• In The Trenches

    Here's What You Need to Know About Primary Care First

    "Getting paid is her forte, each and every day, true player way."
    -- Dr. Dre & Blackstreet


    On Oct. 30, the Washington Nationals defeated the Houston Astros 6-2 in Game 7 of the World Series, completing one of the greatest postseason runs in major league history. The 2019 World Champion Washington Nationals overcame a horrendous April and May, staved off five elimination games in the postseason and defeated the team with the best record in baseball four times, on the road, to claim the team's first championship. They also found a way to make 40,000 adults happily sing "Baby Shark" in public.

    Moving on to health care …

    On Oct. 24, the Center for Medicare and Medicaid Innovation released its much-anticipated request for applications for the Primary Care First program. CMMI first announced the advent of PCF in April as part of the Primary Cares Initiative launch, and the program is now set to officially start in 2021. Obviously, the new PCF program is too complex to fully describe in one blog post, but I will provide the key facts in this high-level summary.

    The AAFP is preparing a more in-depth analysis of the model and supporting materials, including a calculator to assist you in evaluating impact at the practice level. Keep an eye on the AAFP's CMS Primary Cares Initiative webpage for these new resources later this month.

    Model Options

    Eligible family physicians practicing in one of the 26 states/regions selected for inclusion in the program may apply to participate in one of three payment model options.

    The general PCF payment model focuses on practices that provide advanced primary care functions and are ready to assume financial risk in exchange for reduced burden and bonus opportunities based on performance.

    The PCF High-need Populations payment model promotes care for high-need, seriously ill beneficiaries who lack a primary care physician or effective care coordination.

    Certain practices can participate in both models.

    Eligibility Criteria

    To be eligible to participate, applicants must

    • practice in family medicine, internal medicine, general medicine, or hospice and palliative care;
    • have a minimum of 125 attributed Medicare fee-for-service beneficiaries;
    • have 70% of practice revenue generated by primary care services;
    • use 2015 Edition certified EHR technology, support data exchange with other clinicians and health systems via an application programming interface, and connect to a regional health information exchange if available;
    • have experience with value-based payment arrangements; and
    • attest to application within the practice of the five advanced primary care functions of access and continuity, care management, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health.

    Deadlines and Timeline

    Payer solicitation of interest is due Dec. 9. Applications are due from practices on Jan. 22 and from payers on March 13.

    Practices and payers will be selected in spring 2020, with onboarding beginning in the summer and the model launch slated for January 2021.

    A second round is scheduled to begin in January 2022.

    Payment Details

    PCF will provide participating practices a total primary care payment, which includes a prospective professional population-based payment in addition to a flat primary care visit fee for qualifying patient encounters. Practices also will receive a performance-based adjustment.

    The total primary care payment is designed to reduce administrative complexity by eliminating fee-for-service coding, documentation and billing.

    Professional Population-based Payment

    Prospective payment for services provided inside or outside the office are adjusted based on average hierarchical condition category risk of all attributed patients. This payment is

    • $28 for average HCC score <1.2,
    • $45 for average HCC score of 1.2 to 1.5,
    • $100 for average HCC score of 1.5 to 2 and
    • $175 for average HCC score >2.

    Flat Primary Care Visit Fee

    Participating practices will receive a $40.82 flat payment for the following face-to-face encounters provided by a physician or other qualified health care professional:

    • office/outpatient visit evaluation and management codes 99201-99205 and 99211-99215;
    • prolonged E/M codes 99354-99355;
    • transitional care management services codes 99495-99496;
    • home care E/M codes 99324-99328, 99334-99337, 99339-99345 and 99347-99350;
    • advance care planning codes 99497 and 99498; and
    • Welcome to Medicare/annual wellness visits codes G0402, G4038 and G0439.

    Beneficiary Cost-sharing

    Beneficiaries are responsible for 20% of the physician fee schedule-allowed amount for the code that a physician bills to receive the flat visit fee rather than 20% of the flat primary care visit fee of $40.82. Practices are able to reduce or waive cost-sharing, but they assume responsibility for those costs. If a practice plans to waive cost-sharing, it must indicate its intentions on the PCF practice application.

