CPC+ Did Not Cut Medicare Spending, Improve Quality in First Year

April 30, 2019 - The Comprehensive Primary Care Plus (CPC+) did not affect total Medicare spending, and the value-based reimbursement program for primary care practices had little impact on service use and care quality, according to the program’s first annual evaluation report.

After accounting for enhanced CPC+ payments to practices, Medicare spending on beneficiaries treated by providers in CPC+ practices was actually two to three percent greater compared to program expenditures on beneficiaries treated at similar practices not in CPC+, the report shows.

“In the first year, CPC+ provided primary care practices with substantial supports and the practices began the hard work of transforming care delivery,” CMS states in an evaluation report summary.

“However, as expected, there were few effects on cost, service use, and quality for Medicare FFS beneficiaries in the first year. Effects on patient outcomes may emerge with more time as CPC+ practices deepen and expand care delivery changes.”

In 2017, over 2,900 primary care practices and 63 payers across 14 regions participated in what CMS describes as the “largest more ambitious primary care payment and delivery reformed ever tested.”

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CPC+ is a national advanced primary care medical home model that intends to transform primary care through regionally-based, multi-payer payment and care delivery reform. The program uses care management fees and performance-based incentive payments to incentivize primary care transformation across two tracks and five care delivery areas: access and continuity, care management, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health.

In the program’s first year, CPC+ practices included 13,209 primary care practitioners who treated approximately 15 million patients.

For treating the patients, the practices received significant support from Medicare and participating payers in the form of alternative payments, CMS finds. In 2017, the median care management fees given to Track 1 practices exceeded $88,000 and $195,000 per Track 2 practices. Together, that translates to $53,000 per practitioner on average, CMS reports.

Additionally, CMS and most other payers in CPC+ rewarded practices financially for their performance on service use, cost, and/or care quality. In 2017, CMS and nine other payers reimbursed Track 2 practices with prospective payments for services that shifted away from fee-for-service.

CPC+ practices used alternative payments to start changing care delivery in 2017. The practices focused on risk stratifying patients, hiring care managers, and integrating behavioral health in the program’s first year.

READ MORE: Investing in Primary Care Delivers Value-Based Care Results

However, the activities did little to reduce Medicare spending or improve service use and care quality, CMS reports.

Compared to beneficiaries outside of the program, beneficiaries treated at CPC+ practices in both tracks saw slightly greater declines in outpatient emergency department visits (1.2 to 1.6 percent), slightly slower growth rates in primary care ambulatory visits (1.6 to 1.8 percent), and slightly greater improvements in claims-based care quality measures for recommended services for beneficiaries with diabetes and for breast cancer screening (1 percentage point or less).

In addition, CMS reports no statistically significant effects of CPC+ on acute hospitalizations, ambulatory visits to specialists, 30-day readmissions, or the proportions of beneficiaries who received hospice care or an advance care plan visit, or who died.

While performance results were lackluster in the first year, CMS remains optimistic that the value-based reimbursement program for primary care will reduce costs and improve care quality as the practices progress in the next four years of participation.

“In the absence of additional years of data, these early findings do not yet provide strong evidence of causal impacts from CPC+,” the agency writes in the report.

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Based on other literature and the CPC+s theory of change, CMS expects “that any favorable effects of CPC+ on expenditures may emerge over time as the participating practices implement the CPC+ transformations, and as practice changes affect patients’ health, service use, and costs.”

CMS may be waiting for improvements from CPC+ practices, but the agency is not postponing other primary care transformation programs. The agency recently announced five new value-based reimbursement models for primary care practices under the Primary Cares Initiative.

Launching in 2020, Primary Cares Initiative aims to transform primary care in the same five care delivery areas through two tracks: Primary Care First and Direct Contracting. The tracks offer two at-risk value-based reimbursement models and three direct contracting opportunities for diverse primary care practices with value-based reimbursement experience.

Industry leaders have applauded Medicare’s next step into primary care transformation. But the CPC+’s first evaluation report could spell trouble for Primary Cares Initiative, which is built on the CPC+.

Similar to CPC+, certain value-based reimbursement models in Primary Cares Initiative will reimburse practices a flexible monthly payment and adjust payments based on performance on specified care quality, cost, and service use measures.

How financial incentives in primary care transformation initiatives influence costs and/or care quality remain to be seen. However, over time, CMS expects both programs to significantly reduce Medicare spending, enhance care quality, and optimize service use while shifting primary care away from fee-for-service.