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Tuesday Feb 07, 2017

CPC+ Laying Groundwork for Value-based Payment

Too often in primary care, our practices don't get paid for all of the work we do.

For example, the average medical practice wastes roughly 16 hours of staff and physician time each week -- per physician -- on prior authorizations. And we know that for every hour we spend with patients, physicians spend two hours on documentation.

Although the AAFP is working to reduce these types of administrative burdens,  there are still other examples of vital work -- returning patient phone calls, telehealth, etc. -- that aren't reimbursed adequately, if at all.

This year, my practice is one of nearly 3,000 primary care practices working with more than 50 payers to change that. The Comprehensive Primary Care Plus (CPC+) program,  launched in January, is a five-year pilot that aims to move practices away from the volume-driven, fee-for-service payment system. It will do so by providing a new payment structure that encourages flexibility in engaging patients with methods beyond the traditional office visit. Improved payment is expected to allow practices to improve infrastructure, integrate behavioral health and essentially lay the groundwork for the value-based payment systems of the future.

Shawn Martin, the AAFP's senior vice president of advocacy, practice advancement and policy, outlined the specifics of how CPC+ will pay better and differently in a blog post published during the application period last summer.

The short version is that CPC+ offers a payment model with three components that de-emphasize fee-for-service payments and provide prospective payments to support practices as they provide advanced primary care to meet the needs of their patients.

The CPC+ model includes two tracks with slightly different payment components to support practices: track one for those that are building capabilities or track two for practices that are already delivering advanced primary care. Each track has three payment components:

  • Care management fee (CMF): Practices will receive a per-beneficiary-per-month (PBPM) CMF. The fee will be paid prospectively on a quarterly basis and will be based on the complexity of the patient population. The average PBPM CMF will be $15 for track one and $28 for track two. Track two practices will receive a $100 PBPM CMF for the most complex cases, such as patients with dementia. 
  • Performance-based incentive payment (PBIP): All CPC+ practices receive their PBIP as a prospective payment at the beginning of each program year so they can meet patient needs and build capacity. At the end of the program year, practices that do not meet quality and utilization benchmarks will repay some or all of this payment. The PBIP will be equivalent to $2.50 PBPM for track one and $4 PBPM for track two.
  • Payment under Medicare physician fee schedule: All CPC+ practices will continue to bill and receive fee-for-service (FFS) payments. Track one practices will continue to receive standard FFS payments. Track two practices will receive a hybrid payment with a prospective portion paid quarterly -- the Comprehensive Primary Care Payment (CPCP) -- coupled with reduced fee-for-service payments. The CPCP plus FFS payments together will be larger than the practice's historical FFS payment.

The advance payments in this structure will allow practices to invest in the capabilities they need to be successful in transforming care. These capabilities may include care managers, clinical social workers, licensed counselors or other resources needed to deliver robust population health, chronic disease management and care coordination. We will be able to better identify our high-risk populations, more closely monitor utilization, and reduce ER visits and recurrent hospitalizations.

Once we identify patients in those high-risk groups, we can ensure they are linked to resources within our health care system as well as to external resources and work with them to improve their overall health. We also will work to close gaps in care, improve transitions in care and proactively manage chronic diseases.

As a level three patient-centered medical home, we already are doing many of the things we will be judged on in this pilot. Now we will be able to do them even better and get paid accordingly.

This month, CMS is expected to begin accepting applications from payers for an expansion of this concept. CMS will select up to 10 new regions that have sufficient payer commitment to support practices in adopting the CPC+ model. The agency then plans another application period this spring or summer for practices in those new regions.

The AAFP will notify members about opportunities and provide support and resources for those interested in applying. I urge you to consider how your practice -- and your patients -- might benefit from the experience.

Michael Munger, M.D., is president-elect of the AAFP.


A focus on hundreds of millions is a distraction from the misguided CMS designs involving 1 trillion dollars. This one trillion has led the nation to highest cost for lowest yield in outcomes as well as resulting in greater disparities.

Playing along with CMS and HHS for 35 years has not worked for family medicine or health access, especially where increasing proportions of Americans face increasing barriers to care.

CMS has only been teasing us. They send us too few dollars to help us to achieve our full value even though we are the best value among possible clinical interventions. Each small change grant from gets miles of coverage via journals, media, social media, and association postings but the overall impact is to move us farther from true outcome improvements.

So-called “accountable care” must be held accountable also for failure in evidence-based care.

1. There is adequate data to state emphatically that clinical interventions can change the process of care but are not capable of significant changes in outcomes. This is seen in reviews of the literature regarding Pay for Performance, Value Based, Managed Care, Managed Cost, etc. Foundations spending 300 million over 10 years to facilitate care did not significantly change outcomes.

Inherent in these efforts are higher administrative costs in non-delivery areas for added costs without changes in outcomes. This is the opposite of value.

Overall costs made higher can actually shrink the local and community investments that can change outcomes in health, education, economics, and other areas. This is seen across federal and state budgets.

2. Increasing Access Can Help Address Cost and Quality for Those Lacking Access as seen in the Homebound Elderly. Access improvement is something that CMS has rejected for 35 years. This would require paying more for generalist and general specialty services and less for procedural, cognitive, subspecialized services – the ones that clearly have volume abuses. The cost overruns are not about basic services. In fact family medicine already has optimal value with lowest payments for the same outcomes.

