CPC PAYMENT AND ATTRIBUT ION METHODOLOGIES FOR

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CPC PAYMENT AND ATTRIBUTIONMETHODOLOGIES FOR PROGRAM YEAR2019Version 2February 21, 2019Center for Medicare & Medicaid InnovationU.S. Department of Health & Human Services

Table of ContentsAcronyms .viExecutive Summary . 9Chapter 1: Introduction . 211.1CPC Payment Design Overview . 211.2CPC Payment Elements . 21Chapter 2: Beneficiary Attribution . 252.1Attribution . 252.2Eligible Beneficiaries . 272.3Voluntary Alignment. 272.42.52.3.1Making an Attestation on MyMedicare.gov . 272.3.2Beneficiary Attestation List from MyMedicare.gov . 282.3.3Practitioner and Practice Eligibility Check . 292.3.4Interactions with Claims-Based Attribution . 32Claims-Based Attribution . 322.4.1Eligible Visits . 322.4.2Claims-Based Attribution Process . 34Interaction with the Shared Savings Program Accountable CareOrganizations (ACOs). 37Chapter 3: Care Management Fee. 393.13.23.33.4Risk Scores and Risk Tiers. 393.1.1CMS-HCC Risk Scores. 403.1.2Setting the Risk Tier Thresholds . 41Assigning Risk Tiers . 413.2.1Assigning Risk Tiers 1–5 Based on Risk Score . 413.2.2Assigning Risk Tier 5 Based on Dementia Diagnosis (Track 2 Only). 42Retrospective Debits . 433.3.1Debits for Beneficiary Ineligibility . 443.3.2Debits for Duplication of Services. 44Risk Score Growth and CMF Cap . 45Chapter 4: Performance-Based Incentive Payment. 474.1Design Principles and General Features. 474.1.1Principles of Design . 474.1.2Prospective Payment . 48

4.24.1.3Transparency of Performance Goals . 484.1.4Incentive Structure . 494.1.5Incentive Payment Components. 504.1.6Incentive Payment Amounts . 51Quality Component . 524.2.1CAHPS Measurement . 534.2.2eCQM Measurement. 534.3Utilization Component. 544.4Calculation of Performance Scores . 554.54.64.4.1Calculation of Quality Performance Score . 564.4.2Calculation of Utilization Performance Score . 59Benchmarking Overview . 614.5.1Data Source for Benchmarking . 614.5.2Benchmarking Methods . 634.5.3Benchmark Results . 65Illustrative Example of Performance Incentive Retained . 664.6.1Calculation of Performance Incentive Retained for Quality Component . 664.6.2Calculation of Performance Incentive Retained for UtilizationComponent. 674.6.3Calculation of Performance Incentive Retained . 67Chapter 5: Payment under the Medicare Physician Fee Schedule . 695.15.25.3Purpose and Intent. 695.1.1Purpose and Aims. 695.1.2Payment Choices by Year . 705.1.3Implications of CPCP for Practices and Beneficiaries . 71Historical PBPM . 715.2.1Historical Population and Eligibility . 725.2.2Historical Payments . 725.2.3Example Practice Illustration—Main Street CPC . 73CPCP Program Year Calculation . 735.3.1Comprehensiveness Supplement. 735.3.2PFS Updates and Revaluation Changes. 735.3.3Adjusted Historical PBPM . 745.3.4Calculation for Main Street CPC. 745.3.5Frequency of CPCP Calculation and Payment . 745.3.6Debits for Beneficiary Ineligibility . 76

5.4FFS Reduction . 775.4.15.5FFS Calculation for Main Street CPC. 77Partial Reconciliation . 77Chapter 6: Conclusions . 83References . 85AppendicesAppendix A: Glossary of Terms . 87Appendix B: Primary Care Specialty Codes. 95Appendix C: Description of CMS-HCC Risk Adjustment Model . 97Appendix D: Risk Tier Thresholds for First and Second Quarters in 2019. 99Appendix E: CAHPS Domain Survey Questions . 101Appendix F: CPC eCQM Set—Program Year 2019 . 103Appendix G: Utilization Measure Technical Specifications . 105Appendix H: PBIP Tracking Worksheet. 119Appendix I: Evaluation and Management (E&M) Claims in Hybrid Payment . 121

List of FiguresFigure 2-1Figure 2-2Figure 2-3Figure 2-4Figure 3-1Figure 4-1Figure 4-2Figure 5-1Figure 5-2Figure 5-3What Is a Lookback Period? . 26CPC Attribution Methodology . 31Three Steps in CPC Claims-Based Attribution . 35Which Beneficiaries Are Attributed to My Practice Through Claims-BasedAttribution?. 37Beneficiary Risk Tiers . 43Components of the PBIP . 51Overview of Practice Eligibility to Retain Quality and Utilization Componentsof the PBIP. 56How does the CPCP in Track 2 Get Calculated? . 75CPCP—Main Street CPC Example . 76Payment Reconciliation . 82List of TablesTable 1-1Table 2-1Table 2-2Table 2-3Table 3-1Table 3-2Table 3-3Table 4-1Table 4-2CPC Payment Summary . 23BALs Used for 2019 Quarterly Attribution . 29Lookback Periods for 2019 Quarterly Beneficiary Attribution . 32Primary Care Services Eligible for Attribution . 33Risk Tier Criteria and CMF Payments (per Beneficiary per Month) . 39Risk Score Data Used to Determine CMF Payments, by Quarter . 40CCM-Related Services Duplicative of CPC CMF . 45PBIP PBPM by Component for CPC Track 1 and Track 2 Practices. 52Practice Performance and Percentage of PBIP for Patient Experience ofCare . 58Table 4-3 Practice Performance and Percentage of Quality Component of the PBIPRetained for Individual eCQMs . 59Table 4-4 Practice Performance and Percentage of PBIP for Utilization . 60Table 4-5 CPC Quality and Utilization Measures for Benchmarking . 61Table 4-6 Hypothetical Examples of Scoring Transformations for CAHPS Measures . 64Table 4-7 Benchmark Results for the Quality and Utilization Measures in CPC . 65Table 4-8 Percent Payment Retained by Measure—Illustrative Example for MainStreet CPC. 66Table 5-1a Payment Choices for Track 2 Practices 2017 Starters: Track 2 PaymentChoices by Year . 70Table 5-1b Payment Choices for Track 2 Practices 2018 Starters: Track 2 PaymentChoices by Year . 71

FCGCMFCMSCPCCPC DSMIPSNCQANPINPPESNQFPBIPPBPMPCMHAccountable Care OrganizationAgency for Healthcare Research and QualityAlternative Payment ModelBeneficiary Attestation ListCritical Access HospitalConsumer Assessment of Healthcare Providers and SystemsChronic Care ManagementCMS Certification NumberChronic Conditions WarehouseConversion FactorClinician and GroupCare Management FeeCenters for Medicare & Medicaid ServicesComprehensive Primary CareComprehensive Primary Care PlusComprehensive Primary Care PaymentCurrent Procedural TerminologyCalendar YearDiagnosis GroupEvaluation & ManagementElectronic Clinical Quality MeasureEmergency DepartmentEmergency Department UtilizationEnd Stage Renal DiseaseFee-for-ServiceGeographic Price Cost IndexHierarchical Condition CategoriesHealthcare Effectiveness and Information Data SetInternational Classification of DiseasesInpatient Hospital UtilizationMinimum Data SetMerit-Based Incentive Payment SystemNational Committee for Quality AssuranceNational Provider IdentifierNational Plan and Provider Enumeration SystemNational Quality ForumPerformance-Based Incentive PaymentPer Beneficiary Per MonthPatient-Centered Medical Home

an Fee SchedulePhysician Quality Reporting SystemQuarter 1Quarter 2Quarter 3Quarter 4Quality Payment ProgramQuality Reporting Document ArchitectureRelative Value UnitTax Identification NumberValue Based Payment Modifier

