion follows an early demonstration project that showed that what happens between visits is critical for patients with chronic conditions.

The family doctor—the heart of healthcare system and brunt of its current stress—would get more time with patients, especially the sickest ones, and be paid to coordinate care under an alternate payment model that CMS increased 10-fold today.

Called Comprehensive Primary Care Plus, this alternate payment model will be reach 5000 practices in 20 markets over 5 years, covering more than 20,000 doctors. It’s the next step a current program launched in 2012 set to finish this year, which reached 2188 providers across 445 practices. That program covered about 2.7 million patients; CMS’ announcement did not project how many patients would be reached.

It’s all part of CMS’ goal of getting at least 50% of Medicare reimbursements into alternate payment models by 2018. This year’s target was 30%, and the government said that goal has been met. Healthcare is moving away from the old fee-for-service model and toward a system that rewards physicians and hospitals if they keep patients well, prevent illness, and avoid acute care and intensive procedures.

To achieve this, however, the primary care doctor needed more support. For years, this crux of the system has been in increasingly short supply as specialists commanded higher pay and the PCP drowned in administrative burdens, most from insurers with never-ending demands for prior authorization for drugs or procedures. Doctors complained they were spending more time with paper than patients. Or, they had to hire staff to handle these tasks at a cost to the practice, because compensation was based on the doctor’s face time with the patient.

The first wave of CPC has been considered a demonstration project, which Darren A. DeWalt, MD, MPH, of the Center for Medicare and Medicaid Innovation (CMMI) discussed in June 2015 during a panel discussion at the American Diabetes Association Scientific Sessions in Boston. At that time, he said the early results showed that some locations showed savings and others did not, and researchers were trying to figure out the reasons.

What was becoming clear, however, was that what happened “between visits” was critical to the long-term success of care for patients with chronic conditions. This theme was revisited last week at Patient-Centered Diabetes Care, presented by The American Journal of Managed Care and Joslin Diabetes Center

Dubbed CPC+, this expanded program moves away from FFS and “one size fits all” by giving doctors a chance to customize care based on patient need. One track calls for a monthly management fee, in addition to FFS payments, under the Medicare schedule. A second track allows a management fee and replaces traditional FFS payments with a hybrid “bundle” that is smaller but can be paid upfront for comprehensive primary care services to encourage preventive care.

This move comes a little more than a year after CMS approved the first $41 per patient per month fee for primary care physicians to coordinate care for Medicare beneficiaries who had multiple chronic conditions. There have been mixed reviews for whether this is working, in part because patients must designate one practice to receive the fee.

As with the earlier care coordination fee, practices must have electronic health record capability and 24/7 access to care and health information. CMS is accepting payer applications to participate in the program for from April 15 through June 1, 2016, and practice applications from July 15 through September 1, 2016.