Comprehensive Primary Care Plus (CPC+ )

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Comprehensive Primary Care Plus – Interested Payer Overview

  1. 1. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus Comprehensive Primary Care Plus Advancing the Delivery of and Payment for Primary Care Information for Payers 1
  2. 2. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 3Ach sm 1A c Three Main Goals Underlie CPC+ dvance care delivery and payment to allow practices to provide more omprehensive care that meets the needs of all patients, particularly those with complex needs. 2Accommodate practices at different levels of transformation readiness through two program tracks, both offered in every region. ieve the Delivery System Reform core objectives of better care, arter spending, and healthier people in primary care. 5 Years Beginning 2017, progress monitored quarterly Up to 20 Regions Selection based on payer interest and coverage 2
  3. 3. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus Multi-Payer Partnership Essential for Primary Care Reform Multi-payer engagement is an essential component of CPC+ Support from any one payer covers only a portion of a practice’s population True comprehensive primary care possible only with the support of multiple payers In CPC+, CMS will partner with payers that share Medicare’s interest in strengthening primary care to achieve the aim of better care, smarter spending, and healthier people. 3
  4. 4. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus Multi-Payer Collaboration in CPC Since 2012, Comprehensive Primary Care (CPC) initiative brings together Medicare fee-for-service and 38 payer partners across 7 regions to support primary care practice transformation • 95% of payers continue to partner in CPC into its 4th year • Lines of business: commercial, Medicare Advantage, Medicaid managed care, self-insured clients (TPA/ASO) • Partnership with 4 State Medicaid agencies
  5. 5. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus Why Should Payers Partner with Medicare in CPC+? Investment in Primary Care Can Improve Quality, Reduce Total Cost of Care Patient Population Investment in Comprehensive Primary Care Avoidance of unnecessary utilization and cost There is abundant evidence that improved care and improved patient experience can be delivered by modest investments in primary care. CPC+ strategically invests in the kind of primary care most likely to have a favorable impact on total cost of care and aligning payment incentives to reward value rather than volume. 5
  6. 6. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus Medicare Will Align with Public and Private Payer Partners CMS is soliciting interested payer partners: April 15 – June 1, 2016 CPC+ Practices Medicare FFS Public employee plans Medicaid/ CHIP state agencies 6 Commercial insurance plans Medicare Advantage plans Medicaid/ CHIP managed care plans Admins of self-insured groups Self-insured businesses
  7. 7. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus CPC+ Logic Model 7
  8. 8. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus CPC+ Aligned Payer Approach For each payer in the model, these elements need not be identical, but should be oriented so that the practice incentives and goals match those of the model. Financial 1. Commit to pursuing private arrangements with practices participating in both Tracks 1 and 2 of CPC+ for the model’s full duration. 2. Share attribution methodologies with CMS. 3. Provide a care management fee or similar payment to allow practices to meet the aims of the care delivery model. 4. Change the cash flow mechanism from fee- for-service to at least a partial alternative, in whatever arrangement the payer favors, before the end of the first performance year to support Track 2 practices. 5. Offer an opportunity for a performance- based incentive payment. Quality Measurement 6. To the greatest extent possible, align practice quality and performance measures with the model. Data Sharing 7. Supply participating practices with practice- and patient-level cost and utilization data for their attributed patients via reports or other methods of data sharing at regular intervals (e.g., quarterly). Model Assessment 8. Describe monitoring, auditing, and evaluation report, and share data with CMS under 42 C.F.R. 403.1110. 8
  9. 9. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 1 Participation in Both Program Tracks CMS will solicit applications from practices within the regions chosen, beginning July 15, 2016, with applications due by September 1, 2016 at 11:59pm ET. 9 Up to 2,500 primary care practices. Choice for practices poised to increase the comprehensiveness of care through enhanced health IT, improve care of patients with complex needs, and inventory resources and supports to meet patients’ psychosocial needs. Track 2 Track 1 Choice for practices ready to build the capabilities to deliver comprehensive primary care. . Up to 2,500 primary care practices.
