Key Practice Considerations
- CMS is ending the program known as Comprehensive Primary Care Plus (CPC+).
- Practices currently enrolled in CPC+ were given the option of applying by May 21, 2021, to participate in Primary Care First (PCF) or returning to traditional fee-for-service (FFS).
- Regardless of whether practices applied for PCF or chose to return to FFS, they should also participate in an MSSP ACO so they can earn more revenue on the investments they made on care coordination and population health processes in CPC+. If they do not participate in an ACO, practices will have a difficult time making up the revenue they will lose when CPC+ ends.
- This article gives a detailed look into the costs and benefits of both PCF and FFS, and how joining an ACO is a good idea no matter which choice a practice makes.
- As always, the financial decisions your practice makes are very specific to your individual practice’s financial situation. And Aledade is here to help. Contact us at email@example.com for more information on PCF and/or joining an ACO and achieving shared savings.
What is CPC+?
Comprehensive Primary Care Plus (CPC+) was created by the Center for Medicare and Medicaid Innovation (CMMI) with the goal of strengthening care management through multi-payer reform and care delivery transformation. The program has two practice cohorts, which began in 2017 and 2018, made up of over 2,600 practices across 18 regions. Additionally, there are 52 aligned private payers that participate in CPC+. The performance periods were originally set to be five years, but on April 12, 2021, CMMI announced the program will end for all practices on Dec. 31, 2021, regardless of what cohort they were in. For these 2,600 practices, the question is now, “What’s next?”
CPC+ Payment Mechanisms
In CPC+, practices continued to bill and receive payments from Medicare for evaluation and management (E&M) services as usual (or received a hybrid payment in Track 2). However, they also received an additional $6-$30 (Track 1) or $9-$100 (Track 2) monthly care management fee per patient as well as an additional $3 to $4 PBPM performance-based incentive payment (PBIP). The average PBPM for a Track 1 or 2 practice is $15 and $28, respectively. The amount of the PBIP that practices were allowed to keep at the end of the year depended on their performance on quality, patient experience of care, and utilization metrics. This PBIP allowed CPC+ practices that were not in MSSP to be considered an Advanced Alternative Payment Model (AAPM). CPC+ practices that were also in MSSP had their AAPM status determined by whether their ACO was taking risk or not.
CPC+ practices had the option to join Primary Care First (PCF) by May 21, 2021, or continue care management under the fee-for-service (FFS) model. Regardless of which choice a practice made, Aledade believes it should be coupled with participation in a Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO). Doing so allows them to continue the work they have done to improve the quality and comprehensiveness of the care they provide and see a return on their investment in population health.
PCF expands the care management principles of the CPC+ program to include redesign of physician time and places an emphasis on hospital utilization. Its design encourages participation from practices that have built the infrastructure required to succeed in CPC+ and are ready to assume higher levels of responsibility for patient outcomes and expand their efforts to include modifying the physician’s day.
While PCF builds on the learnings from CPC+, it is also a riskier model. CPC+ offers a direct ‘plus-up’, in the form of a quarterly payment, for practices to add care management and other wrap-around services, but PCF does not make the same direct investments. PCF primarily changes how physician practices are paid and offers the opportunity to increase overall revenue if the practice excels at lowering hospitalizations.
PCF Payment Mechanisms
In PCF, the amount that practices receive from traditional FFS payments on E&M will be drastically reduced. Instead of getting paid $92 for an E&M visit or $133 for an AWV, practices will receive a flat-visit-fee of $40 for any E&M, TCM, AWV, or ACP visit, plus a PBPM that ranges from $28 - $175 based on the practice’s average HCC risk score for attributed beneficiaries, also referred to as the practice’s risk group bucket. This monthly payment differs from the CPC+ care management fee in that it is the same for all patients and is not stratified by individual patient risk scores like it was in CPC+. PCF practices will also receive a performance-based adjustment (PBA) that ranges from -10 to 50 percent of their flat-visit-fee and PBPM payments. The PBA will be based on the practice’s performance on four quality measures, plus their performance on Acute Hospital Utilization compared to a national benchmark, a regional benchmark, and their previous selves (continuous improvement). Additionally, starting in year two practices will be subject to a leakage adjustment that accounts for primary care visits attributed patients have outside of the PCF practice. More information on the difference between CPC+ and PCF payment mechanisms can be found in Table 1.1
Table 1. CPC+ and PCF Comparison of Key Characteristics
PCF Participation Requirements
Participating in PCF also has additional costs that practices don’t have to worry about in FFS. CPC+ practices should be familiar with some of these requirements and their associated costs as they were present in CPC+ as well.