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Executive SummaryThis Executive Summary provides an overview of the methodologies that the Centers forMedicare & Medicaid Services (CMS) will use for the Comprehensive Primary Care Plus(CPC ) payment model being tested in Medicare fee-for-service (FFS) in Program Year 2019.The Executive Summary and the detailed technical specifications for each of the methodologiesare organized as follows: Chapter 1 introduces the CPC attribution and payment elements;Chapter 2 describes the beneficiary attribution;Chapter 3 describes the care management fee;Chapter 4 describes the performance-based incentive payment;Chapter 5 describes the payment under the Medicare Physician Fee Schedule (PFS);andChapter 6 provides conclusions.CPC payer partners will offer their own aligned arrangements to CPC practices.ES.1 IntroductionCPC is a national advanced primary care medical home model, tested under the authority ofthe Center for Medicare & Medicaid Innovation (Innovation Center), that aims to strengthenprimary care through multipayer payment reform and care delivery transformation. CPC is afive-year model that includes two primary care practice tracks with incrementally advanced caredelivery requirements and payment options to meet the diverse needs of primary care practicesin the United States. CPC aims to improve beneficiaries’ health and quality of care anddecrease total cost of care. To this end, CPC offers three payment elements to support andincentivize practices to better manage beneficiaries’ health and to provide higher quality of care.The payment designs vary slightly for Track 1 and Track 2 CPC practices. The three paymentelements are the same for 2017 Starters and 2018 Starters.In addition to the attribution methodology, which describes the technical specifications used toidentify the Medicare FFS beneficiaries for whom participating primary care practices areresponsible, this methodology paper will provide detailed specifications for the following threeelements of CPC payments:1. Care management fee (CMF): CMF is a non-visit-based fee that will be paid to bothTrack 1 and Track 2 practices quarterly. The amount of CMF is determined by (1) thenumber of beneficiaries attributed to a given practice per month, (2) the case mix of theattributed beneficiary population, and (3) the CPC track to which the practice belongs.Practices serving a greater number of high-risk beneficiaries are expected to providemore intensive care management and practice support. Thus, the CMF amount is riskadjusted to reflect the attributed population’s risk level. Track 2 practices will receive ahigher CMF for beneficiaries with complex needs.Page 9 of 122

2. Performance-based incentive payment (PBIP): CPC will prospectively pay the PBIP.After each Program Year ends, CPC will retrospectively reconcile the amount of PBIPthat a practice earned based on how well the practice performed on patient experienceof care measures, clinical quality measures, and utilization measures that drive total costof care. Practices will either keep their entire PBIP, repay a portion, or repay all of it. Thefull amount of PBIP that is prospectively paid is determined by (1) the number ofbeneficiaries attributed to a given practice per month, and (2) the CPC track to whichthe practice belongs. The PBIP amount earned in a Program Year is determined by(1) the number of beneficiaries attributed to a given practice per month, (2) the CPC track to which the practice belongs, and (3) the practice’s performance on the measureslisted above. PBIP is calculated separately for each of the quality component (includingpatient experience of care) and utilization components.3. Payment under the Medicare PFS:a. Track 1 practices will continue to bill and receive payment from Medicare FFS asusual.b. Track 2 practices will receive a hybrid payment, meaning they will be prospectivelypaid Comprehensive Primary Care Payments (CPCPs) with reduced FFS payments.CPCP is a lump sum quarterly payment based on historical FFS payment amountsfor selected primary care services. Track 2 practices will continue to bill as usual,and the FFS payment amount will be reduced proportionally to offset the CPCP. TheCPCP amounts will be larger than the historical FFS payment amounts they areintended to replace, as Track 2 practices are expected to increase the breadth anddepth of services they offer.Depending on which CPC Track the practice is in, practice’s eligibility to receive each of thesethree payment types differs, as summarized in Table ES-1.Table ES-1CPC Payment SummaryTrackCMFsPBIPMedicare PFS1 15 average perbeneficiary per month(PBPM) 1.25 PBPM onquality/patient experienceof care and 1.25 PBPMon utilization performanceRegular FFS2 28 average PBPM,including 100 PBPM tosupport patients withcomplex needs 2 PBPM onquality/patient experienceof care and 2 PBPMutilization performanceHybrid payment: ReducedFFS with a prospectiveCPCPES.2 Chapter 2: Beneficiary AttributionCollectively, CPC payments from Medicare, Medicaid, and commercial payer partners areintended to support practice-wide transformation for all patients at the practice, regardless ofPage 10 of 122