    Performance-based Adjustment

    The PBA provides practices an opportunity to increase revenue by up to 50% of its total primary care payment based on acute hospital utilization performance. Downsize risk is capped at negative 10%. The PBA has the following three evaluations.

    National adjustment -- Practices that exceed the 50th percentile national benchmark are eligible for PBA based on their performance against the regional adjusted benchmark. If a practice fails to meet the 50th percentile of the national benchmark but is above the 25th percentile regionally, it gets no PBA. If it performs below the 25th percentile on the regional benchmark, it will receive a negative 10% adjustment.

    Regional adjustment -- Practices that exceed the 50th percentile on the national benchmark are eligible for positive PBA based on performance against regional peers. Those in the

    • top 10% will receive a 34% adjustment to total primary care payment,
    • 11% to 20% range will receive a 27% adjustment,
    • 21% to 30% range will receive a 20% adjustment,
    • 31% to 40% range will receive a 13% adjustment,
    • 41% to 50% range will receive a 6.5% adjustment,
    • 51% to 75% range will receive no adjustment and
    • bottom quartile will receive a negative 10% adjustment.

    Continuous improvement adjustment -- Practices are eligible for a continuous improvement bonus of up to one-third of the total PBA amount if they achieve their improvement target. Continuous improvement bonuses are based on a practice's regional performance. Those in the

    • top 10% will receive a 16% adjustment to total primary care payment,
    • 11% to 20% range will receive a 13% adjustment,
    • 21% to 30% range will receive a 10% adjustment,
    • 31% to 40% range will receive a 7% adjustment,
    • 41% to 75% range will receive a 3.5% adjustment and
    • bottom quartile will receive a 3.5% adjustment.


    The PCF program reflects the major components included in the AAFP's Advanced Primary Care Alternative Payment Model, which was recommended for testing by the Physician-Focused Payment Model Technical Advisory Committee in December 2017. As I have stated numerous times since April, the model is "directionally appropriate." The use of prospective, risk-adjusted, population-based payments for primary care services is structurally sound. Retaining the ability to provide comprehensive services on a fee-for-service basis is important.

    Although the model is directionally appropriate, the adequacy of the payment levels in the PCF program is debatable. The AAFP team (hat tip to care delivery and payment strategist Kate Freeman, M.P.H.) has modeled the PCF program and found it to be consistently better than the Medicare Quality Payment Program's Merit-based Incentive Payment System -- even for those who get the maximum MIPS bonus. Where our modelling of PCF starts to waver is among practices with beneficiary counts below 500-600 and it gets really, really shaky when there are fewer than 300 beneficiaries.

    I still see PCF as a positive advancement in our journey toward payment models that align with and drive advanced primary care, BUUUUUUTTTTTTT be careful. This model isn't for everyone.

    Here are my key takeaways on the model:

    • Scale matters. If your practice has more than 300 Medicare fee-for-service beneficiaries, think about it. If you have more than 600 beneficiaries, think very seriously about it. If you have more than 1,000 beneficiaries, go for it.
    • Experience is important. If you are engaged in a value-based payment program with one or more commercial insurers, Medicare Advantage or Medicaid managed care organization, you are better positioned to be successful because of your experiences with population-based payment and evaluation models.
    • Get smart on HCCs. If you are fluent with HCC scores and you have up-to-date HCC scores on your Medicare patients, you're ahead of the curve.
    • Know your patient population. It is critical that you understand the composition of your Medicare population, their severity of illness, social factors, etc.

    Our AAFP team is here to help you as you and your practice evaluate the model and consider whether to participate. We also are working closely with our state chapters, so I would encourage you to be in contact with them, as well. Remember, this is a voluntary program -- you do not have to participate.

    Good luck and stay connected.

    Now, join me in singing "Baby Shark:" Baby Shark, doo doo doo doo doo doo. Baby Shark, doo doo doo doo doo doo. Baby Shark, doo doo doo doo doo doo. BABY SHARK!

    Shawn Martin is senior vice president of advocacy, practice advancement and policy.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.