Comprehensive Primary Care Plus (CPC+) Overview
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The Physicians Advocacy Institute’s
Medicare Quality Payment Program (QPP)
Physician Education Initiative
Comprehensive Primary Care Plus
(CPC+) Overview
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© 2021 Physicians Advocacy Institute
www.physiciansadvocacyinsitute.org
Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus
MEDICARE QPP PHYSICIAN EDUCATION INITIATIVE
Comprehensive Primary Care Plus (CPC+) Overview
An Advanced Alternative Payment Model (APM) is one of two pathways physicians can choose
under the Quality Payment Program (QPP), which was established as part of the Medicare Access
and CHIP Reauthorization Act (MACRA). Under the Advanced APM pathway, physicians may be
exempt from participation in the Merit-based Incentive Payment System (MIPS) and be eligible to
receive a 5% incentive payment. For successful participation in an Advanced APM, physicians need
to consider three core building blocks:
Understanding the Understanding the
Understanding the
variables and rules relevant QPP rules
basic principles of
impacting performance relating to participation
population health
under specific thresholds and
models
Advanced APMs requirements
This resource focuses on the second of these three building blocks: understanding the variables
and rules impacting performance under specific Advanced APMs, specifically the Comprehensive
Primary Care Plus (CPC+) model. While CPC+ is a two-part model and engages with payers outside
of Medicare, the focus of this overview is on the Medicare component of the model for the QPP
Advanced APM pathway.
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© 2021 Physicians Advocacy Institute
www.physiciansadvocacyinsitute.org
Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus
In 2021, CPC+ operates in 18 different regions and is supported by 55 aligned payers across the
United States, with 2,737 participating primary care practices. There are two rounds of the model:
Round 1, which began January 2017, and Round 2, which began January 2018. Both rounds last
for 5 years and practices are expected to participate for the full length of time but have the right
to withdraw from the model without penalty. Additional details and resources are available on the
CMMI CPC+ website.
Goal of CPC+
The goal of the CPC+ model is to “strengthen primary care through a regionally-based multi-payer
payment reform and care delivery transformation.” CPC+ payment designs provide practices with
the financial resources and flexibility needed to make investments that will improve the quality of
care and reduce the number of unnecessary services their patients receive. The delivery of care
will focus on 5 key comprehensive primary care functions:
Comprehensive Primary Care
Functions
1.Access and Continuity
2.Care Management
3.Comprehensiveness and Coordination
4.Patient and Caregiver Engagement
5.Planned Care and Population Health
Additional information and details on the Comprehensive Primary Care Functions can be found in
the following CMS resource: CPC+ Practice Care Delivery Requirements.
Application Process
Practices may no longer submit applications for Round 1 and Round 2 of the demonstration.
However, both Rounds of the demonstration are still operational and physicians may join practices
in either round by reviewing the list of participating practices. For those interested, a sample of
the application form physician practices previously submitted can be found in Appendix B of the
Request for Application (RFA) for Round 2.
Beneficiary Attribution and Alignment
Eligible patients are attributed either through voluntary alignment or based on claims data.
Voluntary alignment is when a patient identifies with a specific primary care physician/practice.
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© 2021 Physicians Advocacy Institute
www.physiciansadvocacyinsitute.org
Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus
The patient must log on to MyMedicare.gov and attest to a primary care physician/practice.
Voluntary alignment trumps claims-based assignment and is assessed on a quarterly basis.
Attribution Quarter Attestation Cut-Off Date
2021 Q1 October 1, 2020
2021 Q2 January 1, 2021
2021 Q3 April 1, 2021
2021 Q4 July 1, 2021
Patients not attributed under voluntary alignment are then attributed using a 3-step claims-based
process: 1
• Step 1: if the most recent primary care visit is for chronic care management (CCM)-related
services, then a patient will be attributed to the primary care provider/practice that billed
for that service.
• Step 2: those patients not attributed under Step 1 will then be attributed, if applicable,
based on who billed for the most recent Annual Wellness Visit or Welcome to Medicare
Visit.
• Step 3: those patients not attributed under Steps 1 and 2 will be attributed based on who
billed for a plurality of primary care visits.
Attribution is assessed on a quarterly basis with a 24-month lookback period that ends 3 months
prior to the start of the quarter.
Attribution Quarter Lookback Period
2021 Q1 October 2018 – September 2020
2021 Q2 January 2019 – December 2020
2021 Q3 April 2019 – March 2021
2021 Q4 July 2019 – June 2021
Round 1 vs Round 2
Overall, the features of the CPC+ model are structured similarly across Round 1 and Round 2.
However, it is important to note one key difference: Round 2 includes a “comparison group,”
1
Note: a patient could be attributed to a non-CPC+ practice/provider using claims-based attribution.
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© 2021 Physicians Advocacy Institute
www.physiciansadvocacyinsitute.org
Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-pluswhich is not included in Round 1. In Round 2, practices are randomly assigned to either the
intervention group or the comparison group (also known as the control group).
The intervention group practices are expected to implement the care delivery functions and
practices outlined in this document, and they will receive the CPC+ payments outlined below.
The comparison group will be used as a control group to validate the results of the evaluation of
the CPC+ model. These practices are not expected to implement care delivery practice changes,
nor will they receive the CPC+ payments outlined below. Instead, comparison group practices will
receive an annual flat fee of $5,000 for their participation in CPC+ evaluation-related activities.
Those in the comparison group will also not be considered participants in an Advanced APM
(however, they could be considered Advanced APM participants through their participation in
other CMS models or programs). However, these practices would be scored according to the MIPS
APM scoring methodology (discussed in detail below).
Payment Mechanisms
CPC+ contains a 3-part payment mechanism, depending on the Track.
Care •This is a non-visit based fee paid per beneficiary per month (PBPM)
management fee risk-adjusted for each practice to account for intensity of care
(CMF) management services for the practice’s population
Performance- •A prospective payment with retrospective reconciliation based on
based incentive performance in patient experience of care, clinical quality, and
payment (PBIP) cost/utilization measures
Payment under •Under Track 1 this is the fee-for-service (FFS) payment as normal.
the Medicare Under Track 2 this is a hybrid FFS and prospective comprehensive
primary care payment (CPCP) that focuses on converting FFS dollars
physician fee to upfront payments to allow for flexibility in how and where the
schedule patients are managed
Each of these three components is explained in further detail below.
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© 2021 Physicians Advocacy Institute
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Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plusCare Management Fee (CMF)
The CMF is a monthly, risk-adjusted payment to support the overall goal of the model. This
payment is further enhanced under Track 2 to support the care of more complex patients.
Additionally, Track 2 practices are eligible for payments of up to $100 per beneficiary per month
(PBPM) to support the care of patients who fall under the highest risk categories and/or have
dementia. The table below summarizes the payments under different risk tiers for both tracks
which is based on the CMS Hierarchical Condition Categories (HCC) risk adjustment model.
Care Management Fee Summary
Performance-based Incentive Payment (PBIP)
The PBIP is a prospectively paid and retrospectively reconciled payment based on how well the
practice performs on quality measurements (discussed in additional detail below). Prospective
means that CMS will initially pay a practice under the assumption that it will meet a certain
threshold under the quality measure evaluation. Retrospectively reconciled means that if a
practice ultimately does not meet this threshold, the practice will need to pay back a certain
amount of the initial payment. The PBIP has two parts: a utilization portion and a quality portion.
Overall, Track 2 provides an enhanced payment as compared to Track 1 as shown in the table.
CPC+ Performance-Based Incentive Payment
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© 2021 Physicians Advocacy Institute
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Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plusPayments Under the Medicare Physician Fee Schedule
Track 1 practices will continue to bill and receive payments from FFS Medicare as usual. However,
Track 2 practices will receive a combination of payments from FFS Medicare and Comprehensive
Primary Care Payments (CPCP), which are paid upfront, per beneficiary, in a lump sum on a
quarterly basis. These payments will only apply to E&M office visits codes.
The CPCP portion of the payment will be calculated based on the practice’s historical E&M services
for the attributed Medicare patients with an inflation factor of 10%.
Overall, the hybrid payment will either be 40% upfront and 60% of the applicable FFS payment, or
65% upfront and 35% of the applicable FFS payment. CMS has built in a gradual transition period
to either of these combinations. The combination of CPCP and FFS payments available to Track 2
participants each year are summarized below.
Track 2 CPCP and FFS Options
Additional information on the CPC+ payment structure can be found in the following resource:
CPC+ Payment Methodology Paper.
Quality Measurement
CPC+ has a series of quality measure reporting requirements that include electronic clinical quality
measures (eCQMs), patient experience of care measures, and utilization measures.
• Track 1 and 2 practices are required to annually report on the practice-level eCQMs found
in the Quality Measure Reporting Overview document.
• The patient experience of care measures are a combination of Clinician and Group
Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) survey and the
Patient-Centered Medical Home Survey Supplement items. A CMS contractor fields the
patient experience of care survey.
• CMS uses two utilization measures for CPC+: emergency department utilization (EDU) and
acute hospital utilization (AHU).
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© 2021 Physicians Advocacy Institute
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Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plusCPC+ Practices and the Quality Payment Program
Under the QPP, CPC+ practices participating in Round 1 and those participating in the intervention
group of Round 2 are considered to be participating in an Advanced APM. 2 Physicians and other
eligible clinicians 3 on the Participant List for these practices can receive one of three Advanced
APM determinations for their participation.
