CMS Is Putting Primary Care First

Beginning January 2020, primary care practitioners may qualify to participate in one of five new payment model options that focus on supporting care for patients who have chronic conditions and serious illnesses. The Centers for Medicare & Medicaid Services’ (CMS) Primary Care Initiative is a new set of payment models that will provide primary care practices and other providers with five new payment model options under two paths: Primary Care First and Direct Contracting. The five payment options are:

1. Primary Care First
2. Primary Care First – High Need Populations
3. Direct Contracting – Global
4. Direct Contracting – Professional
5. Direct Contracting – Geographic

These payment options are meant to test whether delivery of advanced primary care can reduce total cost of care.

Primary Care First (PCF)

PCF will provide payment to practices through a simplified total monthly payment. Both model options under PCF incentivize providers to reduce hospital utilization and total cost of care by potentially rewarding them through performance-based payment adjustments, providing an upside of up to 50 percent of revenue as well as a small downside (10 percent of revenue) incentive, assessed and paid quarterly. Through the PCF payment model options, high-need patients with serious illnesses who do not have a practice participating in the model will be assigned to a model participant. Participating practices that choose to care for seriously ill population (SIP) patients will be required to provide care to clinically stabilize the patient. Eligible applicants are primary care practices that:

• Are located in one of the selected PCF regions;
• Include PCPs certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine;
• Provide primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location;
• Have primary care services for at least 70 percent of the practices’ collective billing based on revenue;
• Have experience with value-based payment arrangements;
• Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming interface, and connect to their regional health information exchange;
• Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities; and
• Can meet the requirements of the PCF Participation Agreement.

Eligible practitioners (that each practice applicant must identify by national provider identifier in its application) are those in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine. PCF will be tested for five years and is scheduled to begin in January 2020 for practices that are not currently participating in the Comprehensive Primary Care Plus (CPC+) model, but are located in the 18 existing CPC+ regions, and practices in regions in the United States where there are limited comparison group practices in the ongoing CPC+ evaluation. Practices in Alaska, California, Delaware, Florida, Maine, Massachusetts, New Hampshire, and Virginia may also apply. Payers may submit proposals for all 26 PCF regions. Request for Applications are expected to go out in the coming months. PCF is based on the underlying principles of the existing CPC+ model design. CMS has created a comparison table to show the differences between the two models.

Direct Contracting (DC)

DC payment model options aim to engage a wider variety of organizations that have experience taking on financial risk and serving larger patient populations such as accountable care organizations, Medicare Advantage plans, and Medicaid managed care organizations. The DC payment model options are designed to create a competitive delivery system environment where organizations offering greater efficiencies and better quality of care will be financially rewarded.

DC – Professional

Participating entities will bear risk for 50 percent of shared savings/losses on the total cost of care (for Parts A/B services) for aligned beneficiaries, and will receive a capitated, risk-adjusted monthly payment for enhanced primary care services equal to seven percent of the total cost of care for enhanced primary care services (Primary Care Capitation).

DC – Global

Participating entities will bear risk for 100 percent of shared savings/losses on the total cost of care (for all Parts A/B services) for aligned beneficiaries, and will be able to choose between two payment options: Primary Care Capitation (described above) or Total Care Capitation, which is a capitated, risk-adjusted monthly payment for all services provided by DC participants and preferred providers with whom the DC entity has an agreement.

DC – Geographic

Participating entities will bear risk for 100 percent of shared savings/losses on the total cost of care (for all Parts A/B services) for aligned beneficiaries in a target region.

Stakeholder Input

CMS said in a press release that it based the design of these payment model options on considerable stakeholder input. The American Medical Association (AMA) commended the U.S. Department of Health and Human Services for providing potential pathways for physicians providing care to patients with complex and chronic needs. “Providing adequate financial support for high quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s health care system,” said Gerald E. Harmon, MD, a family physician and immediate past chair of the AMA Board of Trustees. (April 22, Robeznieks) For more information, CMS provides the following:

A fact sheet on the CMS Primary Care First payment model options

A fact sheet on the Direct Contracting payment model options

A fact sheet on the CMS Primary Cares Initiative