CMS Allows Some ACOs to Join New Value-Based Care Model
CMS has expanded the participation requirements for the value-based care program CPC+ to include certain Medicare ACOs, including MSSP ACOs.
By - CMS has expanded the eligibility requirements in the Comprehensive Primary Care Plus (CPC+) model to include primary care physicians in certain Medicare accountable care organizations (ACOs), according to an updated fact sheet.
Up to 1,500 primary care practices out of the total 5,000 allowed in CPC+ can also be part of an ACO, reported CMS.
However, only primary care practices that are participating in the Medicare Shared Savings Program (MSSP) are considered eligible for the new payment model, which is scheduled to begin on January 1, 2017. Practices that are part of the Accountable Care Organization Investment Model, Next Generation ACO Model, or any other shared savings program are ineligible.
CMS modified the eligibility requirements after many healthcare stakeholders argued that limiting participation in the CPC+ payment model could discourage some practices from partaking or advancing in ACOs. According to the fact sheet, the changes allow for “sufficient opportunities for practices of differing sizes, structures, and ownership to participate in the model.”
In April, CMS introduced the CPC+ model, which builds on the original Comprehensive Primary Care Initiative. The payment model incentivizes primary care physicians to transition to value-based reimbursement by promoting care coordination and patient-centered care.
Under the CPC+ model, participating physicians are expected to employ advanced primary care. As part of the program, primary care practices would offer 24-hour access to care, proactive chronic disease management programs, enhanced preventative care, and more coordination with other providers.
Participating practices will either receive monthly payments or advanced prepayments from Medicare and partnered healthcare payers to help physicians implement advanced primary care techniques. Based on quality and utilization results, practices will either keep the financial incentives or pay it back to the payers.
The value-based payment model also stipulates that participants in the prepayment track will receive a monthly care management fee of $28 per beneficiary and $100 for each patient that is considered a complex case. The financial incentives are higher than those in the original CPC model.
For primary care practices in ACOs, participants will follow a modified payment program based on three elements:
• Practices within ACOs will still receive the monthly care management fees, which will be paid directly to the practices. These practices, like other group practices or health systems in the CPC+, must provide a signed letter by ACO leadership that states the care management fees will be segregated from shared ACO funds.
• For performance-based incentive payments, primary care practices within an ACO will participate in the ACO’s shared savings and loss arrangement rather than receiving a prospective or retrospectively reconciled payment from the CPC+ model.
• For practices in prepayment track of CPC+, some Medicare fee-for-service payments for evaluation and management will shift to the Comprehensive Primary Care Payments and have a proportional reduction in payment for evaluation and management services. The CPC+ and fee-for-service payments will be found “based on an amount 10% larger than historical billings to support increased comprehensiveness of care.”
CMS also noted that ACO financial benchmark calculations will not be changed by CPC+ participation. All CPC+ payments, such as the care management fee and the Comprehensive Primary Care Payments, will be factored into the ACO’s expenditures.
ACO-aligned participants will be required to submit separate quality reports to CPC+ and MSSP in order to calculate value-based reimbursements.
CMS anticipates CPC+ enrollment for primary care practices to open between July 15 and September 1.
Additionally, the modifications to the CPC+ may incentivize healthcare payers to participate in the multi-payer initiative. Payers that exist in areas with more primary care practices participating in Medicare ACOs can now apply to take part in the value-based payment model by June 8.
“CMS’s goal in CPC+ is to align with all payers on key payment, quality, and data-sharing elements,” reported the updated fact sheet. “By alignment, CMS means that, for each payer in the model, these elements need not be identical but should be oriented so that the practice incentives and goals are consistent across all payers partnering in the model.”
By allowing ACO-aligned primary care practices participate in the CPC+ model, CMS has opened the doors for improving value-based care. While ACOs are designed to transition healthcare organizations to value-based care, the CPC+ focuses the monumental task by centering on primary care practices.
Dig Deeper:
• Accountable Care Organizations Improve Quality, Cut Spending
• Why Primary Care Matters in Medicare Shared Savings Program