In order to participate in PCF, practices must:
- Have an electronic health record (EHR) capable of submitting eCQMs at the practice-site level;
- Adopt and maintain a qualified registry or qualified clinical data registry (QCDR) to report on the Advanced Care Plan measure;
- Be able to conduct a practice level CAHPS survey;
- Participate in a health information exchange (HIE); and
- Have the needed staff to help with care coordination.
Understanding the Return to FFS
Practices seeking a more ‘traditional’ source of revenue can continue to do the care management work they’ve done over the last few years under the FFS model. Over the last few years, Medicare has begun reimbursing for chronic care management services furnished to patients with multiple chronic conditions. Payment for these services ranges from $42 to $92 based on the CPT code billed. Incorporating CCM codes into the services offered by a practice is the other way a practice can make up the lost revenue from CPC+ ending, and support their care management efforts without affecting E&M payments.
How Should I Choose?
Based on Aledade’s analysis of CPC+ practices, we found the majority of practices would be in risk group bucket 1 ($28 PBPM) with only one out of 46 Aledade partner CPC+ practices having an average practice risk score high enough to place them in the third risk bucket ($100 PBPM). Additionally, we found that only a small number of CPC+ practices will come out ahead in PCF compared to CPC+. The average revenue reduction between CPC+ and PCF was 6% for Track 1 practices and 27% for Track 2 practices. Those that saw a revenue increase if they were to transition to PCF were practices that ended up in risk groups 2 or 3.
If transitioning to FFS, practices will likely see a 28% to 38% decrease in their revenue based on their current CPC+ track. Practices that return to FFS can make up some of this revenue decrease by adjusting the care management workflows implemented under CPC+ to also work in FFS. If Track 1 practices were to bill an average of 4.4 CCM visits annually per attributed patient, this would make up the revenue lost from CPC+.
However, depending on the patient population and staffing levels, succeeding in billing the additional four CCM visits per patient per year could prove challenging - both to a practice and to its patients. The documentation needed for CCM codes is more robust than what was required under CPC+. Patients would now have a copay for a service they’d grown accustomed to receiving for free. Table 2 provides an overview of expected average annual revenue per patient among the different programs.
Table 2. Expected Average Annual Revenue per Patient by Model
Join MSSP to See Improved Rewards for Improving Outcomes
Regardless of whether CPC+ practices elected to participate in PCF or return to FFS, they should also consider participating in an MSSP ACO if they are not already. PCF closely aligns with Aledade’s ACO model with a strong focus on quality, hospitalization reduction, and comprehensive primary care. By participating in both PCF and an ACO, practices can get paid twice for the work they’re doing on reducing hospital utilization and total cost of care (once through the performance-based adjustment in PCF, and again through shared savings in MSSP).
Aledade can also help practices that prefer to transition to FFS through personalized support; access to our App, which highlights the importance of care management and population health; and by increasing revenue in the form of shared savings. Our average payment to practices in 2019 was $129 per patient, or the equivalent of an additional 3.1 CCM services. As seen in Figure 1, a Track 1 practice would make up the lost CPC+ revenue if they participate in PCF and an ACO.
If practices decide to do FFS and an ACO, they would only need one additional CCM visit per patient to make up the lost revenue. On the other hand, if practices decide to not join an ACO, they’d be unlikely to make up the lost revenue in PCF alone and it would take over four CCM visits in FFS. Finally, if practices are in an ACO and their revenue decreased compared to benchmark years, this does decrease total cost of care - meaning some of the decrease would come back to them in the form of shared savings.
Figure 1. Estimated Revenue Based on Annual CCM Visits
Contact Aledade at firstname.lastname@example.org for more information on PCF and/or joining an ACO and achieving shared savings.