• 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

    Deadline Extended: The Centers for Medicare and Medicaid Innovation (CMMI) are now accepting applications through May 21, 2021, for the second cohort of the Primary Care First (PCF) Model. Learn more about PCF here and read the request for applications (RFA).

    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 to participate in the first year of the program but will be able to apply in 2021 for a January 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 for 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 (PBPM) 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 identified through claims data and are defined as beneficiaries who meet both of the following criteria:

    1. Serious illness, defined as at least one of the following:
      •  Hierarchical condition category (HCC) risk score ≥ 3.0
      • HCC risk score between 2.0-3.0 AND two or more unplanned hospital admissions in the previous 12 months
      • Presence of proxies for frailty (i.e., orders for durable medical equipment such as a hospital bed or transfer equipment)
    2. Fragmented care, defined as at least one of the following:
      • No single practice provided 50% or more of the beneficiary’s evaluation and management visits
      • High emergency department or hospital utilization patterns over the previous 12 months

    In exchange for taking on these patients with uncoordinated care and complex chronic conditions, a higher 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 populations 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 FFS 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 HCC 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.

    Path B

    Direct Contracting

    The Direct Contracting (DC) models are built on the NextGen ACO model and offer new forms of population-based payment (PBP), enhanced cash flow options, and an increased flexibility that allows practices the ability to meet beneficiaries’ medical and social needs. The DC model aims to reduce cost and improve the quality of care for beneficiaries in Medicare FFS.


    Direct Contracting offers three models:

    Option 1

    Professional model

    What it includes:

    • Monthly risk-adjusted primary care capitation payment for enhanced primary care services, and
    • 50% shared savings/losses.

    Option 2

    Global model

    What it includes:

    • Monthly risk-adjusted primary care capitation payment for enhanced primary care services OR a monthly risk-adjusted total care capitation payment for all services provided by the DC entity and preferred providers with whom the DC entity has an agreement, and
    • 100% savings/losses. 

    Option 3

    Geographic DC model

    The Geographic (“Geo”) DC model will test whether taking on risk for Medicare FFS beneficiaries in a specific region will improve quality and reduce costs.  To learn more, visit the CMS Geo Fact Sheet.

    Timeline

    Professional and Global PBP:

    • Winter 2019 – Organizations submitted letter of interest (LOI)
    • Summer 2020 – Organizations with completed LOI submitted applications
    • October 2020 – Model launch (Year 0 – onboarding year, performance will not be measured, and payment structure does not change until 2021)
    • April 1, 2021 – Performance period begins
    • Early 2021 – RFA for second round of applications

    For more information, see CMS Direct Contracting Model Options.