Decades of the Academy's payment-reform advocacy have borne fruit in the Center for Medicare and Medicaid Innovation's new Primary Care First(innovation.cms.gov) payment model. For some physicians, the initiative -- announced this past spring, with the first call for applicants issued last month and a start date of Jan. 1, 2021 -- stands to finally re-focus payment on comprehensive and continuous patient-centered family medicine rather than on episodes of care.
AAFP analysis suggests that the PCF program, which uses prospective, risk-adjusted, population-based payments for primary care services, is structurally sound and directionally appropriate. The Academy's modeling indicates that it should consistently work better than the Medicare Quality Payment Program's Merit-based Incentive Payment System, even for those getting the maximum MIPS bonus.
Still, it's a first step, meaning there's not enough fruit to go around yet, and not everyone will find the flavor appealing.
The selective program, for which applications(innovation.cms.gov) are due Jan. 22, will be available to physicians in just 26 states and regions. (Expanding the number of participating states moving forward is an AAFP goal.)
And it seems likely to favor practices that are already good at scale, savvy about value-based payment programs and knowledgeable about their patient populations. Academy analysis shows a sweet spot for those who
- have 300 to more than 600 Medicare fee-for-service beneficiaries (especially those at the higher end);
- are already engaged in a value-based payment program with one or more commercial insurers, Medicare Advantage or Medicaid managed care organization;
- are fluent with hierarchical condition category scores (ideally with up-to-date HCC scores on their Medicare patients); and
- have a firm understanding of their Medicare population's makeup (severity of illness, social factors, etc.).
With these caveats in mind, the Academy has readied tools to help members decide whether to apply.
The AAFP Primary Care First Dashboard(680 KB XLSX) and the AAFP Practice Assessment Checklist(46 KB PDF) are designed to help assess a practice's readiness to participate in PCF, addressing criteria including care delivery capabilities, data infrastructure and potential financial impact.
Geography first: In 2021, PCF will be offered in Alaska, Arkansas, California, Colorado, Delaware, Florida, the Greater Buffalo region of New York, the Greater Kansas City region of Kansas and Missouri, the Greater Philadelphia region, Hawaii, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, the North Hudson-Capital region of N.Y., Ohio and the Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma, Oregon, Rhode Island, Tennessee and Virginia.
Beyond that, applicants must
- be primary care physicians or specific nonphysicians -- clinical nurse specialists, nurse practitioners or physician assistants -- practicing in a primary care specialty,
- have a minimum of 125 attributed Medicare beneficiaries (excluding Medicare Advantage) and
- receive 70% of practice revenue from primary care services.
They also must
- have experience with value-based payment arrangements or payments based on cost, quality and/or utilization performance;
- use 2015 Edition Certified Electronic Health Record Technology;
- support data exchange with other providers and health systems via Application Programming Interface;
- connect to their regional health information exchange, if available; and
- attest to advanced primary care functions such as 24/7 access and empanelment.
Opportunity vs. Risk
Practices accepted into the model will receive payments for primary care services through three mechanisms:
- total primary care payment, 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 of about $40 for each face-to-face primary care visit;
- a quarterly performance-based adjustment based on quality and performance on acute hospital utilization, ranging from negative 10% to a bonus of up to 50%; and
- standard fee-for-service for services provided outside those covered by the flat visit fee, such as procedures and vaccines.
Related AAFP News Coverage
AAFP Advises CMS on Making Value-based Model Work for FPs