Value-Based Care Program

Comprehensive Primary Care Plus (CPC+)

At QualChoice, our goal is to make health insurance simple. To do that, we’re helping PCPs make healthcare better. We’re working with healthcare providers, other insurance firms and state and federal groups to help PCPs move from volume-based care to value-based care.

In this model, provider payments are partially based on the quality and efficiency of the care. Providers are rewarded for working together, for providing the right care and for achieving positive outcomes.

Comprehensive Primary Care Plus (CPC+) is a five-year, multi-payer model to improve primary care. Participating primary care practices receive additional payment outside of the fee-for-service, including population-based care management fees for better coordination of patient care and the opportunity for performance-based incentives.

Review the CPC+ Participating Provider Training deck for an overview of the program.

  • What is the difference between CPC & CPC+? CPC+ replaced the CPC Classic program.
  • What are the benefits of CPC+? CPC Classic achieved gross savings and was nearly cost neutral, with positive quality results in its first year. These findings came earlier than expected in a model involving significant changes in the delivery of primary care. CPC+ looks to build on these results.

Frequently Asked Questions

General Information

  • What is the purpose of this program?  The CPC+ program was designed to test improved payment and service delivery models, to achieve better care for patients, smarter spending and healthier communities. Payment redesign offers greater cash flow and flexibility for primary care practices to deliver high-quality, whole-person, patient-centered care while lowering the use of unnecessary services that drive total costs of care.
  • How are primary care practices encouraged and rewarded for their accountability for patient experience, clinical quality and utilization?  Providers are paid a performance-based incentive retrospectively if they meet annual performance thresholds.

Participating Practices

  • Which payers are participating? 
    • CPC+ participants in Arkansas are Arkansas Blue Cross and Blue Shield, Arkansas Medicaid, Humana and QualChoice of Arkansas.

All payers are participating with the common goal of improving primary care to the patient.

    • How were practices selected for these programs? 
    • CPC+ Practices were selected through a competitive application process based on their:
      • Use of health information technology
      • Ability to demonstrate recognition of advanced primary care delivery by accreditation bodies
      • Service to patients covered by participating payers
      • Participation in practice transformation and improvement activities
      • Diversity of geography, practice size and ownership structure
  • Are practices required to participate in CPC+ for the full five years? Practices that participate are expected to do so for the full five years. However, participation is voluntary and practices may withdraw without penalty.
  • What must a practice do to withdraw from the programs? 
    • CPC+ practices must notify CMS at least 90 calendar days before the planned day of withdrawal. They may also notify QualChoice directly of their intent to withdraw.

Member Rosters

  • How do I know which members are CPC+ members? QualChoice posts a list of each provider’s members monthly on the CPC+ landing page in the My Account provider portal.
  • How can I make changes to my CPC+ member roster?
    • QualChoice non-self funded group members are attributed to a PCP based on past claims history. They will be reattributed if their claims history indicates they have changed PCPs.

Performance – Quality and Utilization Metrics

  • What are the performance thresholds?  The performance thresholds are broken into two distinct components, on which QualChoice will pay performance-based incentives retrospectively:
    • Performance on clinical quality/patient experience is based on specific quality performance measures and Consumer Assessment of Healthcare Providers and Systems (CAHPS) metrics.
    • Performance on utilization is based on claims-based measures commonly used to determine total cost of care and measurable at the practice level [e.g., inpatient admissions and emergency department visits that are available in the Healthcare Effectiveness Data and Information Set (HEDIS)].
  • Where are the metrics listed?  Quality and utilization metrics can be found in your QualChoice CPC+ provider contract. These metrics are also summarized in the CPC+ training deck.
  • What are the targets for each measure?  There are no fixed targets. The mean (mathematical average) has to be calculated for every performance metric, based on the data we receive. The goal is to perform above average (better than peers).
  • How are the quality metric thresholds calculated?  Each quality metric will have an arithmetic mean of performance across all participating practices. The goal is to have “above average” performance (better than the arithmetic mean—whether better means higher or lower) compared to other practices. The quality threshold (to be eligible for performance incentives) is above-average performance relative to other practices on all combined quality metrics. This means a practice may or may not perform above average on every single quality metric but may still achieve overall, combined above-average performance.
  • How does a practice earn a performance payment?  Performance incentive payments to practices are based on quality and utilization metric reports. Eligibility for performance payment requires above-average performance relative to other participating practices on all combined quality metrics. This means that a practice may or may not perform above average on every single quality metric, but may still achieve overall combined above-average performance for quality and, therefore, will be eligible for performance payment. The performance on utilization metrics will then be considered and subject to the same methodology.

Payments

  • How are primary care practices paid?
    • Care Management Fee (CMF):  This is 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 use this enhanced, non-visit-based compensation to augment staffing and training in support of population health management and care coordination.
    • Performance-Based Incentive Payment:  QualChoice pays retrospectively and annually an 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 is based on both quality and utilization reports. Reporting data is collected from claims and Category II CPT Codes (non-billable codes).
  • Why do different payers pay different fees?  Each payer determines their own financial support to practices, separately from that of normal fee-for-service.
  • When is the care management fee PMPM paid and how much is the payment?  Care management fees are paid quarterly. The payment is issued in the month following the end of a quarter. Your care management fees are outlined in your QualChoice CPC+ provider contract.
  • How does a provider recognize the care coordination payments on their Remittance Advice?  Care coordination payments are made through normal claims payment. Clinics will see a claim payment for assigned members under CPT code CPCPO. For example, the provider RA will show a claim for an assigned member for a date of service in April, May or June for CPT code CPCPO with the assigned PMPM amount as the allowed amount.
  • What is the timeline for performance incentive payments?  An annual performance incentive payment will be made to eligible practices during the quarter following the performance year.
  • How is the amount of the incentive bonus determined?  The amount of the payment depends on the degree of variance from the average. In other words, the higher the practice performance above the average of practices, the higher the payment amount.

Performance Reports

  • How do providers submit reports? Sign in to My Account at QualChoice.com to upload your reports.
  • What is the timeline for attribution and performance reports?  CPC + member rosters are published the first of each month. Performance reports are published quarterly.

Training and Additional Information