insurance type. As such, CPC Medicare attribution is the mechanism for determining theapproximate size and acuity of the Medicare FFS population receiving regular continuous carewithin the CPC practice. This chapter describes the methodology for attributing Medicarebeneficiaries to CPC practices. CPC uses a prospective attribution methodology to identifythe Medicare FFS beneficiaries in CPC practices. Beneficiary attribution is conducted on aquarterly basis and used to determine payment amounts for CMF, PBIP, and CPCP with FFSreduction (i.e., hybrid payment). CMS will provide each practice with a list of prospectivelyattributed beneficiaries within the first month of the payment quarter. Though Medicarebeneficiaries will be attributed to a practice, beneficiaries remain free to select the practitionersand services of their choice and continue to be responsible for all applicable beneficiary costsharing.The attribution process uses multiple steps to assign beneficiaries to practices. Using Medicareadministrative data, we first identify Medicare FFS beneficiaries eligible for attribution. Thenafter eligible beneficiaries are identified, the attribution process is conducted as follows.Through Q4 of Program Year 2018, CPC is solely using a claims-based attribution algorithm todetermine beneficiary attribution. However, beginning in Program Year 2019, in addition toclaims-based attribution, CMS will prioritize beneficiary choice in CPC attribution byincorporating voluntary alignment as the initial step in attribution. Voluntary alignment—alsoknown as beneficiary attestation—refers to a process by which beneficiaries make anattestation specifying the health care practitioner and practice that they consider to beresponsible for providing and coordinating their health care. While any beneficiary with anaccount on MyMedicare.gov can make an attestation, only attestations by eligible beneficiarieswill be considered for attribution.Eligible beneficiaries not attributed using voluntary alignment will be attributed using claimsbased attribution. We examine the most recent 24-month historical (or “lookback”) period inMedicare claims data to determine which practice to attribute eligible beneficiaries. Claimsbased attribution is first based on Chronic Care Management (CCM)–related services, thenbased on Annual Wellness Visits and Welcome to Medicare Visits, and last based on theplurality of eligible primary care visits within the 24-month lookback period.1. Eligible Beneficiaries—To be eligible for attribution to a CPC practice in a givenquarter, beneficiaries must meet several criteria before the start of the quarter.Beneficiaries must (1) be enrolled in Medicare Parts A and B; (2) have Medicare as primarypayer; (3) not have end stage renal disease (ESRD) and not be enrolled in hospice 1; (4) not becovered under a Medicare Advantage or other Medicare health plan; (5) not be long-terminstitutionalized; (6) not be incarcerated; and (7) not be enrolled in any other program or model1Note that this criterion only applies to beneficiaries who have not been attributed to a CPC practice previously—ifthe beneficiary has been attributed to a CPC practice previously, then developing ESRD or enrolling in hospicedoes not disqualify a beneficiary from being attributed to that CPC practice.Page 11 of 122

that includes a Medicare FFS shared savings opportunity, except for the Medicare SharedSavings Program.2a. Voluntary Alignment: Beneficiary Attestation—Via MyMedicare.gov, beneficiaries canattest to the health care practitioner and practice that they consider to be responsible forproviding and coordinating their health care.Any beneficiary with an account on MyMedicare.gov can make an attestation. However, ifbeneficiary eligibility requirements are not met, the beneficiary is not eligible for voluntaryalignment or claims-based attribution. If all beneficiary eligibility requirements are met, CMS willcheck whether the attested practitioner and practice meet eligibility requirements.2b. Voluntary Alignment: Eligible Practitioners and Practices—If eligible beneficiariesmake attestations, the attested practitioner and practice must meet certain requirementsfor the beneficiary’s attestation to be used.For practitioners participating at a CPC Practice Site, the attested practitioner must be activeat the CPC Practice Site for the given quarter. In addition, the attested practitioner’s CPC Practice must have signed and returned the Mutual Amendment to the CPC ParticipationAgreement on voluntary alignment. For practitioners at a non-CPC Practice Site, the attestedpractitioner must have a primary care specialty code.If these practitioner eligibility requirements are met, the beneficiary’s attestation is used toattribute the beneficiary via voluntary alignment. If these requirements are not met (e.g., apractitioner used to participate with the practice but is not active anymore or a practitioner isparticipating in a CPC practice that did not sign and return the Mutual Amendment), thebeneficiary will be attributed using the claims-based attribution process.3. Claims-Based Attribution—For eligible beneficiaries not attributed via voluntaryalignment, the CPC claims-based attribution algorithm is applied.For eligible beneficiaries not attributed by voluntary alignment, a pool of eligible Medicare claimsduring a 24-month “lookback” period is used for attribution. The attribution lookback period is the24-month period ending three months before the start of the quarter. For example, CMS will useclaims from October 2016 through September 2018 to attribute beneficiaries to CPC practicesfor the first quarter of 2019. The lookback periods that will be used for the 2019 CPC quarterlyattributions are listed in Table ES-2.Page 12 of 122

