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.
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.
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.
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:
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:
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.
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.
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: