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Transcript of CPC+ PAYMENT METHODOLOGIES: BENEFICIARY · PDF file CPC Comprehensive Primary Care . CPC+...

Center for Medicare & Medicaid Innovation U.S. Department of Health & Human Services

CPC+ PAYMENT METHODOLOGIES: BENEFICIARY ATTRIBUTION, CARE MANAGEMENT FEE, PERFORMANCE-BASED INCENTIVE PAYMENT, AND PAYMENT UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE FOR PROGRAM YEAR 2018

Version 1 December 1, 2017

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

Table of Contents Acronyms ................................................................................................................................... viExecutive Summary ................................................................................................................... 1Chapter 1: Introduction ..............................................................................................................13

1.1 CPC+ Payment Design Overview ...............................................................................131.2 CPC+ Payment Elements ...........................................................................................13

Chapter 2: Beneficiary Attribution ..............................................................................................172.1 Attribution ...................................................................................................................172.2 Eligible Beneficiaries ..................................................................................................182.3 Eligible Visits ..............................................................................................................192.4 Attribution Methodology ..............................................................................................21

2.4.1 Attribution Based on CCM-Related Billings .....................................................222.4.2 Attribution Based on Annual Wellness Visits or Welcome to Medicare Visits ..222.4.3 Attribution Based on Plurality ..........................................................................22

Chapter 3: Care Management Fee ............................................................................................253.1 Risk Scores and Risk Tiers .........................................................................................25

3.1.1 CMS-HCC Risk Scores ...................................................................................263.1.2 Setting the Risk Tier Thresholds .....................................................................26

3.2 Assigning Risk Tiers ...................................................................................................273.2.1 Assigning Risk Tiers 15 Based on Risk Score ...............................................273.2.2 Assigning Risk Tier 5 Based on Dementia Diagnosis (Track 2 Only) ...............28

3.3 Retrospective Debits ..................................................................................................293.3.1 Debits for Beneficiary Ineligibility .....................................................................293.3.2 Debits for Duplication of Services....................................................................30

3.4 Risk Score Growth and CMF Cap ...............................................................................30Chapter 4: Performance-Based Incentive Payment ...................................................................33

4.1 Design Principles and General Features.....................................................................334.1.1 Principles of Design ........................................................................................334.1.2 Prospective Payment ......................................................................................344.1.3 Transparency of Performance Goals ...............................................................354.1.4 Incentive Structure ..........................................................................................354.1.5 Incentive Payment Components......................................................................364.1.6 Incentive Payment Amounts ............................................................................37

4.2 Quality Component .....................................................................................................38

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

4.2.1 CAHPS Measurement .....................................................................................384.2.2 eCQM Measurement .......................................................................................39

4.3 Utilization Component.................................................................................................394.4 Calculation of Performance Scores.............................................................................40

4.4.1 Calculation of Quality Performance Score .......................................................424.4.2 Calculation of Utilization Performance Score ..................................................45

4.5 Benchmarking Overview .............................................................................................464.5.1 Data Source for Benchmarking .......................................................................474.5.2 Benchmarking Methods ..................................................................................494.5.3 Benchmark Results .........................................................................................52

4.6 Illustrative Example of Performance Incentive Retained .............................................534.6.1 Calculation of Performance Incentive Retained for Quality Component...........534.6.2 Calculation of Performance Incentive Retained for Utilization Component ......544.6.3 Calculation of Performance Incentive Retained ...............................................55

Chapter 5: Payment under the Medicare Physician Fee Schedule ............................................585.1 Purpose and Intent .....................................................................................................58

5.1.1 Purpose and Aims ...........................................................................................585.1.2 Payment Choices by Year ...............................................................................595.1.3 Implications of CPCP for Practices and Beneficiaries ......................................60

5.2 Historical PBPM ..........................................................................................................605.2.1 Historical Population and Eligibility ..................................................................615.2.2 Historical Payments ........................................................................................615.2.3 Example Practice IllustrationMain Street CPC .............................................62

5.3 CPCP Program Year Calculation ................................................................................625.3.1 Comprehensiveness Supplement ....................................................................625.3.2 Physician Fee Schedule (PFS) Updates and Revaluation Changes ................625.3.3 Adjusted Historical PBPM ...............................................................................635.3.4 Calculation for Main Street CPC......................................................................635.3.5 Frequency of CPCP Calculation and Payment ................................................635.3.6 Debits for Beneficiary Ineligibility .....................................................................66

5.4 FFS Reduction............................................................................................................675.4.1 FFS Calculation for Main Street CPC ..............................................................67

5.5 Partial Reconciliation ..................................................................................................67Chapter 6: Conclusions .............................................................................................................73References ...............................................................................................................................75

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

Appendices Appendix A: Glossary of Terms ................................................................................................. 77Appendix B: Primary Care Specialty Codes .............................................................................. 85Appendix C: Description of CMS-HCC Risk Adjustment Model ................................................. 87Appendix D: Risk Tier Thresholds for First and Second Quarters in 2018 ................................. 89Appendix E: CAHPS Measure Survey Questions ...................................................................... 91Appendix F: CPC+ eCQM SetProgram Year 2018 ................................................................ 93Appendix G: Utilization Measure Technical Specifications ........................................................ 95Appendix H: eCQM Tracking Worksheet ................................................................................. 109Appendix I: Evaluation and Management (E&M) Claims in Hybrid Payment ........................... 111

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation

List of Figures Figure 2-1 What Is a Look Back Period? ................................................................................... 18Figure 2-2 Which Beneficiaries Are Attributed to My Practice? .................................................. 23Figure 3-1 Beneficiary Risk Tie