The monumental shift in health care from fee-for-service or a volume-based approach to value-based care will change health care delivery for the better in the United States. When physicians do what is necessary and avoid over-testing and procedures of limited or no value, the outcomes are best for the patient, and for the entire health care system.
The Centers for Medicare and Medicaid Services have tested and continue to test models in the delivery of value-based care. I was a practicing physician (internist and nephrologist) for 25 years before I founded the nation’s leading concierge medicine company. One of my core beliefs was that if I had more time with each one of my patients, I could have a large impact on reducing acute hospitalizations, making accurate diagnoses, and better control and coordinate care of chronic conditions to avoid acute episodes. This turned out to be true, and the company I founded now has about more than 300,000 patients and about 900 participating physicians. I’m biased, but I believe that it has had a significant impact on reducing federal and private insurance health care spending in the U.S. About 50 percent of my own patients were Medicare age. If this ratio is applied to all our physicians, this focus on the doctor-patient relationship has played a part in reducing Medicare costs.
Primary Care First Model Options According to CMS
Primary Care First Model Options is a set of voluntary five-year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First is based on the underlying principles of the existing CPC+ model design: prioritizing the doctor-patient relationship; enhancing care for patients with complex chronic needs and high need, seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes.
Primary Care First Model Options will be offered in 26 regions for a 2020 start date: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).
Primary care is central to a high-functioning healthcare system and thus, there is 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.
Thorough a second payment model option, Primary Care First also encourages advanced primary care practices, including providers whose clinicians are enrolled in Medicare who typically provide hospice or palliative care services, to take responsibility for high need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination—population groups referred to under the model as the Seriously Ill Population or SIP.
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. The Centers for Medicare & Medicaid Services (CMS) will prioritize patient choice in the assignment of Medicare beneficiaries to Primary Care First practices.
Primary Care First reflects a regionally-based, multi-payer approach to care delivery and payment. Primary Care First fosters practitioner independence by increasing flexibility for primary care, providing participating practitioners with the freedom to innovate their care delivery approach based on their unique patient population and resources. Primary Care First rewards participants with additional revenue for taking on limited risk based on easily understood, actionable outcomes.
In Primary Care First, 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. These measures were selected to be actionable, clinically meaningful, and aligned with CMS’s broader quality measurement strategy. Measures include a patient experience of care survey, controlling high blood pressure, diabetes hemoglobin A1c poor control, colorectal cancer screening, and advance care planning.
CMS will assess quality of care based on a focused set of measures that are clinically meaningful for patients with complex, chronic needs and the serious illness population.
Primary Care First aims to improve quality, improve patient experience of care, and reduce expenditures. The model will achieve these aims by increasing patient access to advanced primary care services, and has elements specifically designed to support practices caring for patients with complex chronic needs or serious illness. The specific approaches to care delivery will be determined by practice priorities. Practices will be incentivized to deliver patient-centered care that reduces acute hospital utilization. Primary Care First is oriented around comprehensive primary care functions: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement; and (5) planned care and population health.
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 allows 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; and
- 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.
Primary Care First provides the tools and incentives for practices to provide comprehensive and continuous care, with a goal of reducing patients’ complications and overutilization of higher cost settings, leading to higher quality of care and reduced spending.
The general Primary Care First payment model option is designed for primary care practices with advanced primary care capabilities that are prepared to accept increased financial risk in exchange for flexibility and potential rewards based on practice performance. Eligible applicants are primary care practices that:
- Are located in one of the selected Primary Care First regions.
- 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 (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE).
- 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.
- Can meet the requirements of the Primary Care First Participation Agreement
Eligible practitioners (that each practice applicant must identify by NPI in its application) are those in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine. CMS may reject an application on the basis of the results of a program integrity screening.
CMS will also encourage other 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.
Seriously Ill Population Option Participation
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 in order to do so, such 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.
To participate in the SIP payment model option, practices that demonstrate relevant capabilities and care experience in their application will have the option when they apply to agree to be attributed and furnish services to the SIP patients that CMS identifies in their service area who express interest in the model. These practices will then be responsible for reaching out to these patients with a focus on ensuring that there 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.
Clinicians enrolled in Medicare who typically provide hospice or palliative care services (e.g., those affiliated with a hospice, palliative care or similar organization) are eligible to care exclusively for SIP patients, either by participating in the model as a practice or by partnering with a Primary Care First participating practice that includes these practitioners on its practitioner roster.
CMS anticipates releasing a Request for Application in summer 2019 for the first cohort of payers and practices. Practices and payers will begin participation in the model in January 2020.
We anticipate accepting another round of Primary Care First applications during 2020, and that any practices accepted to participate in Primary Care First during 2020 would begin participation in the model in January 2021.
The SIP payment model option will also follow this timeline.
Additional eligibility details will be available in the forthcoming Primary Care First Request for Applications (RFA) and Solicitation for Payer Partnership.
Stay up to date on the latest Primary Care First Model Options updates by subscribing to the PCF Model Options listserv.
Information for Interested Stakeholders
CMS hosted webinars on the following dates for interested stakeholders:
- Information Webinar Series (April 30 & May 16, 2019)
- Payment Webinar (June 27, 2019)
- Seriously Ill Population Webinar (July 24, 2019)
- Payment Office Hours (August 6, 2019)
For questions about the model or solicitation process, please email PrimaryCareApply@telligen.com or call 1-833-226-7278.
- Fact Sheet
- Press Release
- CMS Primary Cares Initiative One-Pager (PDF)
- Primary Care First Model Options Overview Slides (PDF)