Center for Medicare and Medicaid Innovation Primary Care Models
Learn about the three latest payment models putting your specialty at the center of a strategy to ensure that all Americans have access to high-quality, affordable, and person-centered care.
What is the Center for Medicare and Medicaid Innovation?
CMMI is a part of the Centers for Medicare & Medicaid Services (CMS) within the U.S. Department of Health and Human Services. CMMI was created by the Affordable Care Act (ACA) in 2010 to test new payment and service delivery models that could improve care quality and efficiency for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. Elevating primary care is central to the Innovation Center’s strategy.
Announced in June 2023, the Making Care Primary (MCP) model includes three tracks that each focus on goals aimed at creating pathways to enter value-based payment. MCP is taking applications now through November 30, and will launch in 2024.
Making Care Primary aims to:
- Ensure patients have access to and receive primary care that is integrated, coordinated, person-centered, and accountable.
- Create a pathway for primary care organizations and practices – especially small, independent, rural, and safety net organizations – to enter value-based arrangements.
- Improve quality of care and health outcomes for patients while reducing program expenditures.
Eligibility Criteria
The model will be tested in eight states based on agreements with state Medicaid agencies regarding alignment around program principles and model dimensions that matter to family physicians. The eight states are Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington.
Organizations ineligible to participate include rural health clinics, concierge practices, current Primary Care First (PCF) practices, current Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model participants, and grandfathered tribal federally qualified health centers (FQHCs). Concurrent participation in MCP and the Medicare Shared Savings Program (MSSP) will not be allowed after the first six months of the model.
Program Tracks
The model includes three tracks that each focus on specific goals. The AAFP has created profiles an a calculator to help you decide which track might be right for you and to estimate the potential revenue.
Track 1. Building Infrastructure
Participants work to establish a foundation for implementing advanced primary care services such as patient risk stratification, data review, workflow development, chronic disease management, and social determinants of health (SDOHs) screening and referral. Payment for primary care will remain fee-for-service (FFS)-based while CMS provides financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities. Participants begin earning financial rewards for improving patient health outcomes.
Track 2. Implementing Advanced Primary Care
Participants build on Track 1 requirements by partnering with social service professionals and specialists, implementing care management services, and screening for behavioral health conditions. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue some financial support for building advanced care delivery capabilities, even as participants are able to earn increased financial rewards for improving outcomes.
Track 3. Optimizing Care and Partnerships
Participants begin using quality improvement frameworks to optimize and improve workflows, address silos to improve care integration, develop social services and specialty care partnerships, and deepen connections to community resources. Payment for primary care will shift to fully prospective, population-based payment while CMS continues minimal financial support to sustain care delivery activities. Participants can earn even greater financial rewards for improving patient health outcomes.
AAFP:
- Policymakers Heed AAFP’s Call to Bolster Primary Care Practices and Improve Competition | Press Release
- Primary Care-focused APM Checks AAFP Advocacy Boxes | AAFP News
- Washington Hears Us on Consolidation and Physician Payment | A Word From the President
- Here’s What I Just Told Senators About Health Care Consolidation | In the Trenches
CMS:
Never tried value-based payment? Want to know why you should? Members share their experiences.
Primary Care First
Primary Care First (PCF) aims to provide increased flexibility to primary care physicians to support innovative care delivery approaches based on patient population needs and preferences. It is a voluntary five-year, multipayer model being tested in 26 regions. Applications to participate are currently closed.
About PCF
PCF alters the payment structure for primary care clinicians from traditional fee-for-service (FFS) to prospective payments with a potential bonus. Practices in model receive payments for primary care services through three mechanisms:
- The total primary care payment (TPCP), 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.
- 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%.
- Standard FFS for services provided outside those covered by the flat visit fee, such as procedures and vaccines.
Resources
AAFP:
- AAFP Primary Care First Dashboard – CPC+ Practices | Excel spreadsheet
- AAFP Primary Care First Dashboard – Non-CPC+ Practices | Excel spreadsheet
- AAFP Practice Assessment Checklist | PDF download
- Primary Care First Model Question & Answer Session with CMMI Staff | PDF download | Member login required
- Primary Care First Model: Interactive Office Hours With CMS | Recorded webinar
CMS:
About ACO REACH
The ACO Realizing Equity, Access, and Community Health (ACO REACH) Model has three key aims:
- Advance health equity to bring the benefits of accountable care to underserved communities
- Promote provider leadership and governance
- Protect beneficiaries and the model with more participant vetting, monitoring, and greater transparency
ACO REACH (previously call the Global and Professional Direct Contracting Model) is a five-year voluntary model that began in April 2021 and includes two voluntary risk-sharing options. In each option, participating providers accept Medicare claims reductions and receive at least some of their compensation from their ACO.
The two participation options are:
- Professional – Includes monthly risk-adjusted primary care capitation payment for enhanced primary care services and 50% shared savings/losses.
- Global - 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 direct contracting (DC) entity and preferred providers with whom the DC entity has an agreement and 100% savings/losses.
Resources