Independent Evaluation of CPC+ and Implications for the Future

November 18, 2021

With gratitude to Nancy McCall • Dana Jean-Baptiste • Ha Tu • Kristin Geonnotti • Rosalind Keith • Dana Petersen • Kaylyn Swankoski • Sean Orzol • Deborah Peikes • Stacy Dale • Eunhae G. Oh

CPC+ Fall Virtual SummitShannon Heitkamp, Pragya Singh, Ann O’Malley

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The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

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Agenda1. Overview of Mathematica’s Evaluation (Shannon Heitkamp)2. Key Payment Lessons From PY 1 to PY 4 (Shannon Heitkamp)3. Findings in Primary Care Participation in Transformation Models (Pragya Singh) 4. Discussion (Ann O’Malley)

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1. OVERVIEW OF MATHEMATICA’S EVALUATION

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This presentation covers Mathematica’s findings from the past 4 Program Years (PYs).

Simplified logic model for the CPC+ evaluation:

Contextual factors outside of CPC+ also influence practice transformation and

related outcomes.

CMS engages payers,

practices, and health IT

vendors in CPC+.

CPC+ provides support to practices.

Practices use support to

make changes in care delivery.

Ultimately, changes are expected to

improve outcomes.

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This presentation covers Mathematica’s findings from the past 4 PYs.

Contextual factors outside of CPC+ also influence practice transformation and

related outcomes.

CMS engages payers,

practices, and health IT

vendors in CPC+.

CPC+ provides support to practices.

Practices use support to

make changes in care delivery.

Ultimately, changes are expected to

improve outcomes.

Our focus today Simplified logic model for the CPC+ evaluation:

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2. KEY PAYMENT LESSONS FROM PY 1 TO PY 4

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Availability of CPC+ payment support from CMS and payer partners in PY 4.

Enhanced payments, made in addition to payments for services, consist of:

1. Payments for CPC+ Participation‒ Mostly care management fees (CMFs)

2. Payments for practice participation‒ E.g., pay for performance (P4P),

shared savings payments

CMS’s supports for CPC+ practices Percentage of payer partners offering support

Enhanced payment 100%

Alternative to FFS payment: 16%

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Practices received substantial enhanced payments, mostly for participating in CPC+.

Sources: PY 4 practice-reported financial data submitted to CMS and PY 4 payment data provided by CMS.

10%

90%

15%

85% Payments forperformance

Payments forparticipation

• $521,671 for Track 1

• $1,081,464 for Track 2

Cumulative median payments from 2017 to 2020

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Not all enhanced payments were unique to CPC+.

Sources: PY 4 practice-reported financial data submitted to CMS; PY 4 payment data provided by CMS; PY 4 CPC+ Payer Survey data.

Proportion of enhanced payments unique to CPC+ (available only to CPC+ practices) in PY 4

Unique to CPC+, 60%

Not unique to

CPC+, 40%

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Unique to CPC+, 60%

Not unique to

CPC+, 40%

Proportion of unique payments provided by CMS vs. payer partners in PY 4

From payer partners, 4%

From CMS, 96%

Sources: PY 4 practice-reported financial data submitted to CMS; PY 4 payment data provided by CMS; PY 4 CPC+ Payer Survey data.

Not all enhanced payments were unique to CPC+.

Proportion of enhanced payments unique to CPC+ (available only to CPC+ practices) in PY 4

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Few payer partners offered payments that moved away from fee-for-service (FFS) in CPC+.

• CMS’s goal: By PY 2, all payer partners would have implemented an alternative to FFS payments.

- Payer partners have fallen far short of this goal.

• Besides CMS, only 16% of payer partners used an alternative to FFS payments.- The same 8 payer partners have been providing alternative to FFS payments since PY 1.- Most of these approaches pre-dated CPC+.- All together, less than 1 in 5 of all patients in Track 2 practices were covered by alternative

payments.

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Track 2 practices’ progress in moving away from FFS.

Reject premise of moving away from FFS or confused by it

Full capitation

Enthusiastic about moving away from FFS

Accept premise of moving away from FFS

but struggle to implement

Pure FFS

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Practices rated CMFs as the most useful CPC+ payment support by far.

CMFs provide a large, stable, prospectively-paid funding source.

CMFs are a primary funding source to pay salaries of key staff, including:

- Care managers/care coordinators - Behavioral health providers

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Considerations for Primary Care First (PCF)

• Most practices in CPC+ had limited experience and/or ambivalent views of alternative payments.

- CPC+ practices that join PCF might need support in transitioning to accepting alternative payments.

• Practices continue to cite CMFs as a key component to making CPC+ care delivery changes.

