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Enhanced Payment Opportunities Under Recently Announced CMS Primary Care Initiative

Primary care physicians in New York’s Capital District and Hudson Valley region may be eligible to receive enhanced payments from Medicare and from certain private payers for participating in Medicare’s recently announced Comprehensive Primary Care Initiative (CPCI) demonstration.

Physicians in the following counties are eligible for the program:  Albany, Columbia, Duchess, Greene, Orange, Putnam, Rensselaer, Rockland, Schenectady, Sullivan, Ulster and Westchester.

Under the CPCI, participating primary care practices will be eligible to receive a per member per month (PMPM) care management fee, in addition to regular Medicare fee-for-service reimbursement.  Private payers may also pay participating providers an additional care management fee or provide support to participating practices in the form of embedded care managers. 

The CPCI demonstration will take place in seven different markets across the country.  New York’s Capital District/Hudson Valley Region is among the seven regions selected by CMS. On June 6, Aetna, CDPHP, Empire, Hudson Health Plan, MVP, and the Teamster’s Multi-Employer Plan all agreed to participate in the CPCI program.  CMS estimates that approximately 75 primary care practices in each of the seven regions will be selected to participate.  CMS will favor practices that are already participating in similar initiatives with private payers and that have begun to transform their practices to a medical home model. 

CMS’s care management fee will be risk adjusted and will range from $8 to $40 PMPM.  CMS estimates that during the first two years of the program the average PMPM care management fee will be $20.  The average fee is estimated to drop to $15 in Years 3 and 4 of the program.  Practices will be free to choose how they use the care management payments; however, they must invest the additional payments to support the five comprehensive primary care functions described below.  Starting in Year 3, participating primary care physicians may also be eligible to participate in shared savings generated within their market. To be eligible to receive shared savings, participating groups will be required to meet certain core quality measures.  Key measures will include patient satisfaction, preventive health, care coordination, and practice transformation. Because the CPCI is considered a “shared savings” program under the Affordable Care Act, participating physicians would be ineligible to simultaneously participate in Medicare’s Shared Savings Program (ACOs). 

To be eligible to participate in the CPCI, primary care practices must receive 60% of their total revenues from one or more of the payers listed above.  Participating primary care practices will sign participation agreements with both CMS and one or more of the above payers.

Other key eligibility criteria include the following:

  • Primary Care Practices.  Participation in the CPCI is limited to primary care practices.  The practice must be led by a board-certified general practitioner, internist, family practitioner, geriatrician or certified nurse practitioner, and must be composed predominantly of primary care providers.  The group must also predominantly provide primary care services.  This requirement is likely to limit the number of hospital-affiliated practices participating in the CPCI, since most tend to be multi-specialty practices.
  • Locale.  The primary care practice must be geographically located within one of the above counties.
  • HCFA 1500.  Only practices that submit claims on the HFCA 1500 form are eligible to participate in the program.  Entities such as Federally Qualified Health Centers (which submit claims based on cost) are not eligible to participate.
  • 200 Medicare Patients.  The primary care practice must have at least 200 non-hospitalized Medicare beneficiaries in its patient panel in order to participate in the CPCI.  Medicare must be the primary payer for each of these beneficiaries.  As with the Medicare Shared Savings Program, Medicare beneficiaries will be assigned to PCPs based on where each patient receives the plurality of primary care services.  Due to the patient assignment methodology, participating physicians can only participate through one primary care group.
  • EHR.  The primary care practice must use an electronic health record (HER) or electronic registry.  CMS has indicated that it will give preference to applicants who have already achieved Stage 1 Meaningful Use for their EHR systems.   
  • 5 Primary Care Functions.  Primary care physicians wishing to participate in the CPCI must commit to the following five functions, which CMS has identified as the foundation for comprehensive primary care:  1. Risk-stratified care management; 2. Increased access and continuity of care; 3. Care management for patients with chronic conditions and preventive care; 4. Patient and care-giver engagement; and 5. Coordination of care across the care continuum.  

Practices wishing to participate must complete the Application Pre-Screening Tool on CMS’s CPCI website:  CMS will only allow practices that agree to meet the criteria in the pre-screening process to submit applications.  Final selection criteria and applications have not yet been completed by CMS. 

Applicants have until July 20, 2012 to complete and submit the Application Pre-Screening Tool.

© 2020 Faegre Drinker Biddle & Reath LLP. All Rights Reserved.National Law Review, Volume II, Number 168


About this Author

The Health Care Practice Group has represented the health care industry for more than 90 years, and we currently maintain one of the largest national practices in the representation of health care organizations. Our practice serves clients nationwide and our health care lawyers have in-depth knowledge of this complex, highly regulated industry and the rapidly changing issues that impact the various sectors of the health care industry (including providers, health care vendors, health professional...