Allowing physicians to participate in both could eliminate an ACO disincentive and boost both initiatives, according to some observers.

May 27—Amid concerns that a new Medicare primary care payment model could steer physicians away from accountable care organizations, up to 1,500 practices will be allowed to participate in both, the Centers for Medicare & Medicaid Services (CMS) decided Friday.

In an emailed announcement, CMS said it will allow up to 1,500 eligible primary care practices currently participating or applying to participate in Tracks 1, 2, or 3 of the Medicare Shared Savings Program (MSSP) as of Jan. 1, 2017, to also participate in the comprehensive primary care plus (CPC+) model. The change was based on stakeholder requests, according to the email.

CMS in April announced CPC+, a voluntary multi-payer primary care payment model, for up to 5,000 practices and more than 20,000 clinicians. The five-year model aims to build on the Comprehensive Primary Care initiative, which is slated to finish at the end of this year and was limited to seven regions. CPC+ will use either monthly payments or advanced prepayments to incentivize certain primary care approaches, such as supporting patients with serious or chronic diseases to achieve their health goals; providing 24-hour access to care and health information; delivering preventive care; and coordinating care with hospitals and other clinicians, including specialists.

The updated policy will allow practices participating in MSSP to participate in either track of CPC+.

ACO Impacts

The change followed warnings by some observers that the new model could create disincentives for physicians to join or stay in ACOs.

“Since it will take some time to sort out the specific opportunities for primary care practices, the CPC+ program will also necessitate a slowdown in the decision-making process for primary care providers and deter enrollment and growth of physician-led ACOs in 2017—not only in selected regions, but more broadly due to uncertainty about the regions and practices selected,” wrote Bob Kocher, MD, a senior fellow at the Schaeffer Center for Health Policy and Economics at USC, and colleagues.

Kocher said in emailed responses to questions that ACOs could benefit from staying in MSSP and augmenting their care model with care coordination supported by CPC+.  

“We think this combination has the potential to improve quality, lower costs, and improve cash flows for doctors since savings take a long time to be realized,” Kocher wrote.

The concern that CPC+ could pull away ACO physicians was echoed by the National Association of ACOs (NAACOS), which noted that only a quarter of 2014 ACOs earned shared savings.

“Given the option of pursuing uncertain shared savings through MSSP or receiving comparable guaranteed payments through CPC+ as well as additional payments under this program, we are deeply concerned many will choose the latter,” Clif Gaus, president and CEO of NAACOS, wrote in a letter to CMS.

Additionally, the change addressed concerns that the CPC+ program in the short term would discourage physician practices from moving from Track 1 to ACO tiers with downside risk because they would be focused on understanding CPC+, Kocher wrote.

However, the policy change appears unlikely to address concerns raised by 56 percent of Medicare ACOs in a recent survey that they may leave the MSSP—which includes the vast majority of Medicare ACOs—due to proposed rules implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The MACRA rules do not allow MSSP Track 1 ACOs, which make up 95 percent of the 434 MSSP ACOs, to qualify as designated alternative payment models (APMs), which would provide their physicians with 5 percent annual bonuses under Medicare.

Although the CPC+ program is among the qualifying APMs under MACRA , the CMS FAQoutlining the ACO and CPC+ combination specified that CPC+ physicians dually enrolled in MSSP Track 1 would not qualify as part of an APM under MACRA.

Combined Benefits

In addition to eliminating an incentive for ACO physicians to depart the MSSP, allowing physicians to participate in both programs may provide benefits for each.

For instance, the fee restructuring included in CPC+ “would be very helpful for physician-led ACOs,” Kocher and colleagues wrote. The enhanced per member, per month (PMPM) and patient support fees provided in CPC+ would give the practices the advance resources they need to implement reforms in their practices to achieve population-level health improvements and Medicare spending reductions.

And the combination could incentivize CPC+ practices to achieve the savings some doubt will occur among practices participating only in CPC+, which offers no specific incentive to lower the total cost of care. (If the CPC+ program increases the total cost of care, healthcare costs for beneficiaries, and total Medicare spending, it would be terminated in accordance with Medicare regulations.)

“We believe the CPC+ program would gain substantially more adoption, have a greater impact on lowering total cost of care, and accelerate the [Obama] Administration’s policy of moving to value-based care if primacy care practices in existing and new Medicare ACOs were allowed to participate in CPC+,” Gaus wrote.

Evidence from the Massachusetts Blue Cross Alternative Quality Contract and other private-sector payment reforms have suggested that a combination of care management fees and capitated primary care with shared savings (instead of performance-based payments) will be more successful at reducing spending while improving quality, according to Kocher and colleagues.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C. office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, May 27, 2016