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CMS pivots on Comprehensive Primary Care Plus model to allow Shared Savings ACOs

Medicare Shared Savings Program ACO's had been barred because CMS believed the combination limited motivation to control the cost of care.

Susan Morse, Senior Editor

CMS Headquarters-Windsor Mill, MD.CMS Headquarters-Windsor Mill, MD.

The Centers for Medicare and Medicaid is revising its policy to include shared savings ACOs in its upcoming Comprehensive Primary Care Plus program.

Primary care practices currently participating, or considering participating, in the Medicare Shared Savings Program may also participate in CPC+, CMS said.

This is a change of policy from April, when CMS announced the Comprehensive Primary Care Plus model that gives practices up-front incentive payments that are kept or repaid based on performance.

In the original model, Medicare Shared Savings Program accountable care organizations were barred from participating based on CMS's belief that the combination limited motivation to control the cost of care.

Health policy experts Bob Kocher and Farzad Mostashari complained about this policy and got it changed. Kocher is the former special assistant to President Obama for healthcare and economic policy and Mostashari was national coordinator for health information technology at the Department of Health and Human Services.

[Also: CMS launches Comprehensive Primary Care Plus, value-based model for primary care practices, multiple insurers]

Instead, of shutting out ACOs, CMS has modified its incentive payment methodology.

The new CPC+ model includes two tracks for all participating practices.

Under Track 1, CMS pays practices a monthly care management fee in addition to the fee-for-service payments under the Medicare physician fee schedule.

The care management fee supports expenses incurred under the new model, including work flow changes, staff hiring, learning activities, reporting, monitoring, and auditing requirements.

Primary care practices within ACOs will receive the same care management fee but will be required to include the funds in their calculations for shared savings and shared loss, CMS said.

Track 2 is a hybrid design that allows for greater flexibility in how practices deliver care outside of traditional office visits. Practices participating in this track receive advanced alternative payment model incentives.

[Also: CMS launches Comprehensive ESRD Care, accountable care model for kidney care]

However, as participation in the Medicare Shared Savings Program does not constitute an advanced alternative payment model, practices taking part in shared savings and CPC+ do not qualify for the advanced alternative payment model incentive payment, CMS said.

Practices within ACOs will forego the CPC+ prospectively paid, retrospectively reconciled performance-based incentive payment, and instead will participate in the ACO's shared savings and shared loss arrangement, CMS said.

The comprehensive primary care payment and reduced fee for service payments together will be calculated based on an amount 10 percent larger than historical billings. The payment, including the 10 percent increase, will be included in the ACO's total expenditures for shared savings and shared loss calculations, CMS said.

Payers may support practices that are part of a CPC+ by submitting to CMS a proposed partnership in an updated version of the Payer Solicitation and Addendum by June 8.

Payers will not be required to use CMS's payment methodology for these practices. Instead CMS wants to see payers align on key payment, quality, and data-sharing elements. The 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, CMS said.

CMS is placing limits on the number of practices which will be able to participate in CPC+. Of the total 5,000 CPC+ primary care practices in ACOs, up to 1,500 may participate. If more than 1,500 eligible practices within a shared savings ACO program apply to participate, a lottery will be held.

The new Medicare Access and CHIP Reauthorization Act of 2015 notice of proposed rulemaking, announced in April, provides details regarding how CPC+ will be affected by the Quality Payment Program. Public comment is being accepted through through June 27. 

Twitter: @SusanJMorse

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