Health System Reform Insight - April 26, 2012
Given the new direction for the nation's health system, the AMA has developed Health System Reform Insight to help you understand what this new direction means to you and your patients.
A new initiative of the Center for Medicare and Medicaid Innovation (CMMI) aims to ensure success of physician efforts to innovate and improve care delivery by cultivating support among private payers.
The CMMI's new Comprehensive Primary Care Initiative (CPC) is designed to foster collaboration at the local level among private health care payers and primary care physicians so that physicians can lead innovative and sustainable new payment and delivery efforts.
In this new initiative, Medicare will work with commercial health plans, Medicaid and other state health plans to offer monthly bonus payments to primary care physicians who better coordinate care for their patients. According to the CMMI, the CPC offers a way to "break through the historical impasse by inviting payers to join with Medicare in investing in primary care" in up to seven selected markets across the country.
The AMA supports the CPC initiative and has urged the Centers for Medicare & Medicaid Services (CMS) to pursue multipayer approaches to new payment and delivery models.
Care and payment models
The CMMI has created two models as part of the CPC initiative: one focusing on care and one on payment. Under the care model, the CPC will fund primary care practices so they are able to:
- Manage care for patients with high heath needs. Participating primary care practices will be able to focus on multiple or serious health conditions.
- Ensure access to care. Participants will be accessible to patients 24/7.
- Deliver preventive care. Participants will proactively assess patients to determine their health care needs and ensure appropriate, timely preventive care.
- Engage patients and caregivers. Participants will be able to encourage patients and their families to actively participate in their care.
- Coordinate care across the medical community. Participants will work with specialists and medical facilities to coordinate care, including through "meaningful use" of electronic health records.
Under the CPC payment model, CMS will pay a monthly care management fee to select primary care practices for their fee-for-service Medicare beneficiaries. During the first two years of the program, the per-beneficiary fee will average $20 a month. During the second two years of the program, the fee will average $15 per beneficiary a month.
In addition, participating physicians will have the opportunity to share in any Medicare savings attributed to the CPC. Participating physician practices also will receive a monthly care management fee from participating private payers. This collaboration across multiple payers should enable physicians to strengthen their capacity to implement practice-wide quality improvements.
Eligible geographic markets
Earlier this month, CMS announced the seven geographic markets in which the CPC will take place. These markets were selected based on private payers' interest in participating. The four statewide markets are Arkansas, Colorado, New Jersey and Oregon. The three regional markets are the Capital District-Hudson Valley region of New York, the Cincinnati-Dayton region in Ohio and the greater Tulsa region in Oklahoma.
How to participate
Once participating private payers in the these markets enter into memorandums of understanding with CMS, the CMMI will release a solicitation to primary care practices in the seven geographic markets. Approximately 75 primary care practices in each designated market will be selected to participate.
The physician solicitations and application details are expected to be issued sometime early this summer. In the meantime, interested physicians should review the initiative's fact sheet to better understand the criteria for this new payment and delivery model.
Physicians have until this date to report on at least 10 electronic scripts, known as e-scripts, or file a hardship exemption to avoid a 1.5 percent reduction in Medicare Part B payments in 2013. View an AMA tip sheet to learn more.
Physicians must be in compliance with standards for the Health Insurance Portability and Accountability Act version 5010 electronic transactions by this date. Physicians who continue to experience difficulties with claims processing should complete a complaint form.