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...