For health care providers, the journey to value-based care starts by taking the first step. For many primary-care physician practices, that first step can–and, in many cases, will–be Medicare's new Comprehensive Primary Care Plus, or CPC+, initiative.
, announced in April by the Centers for Medicare & Medicaid Services, hopes to attract as many as 5,000 primary care practices in 20 regions of the country as participants. The CMS estimated that 20,000 individual doctors within those practices will join and provide care to 25 million beneficiaries under the program.
Working with participating health plans in their regions, practices will be incentivized by Medicare to pivot from providing episodic reactive care to their Medicare patients to providing them with the following comprehensive services:
- Support patients with serious or chronic illnesses to achieve their optimum health status
- Give patients 24-hour access to care and health information
- Deliver preventive care services to patients
- Engage patients and their families in their own care
- Coordinate the care of patients with other providers in the market
Most primary-care doctors have not transitioned to this form of care delivery due to historic reimbursement incentives. Under fee-for-service medicine, providers are trained to be reactive in their care delivery. The Center for Medicare and Medicaid Innovation (Innovation Center) wants to change that, as the CPC+ program builds upon the original CPC program, by offering a big carrot to lead primary-care doctors down an alternative care delivery path and new reimbursement methodologies.
But like any journey into unfamiliar territory, pioneering primary-care practices must have the right staff, supplies and equipment to make the journey successful. I would recommend that practices make the following five assessments to determine whether they're ready to take their first step toward value-based care through the CPC+ program.
Assess the Impact of CPC+ Participation on Practice Cash Flow
First, practices must assess whether their financial position and revenue cycle management can handle shifting their current Medicare patient panel to a new reimbursement model that pays prospectively on a per beneficiary per month, or PBPM, basis.
Practices can join the program on one of two tracks. Track one, which is targeted at less advanced practices, offers a low risk entry level to the program. It keeps the traditional FFS model intact and adds both a prospectively paid comprehensive care management fee and performance incentive payment. The practice must pay back the performance incentive if it doesn't meet certain utilization and quality metrics.
Track two shifts fee-for-service payments to an augmented hybrid model through the introduction of the Comprehensive Primary Care Payment, or CPCP. On this track, prospective payments will increase but payments for traditional evaluation and management visits will be reduced. Incentive payments on track two are higher but also at risk as in track one.
[Editor's note: For a more detailed description of the payment methodologies for the two CPC+ tracks, visit the
on the CMS website.]
In order to ensure success, primary-care practices should do the financial analysis. Practices should know how many Medicare patients they treat on a fee-for-service basis and determine how much revenue that generates in total and as a percentage of overall income. Then practices should compare those amounts with the estimated numbers resulting from moving those same patients into either track one or track two in the CPC+ program.
Reinforce or Rebuild Collaborative Relationships with Payers
The second determination practices must make is the state of their working relationships with health plans in their market. Medicare will subcontract with health plans in the 20 regions to administer the program and work with the primary-care practices in their respective regions.
Ideally, participating practices will have well-established and collaborative relationships with the two or three largest payers in their markets. Clinical performance data, utilization review data and claims data flows effortlessly between practices and payers in those relationships. For some practices, though, that relationship is more antagonistic than amicable. In those cases, practices will need to rebuild those working relationships before they apply to participate in the CPC+ program.
As CPC+ introduces a new form of reimbursement, it would be advisable to explore this methodology with potential commercial payers and cohorts of patients as well to allow providers the freedom to explore and deliver care in new ways.
Determine Whether Practice's Culture is Prepared for Care Transition
Third, practices must take their cultural temperature before signing on to the CPC+ program. Does the practice want to join because it sees this as an alternative revenue stream and a quick way to get extra money? Or does the practice truly buy into the end game and is willing to move out of the four walls of the office and become proactive instead of only reactive? Is it saying it welcomes the opportunity to deliver care in the most optimum and efficient setting?
By just taking this one step, a practice is announcing to its nurses, its mid-levels, its front-office staff and, most importantly, its patients that the practice is going to be innovative and truly put quality of care first. That it's going to do something different. That it's willing to get in front of this value-based care wave and ride it rather than letting it wash over the practice.
If the money is there, if the payer relationships are there and if the culture is ready to innovate, then practices have to make two tactical assessments to determine whether they're ready for the CPC+ program.
Develop or Obtain Staff with Required Skill Sets to Fulfill CPC+ Requirements
So fourth on my preparation checklist would be staff and expertise. Does the practice have the staff to be available to patients 24/7? Does the practice have the staff to conduct outreach to patients to check on their health status and ensure that they're following their comprehensive-care plans? Does the practice have the staff to coordinate patient care with other providers? And does the practice have the expertise in prevention and wellness to keep healthy patients healthy and patients with chronic medical illnesses as healthy as possible?
Practices that answer no to those questions will need to add staff, retrain staff or collaborate with health plans or other providers to gain the necessary competencies to make the CPC+ program successful. The monthly incentive payments to practices under the program are designed to help offset the costs of adding that manpower to their infrastructure.
Build and Enhance Technology Infrastructure to Support Patient Care Services
Fifth and last on my list of considerations is technology infrastructure. Each of the five services to be provided to Medicare beneficiaries under the CPC+ program are enhanced by information technology systems. For example, coordinating the care of patients with other providers requires interoperable EHR systems that can send, receive and share patient information with unaffiliated providers. Also, patient engagement can be greatly facilitated by such things as online portals and telemedicine capabilities. And effective preventive care can be supported by remote monitoring of diagnostic information.
Let's not forget the quality measures that participating practices will need to collect, monitor, aggregate, analyze and transmit to their partner health plans. That information will tell practices how well they're doing in meeting the clinical and financial targets established by the two tracks in the CPC+ system.
This all may seem like a lot of preparation for primary-care practices just to take the first step into the new world of value-based care. For practices willing to make the commitment, though, the return on investment will be there both in the short- and long-term.
In the short term, Medicare is paying practices extra money to join. That's like the government paying you to go to school and learn a new trade that will be in much demand in the future. In the long term, the financial, clinical and technical skill sets and infrastructure acquired by participating practices will position them well for a future in which value-based care is the known world and not uncharted territory.
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