NCQA PCMH PRACTICES ACT NOW: $ignificant Opportunity to $ustain

May 3, 2016 · Paul Cotton

Medicare, America’s largest single health care payer, is about to greatly expand its PCMH support in a new Comprehensive Primary Care Plus demonstration.

CPC+ offers substantial financial support that can significantly increase your ability to sustain all of your hard work and investment in practice transformation.

But to get in on this important opportunity you need to act now by contacting other payers that reward your PCMH status.

Here’s how CPC+ will work

CMS will accept applications from insurers who are willing to collaborate in CPC+ in specific regions or states from now through June 1. For you to be able to participate and benefit, other payers in your area must also participate. Payers will collaborate with population-based care management fees and shared savings to enhance Access and Continuity, Care Management, Comprehensiveness and Coordination, Patient and Caregiver Engagement and Planned Care and Population Health. Having all payers work toward same PCMH goals reduces burden on your practice.

CMS will select up to 20 regions or states that have enough payers willing to participate as demonstration sites. If your region or state is chosen, you will then be able to apply to participate. The window to apply is a short one, from July 15 through September 1. The reward lasts longer. The CPC+ demonstration is expected to last five years.

Rewards are significant if you are accepted

  • In Track 1, practices get an average $15 per-member-per-month (PMPM) fee. In an average-sized practice with 700 Medicare beneficiaries, this can total over $10,000 per month & $126,000 per year.NCQA PCMH CPC+
  • In Track 2 for more advanced practices, the average $28 PMPM for average-sized practices totals more than $19,000 per month & $235,000 per year. Track 2 practices can also earn quality bonuses of more than $33,000 per year. For complex patients in Track 2, there is a $100 PMPM fee to meet their additional needs.
  • On top of that, Medicare is proposing that CPC+ practice will qualify as Advanced Alternative Payment Models that, under the Medicare Access & CHIP Reauthorization Act (MACRA) get automatic 5% bonuses.


NCQA is building on all this by aligning our 2017 PCMH update measures and standards with CPC+. The streamlined PCMH recognition process we are developing also will reduce your workload. NCQA’s pre-validated EHR vendors also can support CPC+ Track 2 requirements to report clinical quality measures electronically.

More CPC+ details from CMS are here. In short, you get much more financial support to sustain PCMH transformation because more payers – including Medicare –will work with you in harmony.

We urge you to:

  • Seize this opportunity.
  • Encourage other payers who support NCQA PCMH transformation to apply by June 1.
  • Apply to have your NCQA PCMH practice participate in CPC+ by September 1.
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