  10. 10. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 2 Attribution Methodology Medicare Approach • Prospective alignment methodology to identify Medicare FFS beneficiaries attributed to CPC+ practices • Methodology attributes beneficiaries to the practice that billed for the plurality of their primary care allowed charges during the most recent 24-month period • CMS will give CPC+ practices a list of attributed beneficiaries prior to January 2017 and each performance year thereafter • Attributed beneficiaries are free to select the clinicians and services of their choice Aligned Payer Approach • Partner payers may use Medicare’s attribution methodology or describe their own approach to identifying members served by CPC+ practices. • CMS is interested in knowing attribution: • Timing • Frequency • Approach for notifying practices 10
  11. 11. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 3 Enhanced Non-Fee-For-Service Support Medicare Approach Medicare Care Management Fee: • Offer non-fee-for-service support to allow Track 1 and 2 practices to provide care management, care coordination, and similar “wraparound” services to all patients, agnostic of payer. • Increase support for Track 2 compared to Track 1 to reflect advancement in practice transformation and care of patients with complex needs. Track 1 Track 2 Risk Methodology HCC risk scores HCC risk scores; claims data for high-risk diagnoses Number of Risk Tiers 4 5 PBPM Amount $15 average ($6 to $30) $28 average ($9 to $100) Purpose Staffing and training related to the model requirements, according to the needs of the attributed Medicare patient population Aligned Payer Approach 11
  12. 12. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 4 Alternative to FFS for Track 2 Practices: Medicare and Payer Alignment Medicare Approach Medicare Hybrid FFS and “Comprehensive Primary Care Payment” (CPCP): • Based on past E&M payments – increased 10% • Paid upfront and partially reconciled • FFS E&M reduced proportionately • Practices select the pace of transition to one of two hybrid payments • Compensates for traditional clinical care yet allows flexibility for care delivery in/outside an office visit FFS FFS 60% CPCP 40% FFS 35% CPCP 65% OR 2016 2019 Aligned Payer Approach • By the end of the first performance year, change the cash flow mechanism for reimbursing practices via at least a partial alternative to traditional FFS payment. – Examples: partial, full, or sub- capitation without downside risk, episodic payment, etc. • Goals: – Compensate for proactive, comprehensive care previously require to be furnished in an office setting. – Allow practices to provide care in a way that best meets patient needs, including by email, phone, patient portal, or other alternative visit modalities. 12
  13. 13. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 5 Performance-Based Incentive Payment Medicare Approach Practices at risk for two prospectively paid practice-level performance components; incentives partially or wholly reconciled retrospectively based on performance Clinical quality and patient experience • Track 1: $1.25 PBPM • Track 2: $2.00 PBPM • Examples: eCQMs, CAHPS Utilization measures that drive total cost of care • Track 1: $1.25 PBPM • Track 2: $2.00 PBPM • Examples: inpatient admissions, ED visits • Must pass quality benchmark to receive Aligned Payer Approach • Track 1 and 2 practices have the ability to qualify for performance-based incentive payments, based on a combination of utilization, cost of care, and/or quality metrics. • Approaches could include shared savings, bonuses, or other financial arrangements, either prospectively or retrospectively. 13
  14. 14. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 6 Quality and Performance Measures Medicare Approach Medicare will use quality and patient experience measures to identify gaps in care, target quality improvement activities, and assess quality performance: 1. Electronic clinical quality measures (eCQMs) 2. Patient experience of care (CAHPS) surveys fielded by CMS or its contractors • Practices will annually report a subset of eCQMs • Practices must use EHR technology that meets the certification requirements specified in the Medicare EHR Incentive Program final rule. • Final CPC+ measures TBA by November 2016. Aligned Payer Approach Payers are encouraged to align quality and patient experience measures with Medicare and other payers in the region. CMS has aligned its quality reporting programs to reduce provider reporting burden by choosing eCQMs which: • Focus on a primary care population • Encompass many National Quality Strategy domains • Are included in other CMS quality reporting programs CMS included many recommended measures from the Core Quality Measures Collaborative Workgroup measure set 14
