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Getting Ready for Primary Care First: Ambitious CMMI Initiative Aims to Redefine Primary Care

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Announced in late April, the Center for Medicare & Medicaid Services’ (CMS) Primary Care First initiative marks a critical step forward in the long and complex journey toward a fundamentally transformed healthcare system.

The advanced primary care model builds on lessons learned from CMS’ earlier value-based care models and reflects significant input from primary care stakeholders.

CMS says the voluntary, regionally based demonstration will prioritize the doctor-patient relationship and enhance care for Medicare, Medicaid, and dual eligible patients with serious illnesses. The approach is also designed to reduce clinicians’ administrative burden and foster greater care flexibility while financially rewarding improved patient outcomes. CMS expects more than 6 million Medicare fee-for-service beneficiaries ultimately will be enrolled in the demonstration.

For providers, Primary Care First represents an important opportunity to participate in a value-based care model with limited downside risk (10% of revenue) and considerable upside potential (50% of revenue). An estimated one-in-four primary care practitioners nationwide may take advantage of the program, according to CMS.

Given its capitated structure – which will include a risk-adjusted, population-based, per-member-per-month payment, plus a flat, $50.52 per-face-to-face patient encounter fee — the initiative could have a substantial impact on existing practice revenue cycle management and other business processes.

If your organization is considering participating in Primary Care First, here’s what you need to do:

1. Pay Attention to the Timeline
CMS has outlined an aggressive, if somewhat fluid and imprecise, timetable for implementing the 5-year program. Provider Requests for Applications initially were scheduled to be released in the spring but are not yet available, although they’re expected to be out in the near future. Other key mileposts announced by CMS include:

  • Summer 2019 – Practice applications due; payers solicited for participation
  • Fall-Winter 2019 – Practices and payers selected
  • January 2020 – Model launch
  • April 2020 – Payment changes begin

2. Evaluate the 2 Participation Paths
According to CMS, Primary Care First is designed to accommodate practices at various stages of readiness for assuming patient outcome accountability. Two participation tracks, or payment models, are available. Practices may participate in 1 or both:

  • PCF Payment Model: Focuses on advanced primary care practices that are ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments. Introduces new, higher payment for practices caring for complex, chronically ill patients.
  • PCF High Need Populations Payment Model: Promotes care for high-need, seriously ill population (SIP) beneficiaries, including dual eligibles, who lack a primary care practitioner and/or effective care coordination. Medicare-enrolled clinicians who provide hospice or palliative care may become involved by partnering with participating practitioners.

3. Determine if Your Practice Meets the Participation Criteria
To take part in Primary Care First (PCF), practices must:

  • Be located in 1 of the selected Primary Care First regions (26 total, including 18 where the CPC+ Tracks 1 and 2 currently are being piloted).
  • Include primary care practitioners (MD, DO, CNS, NP, and PA), 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 account for at least 70% of the practices’ collective billing based on revenue. In the case of a multi-specialty practice, 70 % of the practice’s eligible primary care practitioners’ combined revenue must come from primary care services.
  • Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance, such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments, such as full or partial capitation.
  • Use 2015 Edition Certified Electronic Health Record Technology, 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, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team.
  • Meet the requirements of the Primary Care First Participation Agreement.
    *Note: Practices participating in the SIP option only will not be subject to all requirements.

4. Prepare for the Quality Gateway
CMS will use a focused set of clinical quality and patient experience measures to assess quality of care delivered at the practice. A Primary Care First practice must meet standards that reflect quality care in order to be eligible for a positive performance-based adjustment to their primary care revenue. Measures were selected to be actionable, clinically meaningful for patients with complex chronic needs and serious illness, and aligned with CMS’s broader quality measurement strategy.

The measures include acute hospital utilization, a patient experience-of-care survey, controlling high blood pressure, diabetes hemoglobin A1c poor control, colorectal cancer screening, and advance care planning.

As part of the Primary Care First initiative, CMS will encourage payers – including Medicare Advantage Plans, commercial health insurers, Medicaid managed care plans, and State Medicaid agencies – to align payment, quality measurement, and data sharing with CMS in support of Primary Care First practices.

5. Get Ready for a New Payment Model
In addition to receiving a flat payment of $50.52 (adjusted for geography) for face-to-face treatment, practices participating in the PCF Payment Model will receive population-based payments based on hierarchical condition category (HCC) patient risk coding scores as follows:

Reimbursement for the High-Need Population Payment Model will include a one-time payment of $325 per SIP member for the first visit, as well as payments of $275 per SIP beneficiary per month, plus a flat subsequent visit fee of $50 and a quality payment of up to $50.

For more information on how we’re assisting our clients in evaluating their opportunities and risks in the Primary Care First models, please contact Danny Chiriaco.

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