The Centers for Medicare & Medicaid Services (CMS) is testing payment and service delivery models to achieve better care for patients, smarter spending and healthier communities. CMS believes this can be achieved through payment reform and practice transformation as primary care practices build capabilities and processes to deliver better care. Payment redesign offers greater cash flow and flexibility for primary care practices, allowing them to deliver high-quality, whole-person, patient-centered care while reducing unnecessary services that drive up costs.
QualChoice is pleased to participate in CPC+, a five-year, multi-payer model that builds on and has replaced the original CPC Classic initiative to improve primary care. Participating primary care practices receive additional payment beyond fee-for-service (FFS) including population-based care management fees for better coordination of patient care and the opportunity for performance-based incentives.
Other major participating payers in Arkansas are Medicare, Medicaid, Arkansas Health and Wellness Solutions, HealthScope, Arkansas Superior Select and Arkansas Blue Cross Blue Shield. All share the common goal of improving primary care for the patient.
The three over-arching goals of CPC+ are:
- Improved patient care
- Improved population health
- Lower costs
QualChoice is committed to helping CPC+ participating providers achieve these goals through:
- Payment of a population-based Care Management Fee (CMF): a non-visit based, retrospective payment Per Member Per Month (PMPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for a practice’s specific population. Practices will use this enhanced, non-visit-based compensation to augment staffing and training in support of population health management and care coordination.
- Performance-based incentive payments: a retrospective, annual incentive payment based on how well the practice performs on clinical quality measures and on utilization measures that drive total cost of care. The incentive payment will be based on both quality and utilization reports. Reporting data will be collected from claims and Category II Current Procedural Terminology (CPT) Codes (Non-billable codes). Each practice should have a minimum of 50 attributed members captured on a quarterly Attribution report to qualify for performance incentive payment.
Participants in two different participation tracks will receive care coordination fees during the year. They will also receive performance payments if they meet quality and utilization metrics, after completion of the first year.
- Track One practices will continue to receive their regular FFS payments for covered evaluation and management services throughout the five years.
- Track Two practices will receive a hybrid of FFS and Comprehensive Primary Care Payment (CPCP). The value-based reimbursement will pay for covered evaluation and management services, but the care may be delivered outside of a traditional office visit. For the first 3 years, FFS payments will be reduced, and value-based payments increased, in a phased approach. After 3 years, further FFS reductions may be applied.