August 9, 2020

Volume X, Number 222

August 07, 2020

Subscribe to Latest Legal News and Analysis

August 06, 2020

Subscribe to Latest Legal News and Analysis

CMS Announces Latest Alternative Payment Model - Comprehensive Primary Care Plus

Continuing in its efforts to promote alternative payment models, on April 11, 2016, CMS announced the Comprehensive Primary Care Plus (CPC+) model. CMS hopes to implement CPC+ in up to 20 regions, accommodating up to 5,000 practices, which would potentially encompass more than 20,000 doctors and clinicians and the 25 million people they serve. The model requires the participation of multiple payers, whose participation will be solicited in addition to individual practices. According to CMS, the initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care. The CPC+ model is a 5 year model, expected to begin January 1, 2017. The model builds on the Comprehensive Primary Care initiative launched by CMS in late 2012 that ends at the end of this year.

The CPC+ is another alternative payment and delivery model that is designed to improve the quality of care patients receive, improve patients’ health, and spend health care dollars more wisely. Utilizing primary care medical home concepts, the CPC+ model focuses on five key primary care functions:

  • Access and Continuity;

  • Care Management;

  • Comprehensiveness and Coordination;

  • Patient and Caregiver Engagement;

  • and Planned Care and Population Health.

Participation and Payment

The CPC+ model is an advanced medical home model that CMS hopes will strengthen primary care through a regionally-based multi-payer payment reform and care delivery transformation. Primary care practices may apply to participate in one of two tracks. Track 1 is designed for practices that are prepared to build capabilities to deliver comprehensive primary care. In Track 1, CMS will pay practices a monthly care management fee (an average of $15 per beneficiary per month (pbpm) in addition to the regular fee-for-service payments under the Medicare Physician Fee Schedule for the practices’ services. Track 2 is for primary care practices ready to increase comprehensiveness of care through enhanced Health IT, to focus on improvements to care of patients with complex needs and with the resources to meet patients’ psychosocial needs. Track 2 applicants must submit a letter of support from their IT vendor. In Track 2, practices will also receive a monthly care management fee (an average of $28 pbpm but up to $100 pbpm for patients with complex needs) and, instead of full Medicare fee-for-service payments for Evaluation and Management services, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services. This hybrid payment design will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter.

Applicants in both tracks must have support from multiple payers willing to partner in the CPC+ model.

To promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments ($2.50 pbpm for Track 1 and $4.00 pbpm for Track 2) that they will either keep or repay based on their performance on quality and utilization metrics. The payments under this model are intended to encourage doctors to focus on health outcomes rather than the volume of visits or tests.

Key Components to the Advanced Primary Care Model

The key components of the advanced primary care model featured in the CPC+ are:

  • Services are accessible, responsive to an individual’s preference, and patients can take advantage of enhanced in-person hours and 24/7 telephone or electronic access.

  • Patients at highest risk receive proactive, relationship-based care management services to improve outcomes.

  • Care is comprehensive and practices can meet the majority of each individual’s physical and mental health care needs, including prevention. Care is also coordinated across the health care system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits.

  • It is patient-centered, recognizing that patients and family members are core members of the care team, and actively engages patients to design care that best meets their needs.

  • Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements in care and to develop new capabilities.

RFA Process and Participant Selection

CMS will select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative. CMS will accept payer proposals to partner in CPC+ from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016. The initial request for applications is available here.


CMS continues to test a variety of alternative payment and delivery models. The CPC+ model is the latest with its focus on delivery of comprehensive primary care.

© 2020 Foley & Lardner LLPNational Law Review, Volume VI, Number 110


About this Author

C. Frederick Geilfuss II, Health Care Attorney, Foley Lardner Law Firm

C. Frederick Geilfuss II is a partner and health care lawyer with Foley & Lardner LLP. Mr. Geilfuss counsels health systems, hospitals, medical clinics, rehabilitation agencies, nursing homes, and other health care providers on general operational concerns, regulatory and business matters. He has many years of experience in health care acquisitions, integrated delivery service issues, managed care contracting, defense of providers against government enforcement actions, finance, real estate, administrative and medical staff issues, physician recruitment, fraud and...

Alexis Bortniker, Health Care Attorney, Foley Lardner Law Firm

Alexis Bortniker is a senior counsel and health care lawyer with Foley & Lardner LLP. Her practice focuses on transactional and regulatory matters with an emphasis on counseling health systems, hospitals, and other providers in managed care and physician contracting. Ms. Bortniker is a member of the firm’s Health Care Industry Team.

Previously, Ms. Bortniker was an associate with Choate Hall & Stewart LLP where she gained experience working directly with health care organizations on regulatory and corporate compliance issues, including the development of internal policies and procedures and the review of contracts and employment relationships.