Table ES-2Lookback Periods for 2019 Quarterly Beneficiary AttributionAttribution QuarterLookback Period2019 Quarter 1October 2016–September 20182019 Quarter 2January 2017–December 20182019 Quarter 3April 2017–March 20192019 Quarter 4July 2017–June 2019Eligible beneficiaries that are not voluntarily aligned and have at least one eligible primary carevisit in the lookback period are attributed to practices first based on CCM-related services, thenbased on Annual Wellness Visits and Welcome to Medicare Visits, and last based on theplurality of eligible primary care visits. To be eligible, non-CCM-related services must beprovided by a practitioner who is either active in a CPC practice or has a primary carespecialty code.ES.3 Chapter 3: CMFsThis chapter describes the CMF, which practices will use to support augmented staffing andtraining related to non-visit-based and historically non-billable services that align with the CPC care delivery transformation aims. These include activities to improve care coordination,implement data-driven quality improvement, and enhance targeted care management forbeneficiaries identified as high risk. CMS assigns beneficiaries to risk tiers to determine the CMF payment amount.o All Medicare FFS beneficiaries attributed to a CPC practice will be assigned toone of four risk tiers for Track 1 CPC practices or one of five risk tiers for Track2 CPC practices (shown in Table ES-3).o Each risk tier corresponds to a monthly CMF payment. Higher risk tiers areassociated with higher beneficiary risk, as determined by the CMS HierarchicalCondition Categories (CMS-HCC) risk score, and higher CMFs.Page 13 of 122

Table ES-3Risk Tier Criteria and CMF Payments (per Beneficiary per Month)Risk Tier2Risk Score CriteriaTrack 1Track 2Tier 1Risk score 25th percentile 6 9Tier 225th percentile risk score 50th percentile 8 11Tier 350th percentile risk score 75th percentile 16 19Tier 4Track 1: Risk score 75th percentileTrack 2: 75th percentile risk score 90th percentile 30 33Tier 5(Track 2 only)Risk score 90th percentileorDementia diagnosisN/A 100 Beneficiary risk score is based on the CMS-HCC risk adjustment model.o The CMS-HCC model is a prospective risk adjustment model that predictsmedical expenditures in a given year based on demographics and diagnosesfrom the prior year. 2o For each quarter, the risk tier threshold for each region will be based on the mostrecent risk scores available. Risk scores will be collected for all beneficiaries whoare attributed to a participating CPC practice each quarter, and risk tierassignment will be based on the most recent risk scores available. Risk tier assignment will be based on a regional reference population.o Risk scores for attributed CPC beneficiaries will be compared to the risk scoresfor all Medicare FFS beneficiaries in the same region who meet CPC eligibilityrequirements.o A beneficiary is assigned to a risk tier based on where their risk score falls withinthe regional distribution, as shown in Table ES-3. Track 2 CPC practices will receive a higher CMF for beneficiaries assigned to anadditional complex risk tier.o For Track 2 practices, CMS will pay a 100 per-beneficiary-per-month (PBPM)CMF to support the enhanced services that beneficiaries with complex needsrequire.o Complex beneficiaries who fall within the top 10 percent of the risk scoredistribution and those who, based on Medicare claims, have a diagnosis ofdementia will be assigned to the highest risk tier.For more information about the risk adjustment model, see dvtgSpecRateStats/downloads/evaluation risk adj model 2011.pdf.Page 14 of 122

o We include beneficiaries with dementia to account for the omission of dementiadiagnoses in the CMS-HCC algorithm and to account for the higher level of carecoordination these beneficiaries require.Quarterly, CMS will need to debit the CMF paid to correct for overpayments or duplicatepayments.o The first type of retrospective debit is to account for prior CMF o

Feb 21, 2019 · (CPC ) payment model being tested in Medicare fee- for-service (FFS) in Program Year 2019. The Executive Summary and the detailed technical specification

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