CMS Moves forward with CPC+ that Includes PMPM to PCPs

Another Quality Measure is Being Proposed by CMS But this Focuses on PMPM Payments up Front.

According to CMS, the Original Comprehensive Primary Care (Original CPC) Model, is being replaced with the Comprehensive Primary Care Plus (CPC+) which is intended to allow health care provider practices to apply for one of two program tracks, with increasing payment and care redesign expectations from Tracks 1 to 2.

  1. Track 1 targets practices with multi-payer support that have the health information technology and other basic infrastructure necessary to deliver comprehensive primary care. In Track 1, participating practices will work for five years to implement and develop comprehensive primary care capabilities. In addition to their Medicare fee-for-service (FFS) payments, Track 1 practices will receive a care management fee (CMF) that averages $15 per beneficiary per month (PBPM) in support of this work. Track 1 is the most similar to the Original CPC Model, but CMS has refined the eligibility criteria, care delivery requirements, and incentive payment opportunities to incorporate lessons learned in the Original CPC Model.
  2. Track 2 targets practices proficient in comprehensive primary care that are prepared to increase the depth, breadth, and scope of medical care delivered to their patients, particularly those with complex needs. In support of this advanced work, payment is redesigned to be a hybrid of FFS paid at the time of the visit and FFS prospectively paid through what CMS is calling Comprehensive Primary Care Payments (CPCPs). Beyond the FFS/CPCP payments, Track 2 practices will also receive an enhanced care management fee averaging $28 PBPM to support care management, enhanced to support the more stringent requirements for Track 2 practices and to enable more comprehensive care for their patients with more complex needs.

According to CMS, Tracks 1 and 2 will offer a prospective performance-based incentive payment to reward practices for performance on quality and utilization measures that lead to reductions in total costs of care. The goals of CPC+ are (1) accommodating practices at different levels of readiness for and interest in transformation, and (2) innovating care delivery and payment to empower primary care practices to provide more comprehensive care that meets the needs of all their patients, particularly those with complex needs.

Authority for CPC+ : Social Security Act Section 1115A

Section 1115A of the Social Security Act provides authority for CMS to create CPC+, a redesign to include different care delivery requirements and payment options for different U.S. primary care practices. Also, CMS states that multi-payer involvement is essential to CPC+, since the goal is to ensures financial support for practices to make changes to care delivery. Further, when payers share cost, utilization, and quality data1 with practices at regular intervals, it facilitates practices’ ability to manage their patient population’s health, leading to smarter spending, better care, and healthier people. CPC+ will be regionally based and there will be a staged application process (payer solicitation period April 15, 2016 to June 8, 2016; practice application period August 1, 2016 to September 15, 2016). The selection of payers will inform the selection of regions; the practice application will be open in only these to-be-determined regions. Payers must support practices in both tracks. Practices will apply for the track (1 or 2) for which they are eligible.

1 All data sharing and data analytics in the CPC+ will comply with applicable law, including the privacy and security requirements promulgated under the Health Insurance Portability and Accountability Act (HIPAA)

CMS Application Policies and Impacted Medicare Beneficiaries

CMS will accept up to 2,500 practices into each Track. In aggregate, up to 3.5 million Medicare FFS beneficiaries, as well as millions of other Medicare Advantage, Medicaid, and commercial patients, could be impacted over the course of this model.

Michael F. Arrigo

Michael Arrigo brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health IT, and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations who provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and medical billing, fraud damages, as well as electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, medical malpractice, insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software SA (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls IT audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and is published in Healthcare IT News.

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