Medicare Advantage Improves Primary Care Health Outcomes

My name is Amanda

This month the Centers for Medicare & Medicaid Services (CMS) unveiled a new initiative to improve primary care in Traditional Fee-For-Service (FFS) Medicare to better align with robust primary care in Medicare Advantage (MA). The new five-year, regionally-based and multi-payer initiative, called the CMS Comprehensive Primary Care Plus (CPC+) model, builds on the four-year Comprehensive Primary Care (CPC) initiative launched in late 2012. The program is designed to provide primary care clinicians with the resources and flexibility to improve health care delivery for seniors and disabled beneficiaries. CMS released a Fact-Sheet on how the CPC+ initiative will be implemented. The initiative will cover up to 20 regions, accommodate up to 5,000 practices, and encompass more than 20,000 clinicians as well as the 25 million people they serve. CMS stated that the CPC+ model aims to benefit patients by helping primary care practices:

  • Support patients with serious or chronic diseases to achieve their health goals;
  • Give patients 24-hour access to care and health information;
  • Deliver preventive care;
  • Engage patients and their families in their own care;
  • Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

The initiative is consistent with the work Medicare Advantage (MA) has been doing to improve health outcomes and reduce health care costs through robust primary care by introducing a payment model that moves away from FFS Medicare and towards the capitated, risk-based payment structure of MA. In fact, data has shown that MA beneficiaries are about 20% more likely to have an annual preventive care visit as compared to their FFS Medicare counterparts. The payment models and focus areas of CPC+ align with the goals of MA and underscore the commitment of CMS to move FFS Medicare from volume to value. The CPC+ model has five focus areas: 1) increased access to care, 2) proactive patient management, 3) access to comprehensive, coordinated care, 4) patient-centered care, and 5) data-driven care to guide decision making and ensure enhanced quality is leading to better outcomes for patients. These key focus areas are already working in MA through primary care systems that utilize innovative delivery models to improve patient’s health and lower long-term health care costs.

Within the CPC+ model, there are two payment tracks. CMS and other payers will provide prospective monthly care management fees (CMFs) to primary care practices based on their track and beneficiary risk tiers. The goal of these payments is to give practices the resources to support investment in staffing, training, and innovations that support the improved primary care model.

In Track 1, practices will receive the CMFs in addition to the FFS Medicare payments the practice already receives.

  • In Track 2, practices will receive the CMFs and a hybrid of FFS Medicare payments and the “Comprehensive Primary Care Payment” (CPCP). Within this hybrid model, practices will receive a percentage of their expected Medicare reimbursement for Evaluation & Management (E&M) claims payments upfront in the form of a CPCP and reduced Medicare reimbursement amounts for E&M claims.

It is important to note that CPC+ was recently proposed as an Advanced APM under special rules for medical homes in under the Medicare Access and CHIP Reauthorization Act (MACRA). The five-year CPC+ model is scheduled to begin January 2017. CMS will accept payer proposals to partner with Medicare April 15-June 1, 2016. On April 28th CMS will conduct a webinar for interested payers. CMS will accept proposals within selected regions July 15-September 1, 2016. CMS will enter into a memorandum of understanding with partners to align payments, data and quality metrics throughout the five-year initiative. The CPC+ model builds on the Comprehensive Primary Care (CPC) initiative that started in October 2012 and runs through December 31, 2016. More information on the initiative can be found here and the logic model CMS outlined for CPC+ is below.