- CPC+ practices in PCF will have to adapt to not receiving CMFs.

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Questions?

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3. FINDINGS ON PRIMARY CARE PARTICIPATION IN TRANSFORMATION MODELS

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Goal of the analysis

• Practices and patients not participating in cutting-edge transformation models could be left behind.

• Studying participation patterns in existing Innovation Center models can inform future model design and outreach strategies needed to attract a diverse set of practices.

• We analyze participation rates in CPC+ and how CPC+ practices differ from other primary care practices in CPC+ regions. We also examine how practices that left CPC+ differ from practices that continue to participate.

• We used a unique data set on all primary care practices in CPC+ regions assembled from IQVIA’s (a commercial health care data vendor) rosters of primary care practices and data from multiple sources on practice, patient, and county characteristics.

-- All primary care practices in CPC+ regions Applicants Participants

Participation rates in CPC+ 100%(19,809)

22%(4,366)

15%(3,051)

Percentage owned by a hospital or health system 32% 51% 54%

Percentage of practices that have:

6+ PCPs

3‒5 PCPs

1‒2 PCPs

Participation in prior primary care transformation initiatives 26% 54% 61%

Percentage of beneficiaries who are dually eligible for Medicare and Medicaid 22% 17% 15%

Average risk score of Medicare FFS beneficiaries

Average monthly expenditures per Medicare FFS beneficiary

CPC+ practices were diverse but were not representative of all primary care practices.

1.15 1.12 1.10

$975 $902 $882

12%25%

63%

23%36%

41%

27%

37%36%

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Track 2 CPC+ practices were larger and substantially more likely than Track 1 practices to have had prior primary care transformation experience.

Characteristic Track 2 Track 1

Median number of primary care practitioners 4.0 3.0

Prior transformation experience 73% 48%

At least one practitioner with meaningful use 93% 87%

Located in an urban area 80% 72%

-- Practices that voluntarily withdrew from CPC+ or were

terminated by CMS

Practices that remained in CPC+ as of

December 30, 2020

Number of practices 151 2,599

Owned by a hospital or health system 31%*** 56%

Percentage of practices that have:

6+ PCPs

3–5 PCPs

1–2 PCPs

Participated in prior primary care transformation initiatives 37%*** 63%

CPC+ funding from CMS and other payers in PY1, per practice (median)

► Track 1

► Track 2

Percentage of beneficiaries dually eligible 18%*** 14%

Average risk score of Medicare FFS beneficiaries ***

Average monthly expenditures per Medicare FFS beneficiary

$51,574***

Practices that left CPC+ were different from those that stayed.

*** Difference between this group of practices and the practices that remained in CPC+ was statistically significant at the 0.01 level.

$92,508

$132,937*** $208,276

$946*** $879

1.18 1.10

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Other related studies point to similar conclusions: less-resourced practices are less likely to participate.• Fraze et al., 2018

- Compare populations served in Hospital Service Areas (HSAs) with and without CPC+ practices.

- Practices located in wealthier areas with higher education levels and less use of inpatient services were more likely to join.

• Adler-Milstein et al., 2021 - Examine longitudinal participation in delivery and payment reform among U.S. primary

care organizations.- Participation rates in Medicare and Medicaid Meaningful Use (MU), Medicare Shared

Savings Program Accountable Care Organization (MSSP ACO), and the National Committee for Quality Assurance’s (NCQA) Patient Centered Medical Home (PCMH), are low, and even lower for less-resourced practices. Multi-program participation is also low.

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Implications • Some practices (and the populations they serve) could be left behind if they are

less likely to participate in voluntary models, and if such care delivery and value-based payment models prove to have meaningful effects.

• Understanding the reasons for low participation among less-resourced practices and designing models and outreach strategies that attract a diverse set of providers are crucial.

• Small and independent practices may face increased pressure to join hospital-anchored systems that can provide more support and infrastructure for participation in these programs. The resulting vertical integration could lead to increased total costs of care.

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Need to broaden practice engagement efforts and design models and outreach strategies.

• The differences between Track 1 and Track 2 CPC+ practices suggest that even within the same model, it may be possible to offer different packages of incentives and requirements to get a more diverse set of practices to participate in new models.

• Additional financial incentives for serving more disadvantaged patients could attract practices who serve a higher proportion of them.

• Certain programs could be designed to prepare practices to meet the eligibility requirements of transformation models and successfully participate in value-based payment arrangements and improve quality of care.

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Discussion

We want to hear from you.

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Discussion

What is the most important feature of primary care transformation models going forward?

How could CMS make primary care models more feasible for small and independent or less-resourced primary care practices?

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