Getting the Price Right: Approaches to Pay for Comprehensive - - PowerPoint PPT Presentation

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

Center for Medicare & Medicaid Innovation

Getting the Price Right: Approaches to Pay for Comprehensive Primary Care

AcademyHealth Annual Research Meeting June 2017

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Christiane LaBonte, MS Division of Advanced Primary Care

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

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Agenda

1) Comprehensive Primary Care (CPC): 2012-2016 2) CPC+: 2017-2022 3) CPC+ Care Delivery Transformation 4) CPC+ Payment Design to Support Care Delivery 5) Primary Care Valuation Study

For more information:

https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus

Center for Medicare & Medicaid Innovation Comprehensive Primary Care Plus

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~327,000 Medicare Beneficiaries ~2.7 Million Active Patients ~79,000 Medicaid Beneficiaries

PATIENTS

Ohio/Northern KY Hudson Valley, NY Greater Tulsa, OK Arkansas Colorado New Jersey Oregon

REGIONS

445 Practice Sites 2137 physicians 36 Public and Private Payers

PARTNERS

CPC Engaged Numerous Partners Across Seven Regions

Center for Medicare & Medicaid Innovation Comprehensive Primary Care Plus

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>1.76 million

Medicare Beneficiaries

ROUND 2

2,891

Practice Sites

13,090

Clinicians

ROUND 1

Comprehensive Primary Care Plus

12

New Payers

Including 5 supporting Round 1 regions

5

Years

From 2018-2022

4

New Regions

Selected based on payer commitment to partnership Up to 1,000

New Practices

Depending on interest and eligibility

53

Payer Partners

58

HIT Vendor Partners

5

Years

2

Tracks

14

Regions

America’s Largest-Ever Initiative to Transform Primary Care

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

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Five Functions Guide CPC+ Care Delivery Transformation

24/7 Patient Access Patient Assignment to Care Teams Patient Risk Stratification Hospital/ED Discharge Follow-Up Coordination with Other Providers Patient and Family Advisory Councils Practice and Payer Data Insight Care Plans for Chronic Disease Patients Out-of-Office Care Options Integrated Behavioral Health Psychosocial Needs Assessment Self-Management Support Tools Full Care Team Data Review

Access and Continuity Care Management Comprehensiveness and Coordination Patient and Caregiver Engagement Planned Care and Population Health

Track 1 requirements Additional requirements for Track 2

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

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Payment Innovations* Support Practice Transformation

Care Management Fee (PBPM) Payment Structure Redesign Objective

Support augmented staffing and training for delivering comprehensive primary care Reduce dependence on visit-based fee-for- service to offer flexibility in care setting

Track 1

$15 average N/A (Medicare FFS)

Track 2

$28 average; including $100 to support patients with complex needs Upfront “Comprehensive Primary Care Payment” (CPCP) + Reduced FFS

Online Resources: Payment Innovations Brief and Video *A performance-based incentive payment is not in RAND’s scope of work

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

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PBPM Care Management Fees Determined by Patient Risk Levels

$9 $11 $19 $33

1st risk quartile 2nd risk quartile 3rd risk quartile 75% 90% 100% 50% 25% 0% 4th risk quartile

Track 1: Four Risk Tiers (Average $15) Track 2: Five Risk Tiers (Average $28)

• Risk adjusted, PBPM (non-visit-based) payment
• Designed to augment staffing and training,

according to specific needs of patient population

• No beneficiary cost sharing
• Risk tiers relative to regional population

$6 $8 $16 $30

Top 10% of risk or dementia diagnosis

Complex Tier: $100

Payments Support Practice Capabilities to Better Manage Care

?

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

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Track 2 Reimbursement Redesign Offers Flexibility in Care Delivery

• Practices receive enhanced fees with roughly half of expected FFS payments

upfront and subsequent FFS billings reduced by the prepaid amount

• CPCP reduces incentive to bring patients into the office for a visit but maintenance of

some FFS allows for flexibility to treat patients in accordance with their preferences

• Practices select the pace at which they will progress towards one of two hybrid

payment options (both roughly 50/50) by 2019

Hybrid of FFS and Upfront “Comprehensive Primary Care Payment” (CPCP) for Evaluation & Management FFS FFS

60%

CPCP

40%

FFS

35%

CPCP

65%

OR

2016 2019

Designed to Promote Population Health Beyond Office Visits

Total CPCP/FFS is ~10% larger than historical FFS to compensate for more comprehensive services

?

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

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Primary Care Valuation Study

Estimate the marginal costs of delivering comprehensive primary care

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• Obtain costs from physicians who have implemented CPC functions
• Not an attempt to re-price the Resource Based Relative Value System

Data would inform future price of CMF and CPCP

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Mixed-methods data collection from practice leaders

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• Semi-structured interviews on CPC functions, written cost survey
• 50 practices, 20 CPC+ participants
• Stratified by practice size, Census region, rural/urban status, system affiliation
• Practices are compensated for participation
• Accurately compensate practitioners for providing CPC functions
• Mitigate incentives toward volume
• Data collection and analysis through winter 2017-2018

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

Center for Medicare & Medicaid Innovation

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Questions?

For questions, please email christiane.labonte@cms.hhs.gov