From original Medicare and Medicaid through DRGs, HMOs, CPC+ and more, all healthcare payment models — at least allegedly — have been designed to address a mix of three fundamental issues: increase access to care, improve clinical outcomes, and reduce unnecessary costs. Most have started in Medicare and spread to the private-payer market, so Medicare payment models can have widespread impact on the industry and patients alike. Today brings us a new advanced payment model designed to address many of the shortcomings of earlier models: Primary Care First (PCF).
Accepting the first wave of provider applications through Jan. 22, 2020, Primary Care First is a set of five-year payment model options designed to test whether changing how Medicare pays for primary care can lead to reductions in acute hospital utilization and lower total cost of care while preserving or improving quality.
Which practices qualify for primary care first (PCF)?
Primary Care First is based on the underlying principles of the CPC+ model. Since primary care is central to a high-functioning healthcare system, there’s an urgent need to preserve and strengthen primary care as well as a need for support of serious illness care services for Medicare beneficiaries.
Primary Care First addresses these needs by creating a seamless continuum of care and accommodates a continuum of interested providers. The payment options test whether delivery of advanced primary care can reduce total cost of care, accommodating practices at multiple stages of readiness to assume accountability for patient outcomes. Primary Care First will focus on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments.
How will practices get paid under Primary Care First?
Many CPC+ participants have complained about its administrative hassle and cost. Primary Care First is designed to address that, introducing a simple payment model that CMS calls a major step away from fee-for-service and towards paying for value. Participating practices will receive a majority of their primary care professional revenue for treating attributed beneficiaries in the form of a prospective population-based payment (PBP), or professional PBP.
Practices will be able to use these funds for innovative care delivery approaches, including those that aren’t dependent on office-based, face-to-face care, such as telehealth services (like the comprehensive medication management provided by RxLive), care managers, and 24/7 primary care access. The amount of a practice’s professional PBP will be determined for each quarter based in part on the average risk profile of its entire attributed patient population. Practices with high-risk, complex chronic patient populations will receive a higher professional PBP than practices primarily serving average or low-risk patients.
To ensure that practices continue to provide care to their attributed patients, the professional PBP for each practice will be adjusted by a leakage penalty, which is based on the percentage of evaluation and management services or chronic care management (CCM) services that beneficiaries receive outside of the Primary Care First practice to which they have been attributed.
What are the benefits for the provider?
Primary Care First aims to be transparent, simple and hold practitioners accountable by:
- Providing payment to practices through a simple payment structure, including:
- A payment mechanism that enables care to be driven by clinicians, rather than administrative requirements and revenue cycle management
- A population-based payment to provide more flexibility in the provision of patient care along with a flat primary care visit fee
- A performance based adjustment providing an upside of up to 50% of revenue as well as a small downside (10% of revenue) incentive to reduce costs and improve quality, assessed and paid quarterly
- Providing practice participants with performance transparency, through practitioner-identifiable information on their own and other practice participants’ performance to enable and motivate continuous improvement.
CMS will use a focused set of clinical quality and patient experience measures to assess quality of care delivered at the practice.
What are the patient benefits?
Primary Care First prioritizes patients by emphasizing the doctor-patient relationship. The model aims to improve the experience for beneficiaries by reducing administrative burdens so practitioners can spend more time with patients. CMS will prioritize patient choice in the assignment of Medicare beneficiaries to Primary Care First practices. PCF is also designed to enhance care for patients with complex chronic needs and high-need, seriously ill patients under its Seriously Ill Population (SIP) option.
Which practices qualify for PCF?
As spelled out starting on page 9 of the Center for Medicare & Medication Innovation’s (CMMI) PCF request for applications, practices most qualified for the first phase of PCF are primary care practices with advanced primary care capabilities — including those that specialize in caring for complex, chronically ill patient populations — that are prepared to accept increased financial risk in exchange for greater flexibility and potential rewards based on practice performance.
There are various qualifications that must be met to participate in the first year (see CMS fact sheet). Eligible practices must:
- Serve at least 125 attributed Medicare beneficiaries at a particular location (multi-site practices would need to submit separate applications for each practice location).