The new payments will not facilitate the recovery of access - which is about recovery of the workforce and not insurance coverage or method of payment. CMS must redesign 1 trillion rather than distractions of hundreds of millions.

Adding more cost without improving outcomes is what has been done by CMS, medical associations, and academic institutions for decades. Those less organized and those left behind by these designs and those most likely to be serving them (family physicians) have suffered enough.

3. Spending specific to family practice is specific to improving distributions of dollars, jobs, and social determinants where needed - the real determinants of outcomes. This is an indirect rather than a direct impact. It is also due to the population based distribution of family practice.

Population based distributions are best for improving outcomes. Social Security, disability, SNAP, and very few other spending distributions are population based and have value for changing outcomes. It may be difficult for clinically focused to understand beyond short term focus. But long term local investments in child development, housing, nutrition, police, fire, public health, and other spending can make a difference where spending is least and outcomes are worst.

Health spending is what helps to create disparities. Those at the top want to spend less than $10,000 per person, but their misguided efforts to slash costs tend to preserve the low value areas while compromising high value care. The decades of design changes and reforms have not changed inequitable spending as over $29000 per person is spent in 79 top physician concentration counties with 10% of the population with less than $3500 per person spent where 40% of Americans have fallen behind in 2621 lowest physician concentration counties.

Distortions of health, education, and other spending are what help to widen disparities. A few hundred million more for those organized enough to participate in various grants is not specific. The dollars need to go where people and places are least organized. The designers have failed to address this and have worked to preserve spending for those doing best while compromising spending for those left behind.

More spending via family practice is a best vehicle for access improvements and this spending distribution is also optimal for improvements in outcomes over time – but it is not about clinical efforts. It is about the distribution of family practice positions.

4. Family physicians need substantially greater payment and lower costs of delivery to expand team members and resolve access barriers. This is money that CMS and other payers have, but they have not been willing to put this on the table in the past 35 years of designs. A design that sends only 160 billion or 6% of health spending for 55% of services has been made more difficult by higher cost of delivery. This is totally inadequate for access. Even worse, the much greater spending elsewhere contributes to disparities.

Family medicine is the only specialty with the scope, awareness, and distribution to truly impact health outcomes - not necessarily by our care but due to the economic impact of our practices, due to our continuity in community, and due to our organization of community efforts. Numerous state and national Family Physicians of the Year have accomplished far more than decades of AAFP leaders.

Supporting more to be more in more places is what AAFP needs to accomplish. The designers have not paid us enough for the basic care much less support of team members for the higher functions. We need to be paid to stay and develop community connections and continuity with patients, families, communities, and other providers with team members that facilitate all of these functions.

5. Family medicine should return to evidence basis in certification activities, in pay for performance, and in “quality” studies. Even worse is the inability to see through "quality" studies that have numerous flaws - lazy generalizations, more variations within compared subjects than between subjects, apples to oranges failures, and other flaws known for over a 100 years dating back to intelligence testing by race, ethnicity, and gender. http://www.kevinmd.com/blog/2017/01/deadly-risk-treated-male-physician.html Medical error studies, male vs female internists, rural vs urban hospitals, Primary Care Medical Home studies, and others make it look like some clinical intervention will work, but the error studies are in error.

With appropriate critical review, it is possible to see through the distractions to understand what must happen for outcomes changes.

Outcomes can only be changed by changing behaviors, environments, situations, community resources, jobs, social determinants, and child development.

It may appear that higher levels of primary care result in better outcomes, but correlation is not causation. Counties, states, and nations doing better also invest in primary care at higher levels. Those attending the Second Starfield Conference need to understand this as Starfield did in her earliest works.

The US design makes matters even worse as generalist spending is near the lowest in developed nations – matching poor population support. Trying to force primary care to do better with limited support – support that is even more limited where most Americans reside – can only contribute to burnout, declining productivity, turnover, and lack of continuity.

Those who promote clinical interventions or the minimal influence of digital clinical interventions are distracting our nation from real solutions that work to improve outcomes in health, education, economics, and more.

Efforts that do not change outcomes significantly while increasing costs are the opposite of value.

Posted by Robert C. Bowman, M.D. on February 08, 2017 at 01:53 PM CST #

Thank you for your comments Dr. Bowman. It is amazing how willing the AAFP is to drink this sort of bureaucratic kool-aid. It makes one wonder what the real agenda is. Nothing has harmed our specialty more than the bureaucratization that has come at the hands of the federal government for which the AAFP has been a constant and reliable enabler.

The problems of proper data collection and application for quality based payment are inherently huge and are only worsened by poorly designed EHR systems (thanks to the ACA) and ICD-10 which is quite simply a nightmare. Standards of care change yearly and to date CMS has been unable to keep up with them in regard to their standards. Quality standards also uniformly fail to account for unique patient circumstance, noncompliance, regional and economic issues, etc. Thanks to CMS the answer to each of these hurdles is additional bureaucratic burden. This burden is crippling our specialty and driving costs up. It is leading to decreased access to care, office inefficiencies and higher overhead, not to mention provider burnout.

As the AAFP continues to endorse these boondoggles from their politically driven ivory tower thrones they continue to harm their members and our specialty.

There has to be a sea change in family medicine if we are to survive and thrive. So far, the AAFP has shown itself to be part of the problem, not the solution.

Posted by George T. Barron, MD on February 09, 2017 at 08:22 AM CST #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.