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Part B Insider (Multispecialty) Coding Alert

Part B Payment:

CMS Continues Its Focus on Primary Care with New Initiative

CPC+ model highlights the move to quality care with major monetary incentives.

As Medicare unveils MACRA-backed quality proposals entrenched with affirmations that patient care will come first, the fee-for-service models that have become the norm in decades past will continue to diminish. CMS hopes that coordinated care starting at the base level and across various health care platforms will eventually be standard, and with the steady stream of proposals encouraging this type of health care commitment, one-size-fits-all may eventually be a thing of the past.

Foundation. A few short weeks ago, Medicare disclosed its Physician Fee Schedule for CY 2017 that highlighted the current trends supporting the Medicare Shared Savings Programs (MSSP) and advanced Alternative Payment Models (APM) while verifying its present focus on primary care and coordination of services between practices, hospitals, specialties, and business partners.

This week, CMS delivered with a new primary care model open for application on August 1, 2016 through Sept. 15, 2016 called Comprehensive Primary Care Plus (CPC+), making good on its earlier promise and outlined in an August 1, 2016, CMS press release.

The lowdown. Brought to you from the CMS Innovation Center, CPC+ is set to commence on Jan. 2017 and will promote the importance of primary care in the health care community. Here is a quick take on the program from the provider perspective:

  • 5-year primary care medical home model starting Jan. 2017.
  • Encourages providers to assist patients in the way they see fit with compensation for favorable outcomes.
  • Will be open to practices of all shapes and sizes that qualify for incentive pay for advanced APMS under the proposed QPP.
  • Reaffirms the coordination and delivery of preventive care.
  • Select regions across the nation will be allowed to apply to the program during the application period and include these states: Arkansas, Colorado, Hawaii, Michigan, Montana, New Jersey, Oklahoma, Oregon, Rhode Island, Tennessee and regions in Kansas and Missouri (Greater Kansas City Region), New York (North Hudson-Capital Region), Ohio (Statewide and Northern Kentucky Region), and Pennsylvania (Greater Philadelphia Region).

“As a key part of CPC+, CMS and partner payers are committed to supporting primary care practices of all sizes, including small, independent, and rural practices,” Patrick Conway MD, CMS deputy administrator and chief medical officer said in the August 1 news release. “We see CPC+ as the future of primary care in the US and are pleased to partner with payers across the country that are aligned in this mission to transform our health care system. This model allows primary care practices to focus on what they care about most – serving their patients’ needs when and how they choose.”

Here Are the Payment Details

“CPC+ will prospectively pay and retrospectively reconcile a performance-based incentive based on how well the practice performs on patient experience measures, clinical quality measures, and utilization measures that drive total cost of care,” the CMS Innovation Center model summary states.

With two tracks to choose, CPC+ gives providers some options. The higher model, Track 2, estimates that the care management pay per patient will be around $28 monthly and possibly up to $100 for the treatment of more chronic conditions. Track 1 uses an FFS model, and CMS suggests that estimated payment to be around $15 per patient.

Looking ahead. As new programs are integrated under MACRA, the landscape of the Medicare system will continue to reshape itself.

“Today’s announcement is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality,” the CMS news release states. “This new model supports the Administration’s goal to have 50 percent of traditional Medicare payments flowing through alternative payment models by 2018 (already, 30 percent of Medicare payments go through alternative models).”

Resources: For a comprehensive read of the CMS press release on the CPC+ initiative, visit

Check out the CMS Innovation outline on primary care models at