- Are located in one of the selected Primary Care First regions. These include non-participants in the 18 existing CPC+ regions, as well as practices in Alaska, California, Delaware, Florida, Maine, Massachusetts, New Hampshire and Virginia. (See PCF map and more information from CMS.)
- 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 (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE).
Eligible practitioners are MDs, DOs, CNSs, NPs and PAs certified and practicing in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine.
- Practice and payer selections will take place in Winter-Spring 2020. The model will begin in January 2021. CMS will focus on onboarding participating practices and payer partners to the model from July-December 2020.
- Payers — CMS will also 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.
What’s the SIP option?
CMS will attribute Seriously Ill Population (SIP) patients lacking a primary care practitioner or care coordination to Primary Care First practices that specifically opt to participate in this payment model option. Practices may limit their participation in Primary Care First to exclusively caring for SIP patients, but to do so, these practices must demonstrate in their applications that they have a network of relationships with other care organizations in the community to ensure that beneficiaries can access the care best suited to their longer-term needs.
Practices interested in participating in the SIP payment model option can agree to be attributed and furnish services to SIP patients when they apply. These practices will have to demonstrate they have relevant capabilities and care experience in their application. They will then be responsible for reaching out to these patients with a focus on ensuring that their care is coordinated and that SIP patients are clinically stabilized. Practices will also be allowed on a case-by-case basis to accept patients into SIP who are referred to the practice and deemed eligible by CMS.
Payment for SIP patients differs from that established under the general payment option for Primary Care First. Payment amounts for SIP patients will be set to reflect the high-need, high-risk nature of the population as well as include an increase or decrease in payment based on quality.
What about CPC+?
Current CPC+ participants aren’t eligible for the first year of PCF, but are the only providers to be eligible for participation in the five-year PCF program as of its second year, probably to enable them to complete their CPC+ participation.
Key differences between PCF and CPC+
For practices that are prepared to take on more accountability — and greater opportunity for reward — Primary Care First focuses on fostering practice independence and rewarding outcomes by reducing administrative burdens and paying for outcomes instead of process requirements. See table highlighting differences in the CMS fact sheet.
The American Medical Association (AMA) asked in September, “PCF or CPC+? It depends,” stating that “Operating at top performance, PCF practices could out-earn CPC+ practices. As currently proposed, PCF standard payments are designed to match current Medicare payments, but the highest-performing practices could receive significant increases in payment — higher than the maximum they could receive under CPC+.” However, the AMA noted that under CPC+, payments are more stable and higher than FFS, and payments to PCF practices could vary significantly from quarter to quarter.
Don’t wait to implement your primary care first program
This is a somewhat short explanation of the new Primary Care First model, its benefits and risks, and who may qualify in its first year. We’re including a few additional links to resources below.
But after so many years of specialist reimbursement taking the lead over that of well-coordinated primary care, PCF appears to well-align with the commitment of RxLive and many of our existing customers to be rewarded for delivering value-based care that’s truly patient-focused…freed of mounds of paperwork (well, mostly…) and rewarded for delivering strong and sustainable outcomes.
In fact, for those provider organizations that participate in PCF and particularly to qualify for higher payments under the Seriously Ill Population (SIP) option, practices can actually reap greater benefits than with FFS or CPC+ when they’re caring for patients with complex, chronic needs such as comprehensive medication management challenges like those managed by RxLive on providers’ behalf. Those practices will receive a larger population-based payment for the Medicare-covered services provided to this population. Combined with the flat primary care visit fee revenue, in aggregate these practices’ payments under the model will be larger than the Medicare FFS reimbursement they have historically received for delivering primary care services to complex chronic patients. The larger population-based payment is intended to account for the higher disease burden in these populations and the increased resources required to serve patients with multiple chronic illnesses.
Lean on a trusted partner to implement value-based pharmacy programs
We hope this overview and links to related resources are of assistance if you are considering Primary Care First. Please know that the comprehensive medication management services of RxLive stand ready to assist you if you choose to participate in PCF or other value-based programs seeking to improve clinical outcomes and manage costs. Contact us to learn more.
Additional resources and support
- How payment works under PCP (CMS webinar)
- Request for Applications
- Application portal
- Seriously Ill Population (slides from webinars part 1 and 2)
- Primary Care First model options (website)
- Email: firstname.lastname@example.org