  15. 15. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus Tentative CPC+ Quality Measure Set • CPC practices must meet the certified Health IT requirements in order to report measures. • The final list of measures will be determined no later than November 2016. • Providers will be required to report a subset of these measures. CMS ID# NQF# MEASURE TITLE MEASURE TYPE/ DATA SOURCE CLINICAL PROCESS/EFFECTIVENESS (9) CMS159v5 0710 Depression Remission at Twelve Months Outcome/ECQM CMS165v5 0018 Controlling High Blood Pressure Outcome/ECQM CMS131v5 0055 Diabetes: Eye Exam Process/ECQM CMS149v5 N/A Dementia: Cognitive Assessment Process/ECQM CMS127v5 0043 Pneumococcal Vaccination Status for Older Adults Process/ECQM CMS137v5 0004 Initiation and Engagement of Alcohol and other Drug Dependence Treatment Process/ECQM CMS125v5 2372 Breast Cancer Screening Process/ECQM CMS124v5 0032 Cervical Cancer Screening Process/ECQM CMS130v5 0034 Colorectal Cancer Screening Process/ECQM PATIENT SAFETY (3) CMS156v5 0022 Use of High-Risk Medications in the Elderly Process/ECQM CMS139v5 0101 Falls: Screening for Future Falls Risk Process/ECQM CMS68v6 0419 Documentation of Current Medications in the Medical Record Process/ECQM POPULATION/PUBLIC HEALTH (4) CMS2v6 0418 Preventive Care and Screening: Screening for Depression and Follow-Up Plan Process/ECQM CMS122v5 0059 Diabetes: Hemoglobin HbA1c Poor Control (>9%) Outcome/ECQM CMS138v5 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Process/ECQM CMS147v6 0041 Preventive Care and Screening: Influenza Immunization Process/ECQM EFFICIENT USE OF HEALTHCARE RESOURCES (1) CMS166v6 0052 Use of Imaging Studies for Low Back Pain Process/ECQM CARE COORDINATION (1) CMS50v5 N/A Closing the Referral Loop: Receipt of Specialist Report Process/ECQM 15
  16. 16. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus CPC+ and the Alternative Payment Model (APM) Framework Track 1 Track 2 16
  17. 17. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 7 Data Feedback to CPC+ Practices Medicare Approach Medicare will provide cost and utilization data on attributed Medicare FFS beneficiaries, including: • Historical cost and utilization • Quarterly reports on services and financial expenditures • Annual per-capita expenditure and quality reports on a beneficiary level Medicare is committed to participating in multi- payer data aggregation, if available in a region Aligned Payer Approach Payers are encouraged to align with Medicare and other regional payers on the structure, format, and schedule of sharing data with practices, including: • Data on cost, utilization, and quality • Distributed at regular intervals • At the practice population and member-levels for all members attributed to CPC+ practices • With guidance to help practices use these data Payers may also propose a common platform for sharing data with practices through an existing multi- payer database, payer health information exchange, or other capable data system within a region. 17
  18. 18. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 8 Monitoring, Auditing, and Evaluation Medicare Approach Monitoring CMS will use data from various sources to help ensure that practices understand their progress towards meeting care delivery requirements and highlights opportunities for additional learning activities. Auditing CMS will use program integrity data to ensure practice compliance with the terms of the Participation Agreement and highlight noncompliant practices for heightened CMS scrutiny. Evaluation CMS will contract with an independent evaluator that will use mixed-methods approach, for each track to evaluate: • Implementation: How the model was implemented, assessing barriers and facilitators to change. • Impact: The degree to which each track improved key outcomes, including lower total cost of care and improved quality of care. Aligned Payer Approach • Share with CMS the proposed monitoring and evaluation strategy to track practice progress in implementing CPC+ as well as assessing changes in cost of care, quality improvement, and patient experience of care. 18
  19. 19. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus Opportunities for Stakeholder Learning, Collaboration, and Support Web-based platform for CPC+ stakeholders to share ideas, resources, and strategies for practice transformation. National webinars and annual National Stakeholder Meeting • Cross-region collaboration. Virtual and in-person regional learning sessions • Engagement with CPC+ stakeholders. • Outreach and support from regional learning faculty. Learning Communities 19 CPC+ Practice Portal Online tool for reporting, feedback, and assessment on practice progress.
  20. 20. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus CPC+ Region Selection What is a region? Overlapping, contiguous geographic locales covered by multiple payers interested in partnering in CPC+ How will CMS choose up to 20 regions? Choice will be contingent upon market penetration by interested payers and payer alignment with the CPC+ model • Aim for geographic diversity • Existing CPC regions will be included in CPC+, contingent on payer support • Preference for MAPCP and SIM Model Test states where Medicaid is a participating payer • All regions with Medicaid partnership receive extra points in proposal scoring 20
  21. 21. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus Timeline for Partner Payers April 2016 Payers respond to the CPC+ Payer Solicitation and outline their covered lives, geographic scope, and commitment to aligning with CPC+ July 2016 CMMI makes a determination of which regions have sufficient payer interest – both in covered lives and in alignment of proposals. CMS signs MOUs with those payers. The practice application opens in selected regions. October 2016: Practice participants are selected January 1, 2017 CPC+ goes live; payers begin aligned payment and support for participating practices December 2017 Deadline for all payers to align with the Track 2 departure from traditional FFS 1 2 4 5 3 21
  22. 22. Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus For More Information on CPC+ Visit https://innovation.cms.gov/initiatives/ Comprehensive-Primary-Care-Plus for Payer Solicitation, Payer MOU, FAQs Email CPCplus@cms.hhs.gov 22