• CMS Primary Cares Initiative

    New Alternative Payment Models for Primary Care Physicians

    Is this right for my practice?

    The CMS Primary Cares Initiative provides new alternative payment models for primary care physicians. The program includes five new payment model options under two paths: Primary Care First and Direct Contracting.

    Path A

    Primary Care First

    The Primary Care First (PCF) models offer a multi-payer system meant to create opportunities for practices ready to take on more risk through payments based on utilization outcomes.

    Comprehensive Primary Care Plus (CPC+) practices are ineligible for participation in the first year of the program but will be able to apply in 2021 for a Jan. 2022 start.

    Is the PCF model right for your practice?

    Evaluate potential opportunities and risks for your practice. Use the tools below to assess   your practice’s readiness to participate in PCF, including care delivery capabilities, data infrastructure, and potential financial impact.

    PCF offers three ways to participate:

    Option 1

    Participate only in the PCF general model

    How it works:

    The PCF general model alters the payment structure to primary care clinicians from traditional fee-for-service to prospective payments with a potential bonus. Practices accepted into the model will receive payments for primary care services through three mechanisms:

    1. The total primary care payment, which is made up of a risk-adjusted population-based payment (ranging from $28 to $175 per beneficiary per month based on average panel risk) and a flat visit fee (~$40) for each face-to-face primary care visit.
    2. A performance-based adjustment paid quarterly, based on five quality measures and performance on acute hospital utilization. The performance-based adjustment applies to total primary care revenue and ranges from -10% to a bonus of up to 50%.
    3. Standard fee-for-service (FFS) for services provided outside those covered by the flat visit fee, such as procedures and vaccines.

    Option 2

    Participate only in the PCF high-need-populations model

    How it works:

    The high-need-populations PCF option allows PCF practices to opt in to the seriously-ill-population (SIP) portion of the model. SIP patients are determined through claims data and are defined as beneficiaries who have:

    1. multiple co-morbid conditions,
    2. patterns of emergency-department and/or hospital utilization,
    3. the presence of proxies for frailty (i.e., orders for durable medical equipment such as a hospital bed), or
    4. no primary care practitioner.

    In exchange for taking on these patients with uncoordinated care and complex chronic conditions, a higher per-beneficiary per-month (PBPM) payment ($325 for the initial visit, then $275 PBPM) will be made for the initial 12 months the patient is assigned to the practice.

    Palliative care and hospice practices can apply to participate only in the SIP portion of the PCF model.

    If practices participate only in the SIP portion of the PCF model, they are ineligible for the additional population- and performance-based payments but will receive the flat visit fee (~$40) in addition to the PBPM.

    Option 3

    Participate in both the PCF general model and high-need-population model

    How it works:

    Practices choosing to participate in the hybrid PCF and SIP option must meet the eligibility criteria for both models. Hybrid practices will have PCF general patients aligned directly to their panel through voluntary and claims-based attribution. The main difference between the SIP- only and the hybrid option is that hybrid practices can continue to care for SIP- attributed patients once they’ve been transitioned out of the SIP program. These patients will then be attributed to the practice’s PCF general model, and the practice will receive general PCF payments. Alignment between SIP and PCF general is meant to create a seamless care continuum that ensures longitudinal care management.

    SIP-only practices will also be allowed to care for their patients when they transition out of the SIP model; however, the practice will receive standard FFS reimbursement post transition.

    Is this model right for your practice?

    Understanding how many Medicare patients you see, how well you know them, and assessing your comfort with financial risk will be key to determining whether PCF models are right for you. Elements outlined as requirements to participate in PCF models favor practices that are already good at scale, savvy about value-based payment programs, and knowledgeable about their patient populations.

    AAFP analysis shows strong potential for practices:

    • with more than 600 Medicare fee-for-service beneficiaries (but no fewer than 300);
    • already engaged in a value-based payment program with one or more commercial insurers, Medicare Advantage or Medicaid managed care organization;
    • fluent with hierarchical condition category risk scores (ideally with up-to-date HCC scores on their Medicare patients); and
    • that have a firm understanding of their Medicare population's makeup: severity of illness, social factors, etc.


    PCF Timeline