CPC+ and EMS: Opportunity in the Hudson Valley

Aug 15, 2016 by

The Center for Medicare and Medicaid Services (CMS) recently opened the application for the Comprehensive Primary Care Plus (CPC+) program.  The goal of the five year program, starting in 2017, is to reward value and quality through a new payment system. This allows for primary care providers to implement new healthcare strategies that are not currently reimbursable through the traditional fee for service model and be properly reimbursed for giving extra time and coordination to patients who require increased levels of care, with the goal of improving access and reducing costs.

How Does It Work

The basis of the program is that Primary Care Providers who enroll in the program will switch from a fee for service payment plan to a three (3) part payment plan split into two (2) ‘tracks’- Track 1 and Track 2.  Each track has a list of things it needs to accomplish such as 24/7 Access and Hospital/ ED Discharge Follow Up.  Track 2 has higher expectations and goals than Track 1 (see the diagram) and will received more lump sum or value based payments than Track 1.

Program Objectives- Orange objectives are for both Track 1 and Track 2 practices while red objectives are for Track 2 only. Credit- Centers for Medicare and Medicaid.


The three (3) part payment plan, has different rates for each track.  Track 2 will receive more money than a comparable Track 1 due to their achievement of advanced objectives..  The Care Management Fee will be payed quarterly to practices based on the number of patients they see and the care management they provide based on what is required of each patient (ex. The more complex patients, the more money is received).  The Performance-Based Incentive Payment reimburses practices based on things such as patient experience and utilization rates.  The third component is Medicare Physician Fee Schedule.  Track 1 practices will continue to bill under a traditional fee for service model, while Track 2 will see a reduction in fee for service payments as they will receive more money from the other two fees.  Over the 5 year period of the program, payment will decrease from fee for service and increase from the The Care Management Fee and Performance-Based Incentive Payment for both Tracks.


So what does this mean for EMS?

What it means is that primary care practices who opt into the program will be given more lump sum payments and now have financial incentive to reduce the cost of care and implement creative new cost effective modalities of care for their patients.  Several of the basic (Track 1) objectives align well with EMS and community paramedicine.

The first is ‘24/7 Access’ which means a patient should have access to a provider who is integrated with their electronic medical record (EMR) at all times.  While EMS traditionally does not utilize physician based EMR, this is something that needs to change in order for EMS to grow and effectively implement initiatives such as community paramedicine.  If our ePCR’s can be linked with a health system/ physician based EMR, or we can at least have access to it, we can help close the gap on 24/7 care.  For example, if a patient calls their physicians office after hours and isn’t sure what to do, there is no reason a community paramedic can’t respond and assess the patient and relay the findings to the on call doctor and together come up with a care plan for the patient (ex. Treat and release, transport to the ED etc).  This concept also goes along with the ‘Out of Office Care Options’ objective that is outlined for Track 2 practices.

Another objective is to have Hospital/ ED Discharge Follow Up.  EMS based discharge follow up programs have been launched throughout the country, typically with the goal of reducing 30 day readmission rates.  Why can’t we work with physicians and care managers to visit these patients at home, where they are most comfortable and in the best position to recover?  Additionally, home based healthcare is unique as it sees the patient in their environment, where they live their lives, not in an office.

There is also a vague objective of ‘Coordination with Other Providers’.  EMT’s and Paramedic’s are the ‘other’ providers.  While we are not the first profession that ever comes to mind in healthcare, we certainly play an extremely important role.  EMS needs to work with and integrate better with other healthcare providers, particularly physicians.  We need to become part of the network or system.  Our ePCR’s need to be able to be integrated into EMR.

So why would a physician enrolled in the CPC+ program want to work with EMS?  As written about above, there are many objectives EMS can help fulfill.  EMS is clearly a cost effective solution in healthcare.  What’s more, community paramedicine and other EMS based mobile integrated healthcare programs have shown results that they work, whether through reducing utilization or improving patient outcomes.  So if a practice now gets reimbursed through lump sum conjoined with incentive based payments the possibility of community paramedicine becomes real at the small practice level.

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