CMS Accepting Applications for Capitated Primary Care Model

August 04, 2016

Medicare is now accepting applications from primary care physicians who want to receive monthly capitation payments for evaluation and management (E/M) services as well as care management apart from office visits — think phone calls, emails, and remote monitoring.

Selected physicians will participate in a 5-year experimental payment model called Comprehensive Primary Care (CPC) Plus, which is designed for medical homes. The Centers for Medicare & Medicaid Services (CMS) wants to recruit as many as 5000 practices with upwards of 20,000 clinicians to treat 25 million patients, who will not be limited to beneficiaries of traditional Medicare. CMS is partnering with private insurers, state Medicaid programs, and Medicare Advantage plans that agree to adopt the same metrics for payment, data sharing, and quality. As a result, participating physicians won't have to reorganize their practices just for the sake of patients in traditional Medicare.

CPC Plus is a more ambitious version of a capitated payment model in Medicare called Comprehensive Primary Care, which gives practices an average of $15 per beneficiary per month (PBPM) for care coordination on top of normal fee-for-service (FFS) reimbursement. This program, which expires in December, is credited with reducing hospital readmissions below national benchmarks as well as overall spending on physician services.

The new program offers physicians the choice of two payment tracks. The easier of the two tracks in CPC Plus resembles the original CPC program. In addition to FFS reimbursement, physicians receive a care-management fee of $6 to $30 PBPM, or $15 on average, with the amount depending on the complexity of the patient's medical needs.

Care-management payments go up to $28 PBPM on average and as high as $100 in the second track, but to earn that, physicians must provide "more comprehensive services for patients with complex medical and behavioral needs," according to CMS. These physicians receive not only the care-management fee but also another capitation fee that covers a portion of their E/M services, whether or not they're provided during a face-to-face visit. Physicians would continue to bill on an FFS basis for E/M services, but reimbursement would be at a lower rate to reflect the second capitation payment. By 2021, physicians in this CPC Plus track must receive either 40% or 65% of their estimated E/M revenue up front.

The monthly payments don't stop there. Physician practices in both tracks of CPC Plus will strive for a bonus based on how well they perform on quality-of-care and cost metrics. The bonuses will be doled out in advance — $2.50 PBPM in track one and $4 PBPM in track two — but if physician performance doesn't measure up, the bonuses must be repaid.

CMS has selected 14 regions for CPC Plus:

  1. Arkansas: Statewide

  2. Colorado: Statewide

  3. Hawaii: Statewide

  4. Kansas and Missouri: Greater Kansas City Region

  5. Michigan: Statewide

  6. Montana: Statewide

  7. New Jersey: Statewide

  8. New York: North Hudson-Capital Region

  9. Ohio: Statewide and Northern Kentucky Region

  10. Oklahoma: Statewide

  11. Oregon: Statewide

  12. Pennsylvania: Greater Philadelphia Region

  13. Rhode Island: Statewide

  14. Tennessee: Statewide

CPC Plus qualifies as an Advanced Alternative Payment Model (APM), one of two payment tracks under the Medicare Access and CHIP Reauthorization Act (MACRA). Such Advanced APMs receive an annual lump-sum bonus of 5%, plus they're exempt from penalties that threaten physicians in the other MACRA payment track, called the Merit-Based Incentive Payment System (MIPS).

CMS opened up the application process for CPC Plus on August 1. The deadline for submitting an application is September 15. Information on how to apply is available on the CMS website.

Follow Robert Lowes on Twitter @LowesRobert


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.