Qualifying Advanced APM Partially Qualifying Advanced
Neither a QP or PQ
Participant (QP) APM Participant (PQ)
•Eligible to receive a 5% •Not eligible to receive a 5% •Subject to MIPS participation
incentive payment incentive payment using the APP or other MIPS
•Exempt from MIPS •Exempt from MIPS reporting methods
(however, the APM Entity
could elect to participate in
MIPS using the APM
Performance Pathway (APP)
or other MIPS reporting
methods and be eligible to
receive a positive payment
adjustment)
While the QP/PQ determinations apply at the individual level, they are determined at the APM
Entity level, in this case the CPC+ practice level. All physicians and other eligible clinicians on the
practice’s Participant List must collectively meet the thresholds for becoming a QP or PQ. Unlike
QPs, PQs would not be eligible to receive a 5% incentive payment for their participation, but they
would be exempt from MIPS participation. However, the practice may elect to participate in MIPS
using the APP. Under the APP, all physicians and other eligible clinicians in the practice would be
evaluated as a group in three of the four MIPS categories: quality would be 50% of the MIPS score,
promoting interoperability would be 30%, and improvement activities would be 20%. The
Improvement Activities performance category score will be automatically assigned based on the
requirements of the MIPS APM in which the MIPS eligible clinician participates; in 2021, all APM
2
As discussed above, practices who are in the comparison group of Round 2 will be scored according to the MIPS APM
scoring standard. These practices and their physicians may be eligible to receive a positive payment adjustment based
on their performance in the MIPS performance categories.
3
For 2021, eligible clinicians are defined as physicians, physician assistants, osteopathic practitioners,
chiropractors, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, physical &
occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, and
registered dietitians or nutrition professionals, dentists and dental surgeons, and optometrists.
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© 2021 Physicians Advocacy Institute
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Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plusparticipants reporting through the APP will earn a score of 100%. The Promoting Interoperability
performance category will be reported and scored at the individual or group level, as is required
for the rest of MIPS.
The cost category is reweighted to 0% because physicians are already subject to a cost assessment
under the CPC+ model.
Continuing in 2021, physicians who are participating in APM arrangements with other payers (e.g.,
Medicare Advantage plans), “Other Payer Advanced APMs,” can have that participation count
towards the requirements for the QPP Advanced APM pathway.
There are four ways for physicians or other eligible clinicians to meet the QP and PQ thresholds:
Medicare Payment Medicare Patient All Payer Payment All Payer Patient
Count Count Count Count
•based on the •based on the •based on the •based on the
percentage of percentage of percentage of percentage of
Medicare payments Medicare patients payments received patients seen
received through a seen through a through a Medicare through a Medicare
Medicare Advanced Medicare Advanced Advanced APM and Advanced APM and
APM APM Other Payer Other Payer
Advanced APM Advanced APM
Under the Medicare Option, only payments and patients from Medicare FFS patients are
considered. All-Payer Combination Option, there is a minimum threshold for Medicare
patients/payments that must be met before the All Payer options kick in. The All-Payer options,
therefore, do not replace or supersede the Medicare Option, and instead utilize a pair of
calculations using first the Medicare Part B patient/payment count method, and then the All-
Payer patient/payment count method for services furnished through Other Payer APMs.
Medicare Payment Count Method Medicare Patient Count Method
QP 50% of Medicare Part B payments are 35% of Medicare Part B patients are seen
received through a Medicare Advanced APM through a Medicare Advanced APM
PQ 40% of Medicare Part B payments are 25% of Medicare Part B patients are seen
received through a Medicare Advanced APM through a Medicare Advanced APM
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© 2021 Physicians Advocacy Institute
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Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plusAll Payer Payment Count Method All Payer Patient Count Method
QP Step 1: Receive 25% of Medicare Part B Step 1: 20% of Medicare Part B patients are
payments are received through a Medicare seen through a Medicare Advanced APM
Advanced APM
Step 2: 50% of all payments are received Step 2: 35% of all patients are seen through a
through a Medicare Advanced APM and Other Medicare Advanced APM and Other Payer
Payer Advanced APM Advanced APM
PQ Step 1: Receive 20% of Medicare Part B Step 1: 10% of Medicare Part B patients are
payments are received through a Medicare seen through a Medicare Advanced APM
Advanced APM
Step 2: 40% of all payments are received Step 2: 25% of all patients are seen through a
through a Medicare Advanced APM and Other Medicare Advanced APM and Other Payer
Payer Advanced APM Advanced APM
To learn more about the MIPS APM scoring methodology, please see PAI’s MIPS APM Scoring
Overview resource.
Where can I go for more information?
For additional information on the QPP requirements for Advanced APM participation please see
the QPP Advanced APM Overview resource, available on PAI’s website under the Advanced APM
Pathway page. Additional resources are available on the CMS CPC+ website.
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© 2021 Physicians Advocacy Institute
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Source: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plusYou can also read
