CMS Primary Cares Initiatives

MACRA Basics

CMS Primary Cares Initiative

New Alternative Payment Models for Primary Care Physicians

CMS Primary Cares Initiative, the program recently announced by the Centers for Medicare & Medicaid Services (CMS), provides new alternative payment models for primary care physicians. The program includes five new payment model options under two paths:

Learn more about what each option entails.


Primary Care First

The Primary Care First (PCF) models are designed to be transparent, simple, and create opportunities for practices ready to take on more risk through payments based on utilization outcomes.

There are two models in PCF:

PCF - General

What it includes:

  • Risk-adjusted population-based payment (ranging from $24 to $175 PMPM based on average panel risk).
  • Flat visit fee ($50) for each face-to-face primary care visit with a primary care physician (procedures and vaccines will still be billable through fee-for-service).
  • Upside performance-based payment that is potentially up to 50% of total revenue.
  • Downside risk is capped at 10% of revenue. This incentive is intended to reduce costs and improve outcomes. 

PCF - High-need Populations

How it works:

The High Need Populations PCF model allows PCF practices to opt in to the Seriously Ill Population (SIP) portion of the model. SIPs are determined through claims data and are defined as having multiple co-morbid conditions, patterns of emergency department and/or hospital utilization, the presence of proxies for frailty, and no primary care physician. In exchange for taking on these patients with uncoordinated care and complex chronic conditions, a higher PMPM payment ($325 for the initial visit then $275 PMPM) 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 only participate 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 ($50) in addition to the PMPM.

Eligibility Criteria

Practices will be eligible to apply if they meet the following criteria:

  • Primary care physicians (MD and DO) and non-physicians (CNS, NP, PA), practicing in a primary care specialty (internal medicine, general medicine, geriatric medicine, family medicine and hospice and palliative medicine)
  • A minimum of 125 attributed Medicare beneficiaries (excluding Medicare Advantage)
  • 70% of practice revenue coming from primary care services
  • Experience with value-based payment arrangements/payments based on cost, quality, and/or utilization performance
  • Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE) (in regions where one is available)
  • Attest on practice application to advanced primary care functions (24/7 access, empanelment, etc.
  • Participation is limited to eligible physicians and practices, as outlined above, in the following states/regions:
    • Comprehensive Primary Care Plus (CPC+) states/regions: Arkansas, Colorado, Hawaii, Greater Kansas City Region of Kansas and Missouri, Louisiana, Michigan, Montana, Nebraska, North Dakota, Greater Buffalo Region of New York, North Hudson-Capital Region of New York, New Jersey, Ohio and Northern Kentucky Region, Oklahoma, Oregon, Greater Philadelphia Region of Pennsylvania, Rhode Island, and Tennessee
    • CPC+ participants are ineligible for participation during the first year of the PCF model
    • New states/regions added for PCF: Alaska, California, Delaware, Florida, Maine, Massachusetts, New Hampshire, and Virginia
    • Regions were selected based on CPC+ regions and regions with limited CPC+ comparison group practices

Timeline

  • April 22, 2019 – CMS Primary Cares Initiative announced
  • April 30, 2019 – Overview Webinar
  • May 16, 2019 – Overview Webinar
  • Spring 2019 – Practice applications open
  • Summer 2019 – Practice applications due and payer solicitation begins
  • Fall-Winter 2019 – Practices and payers selected
  • January 2020 – Model launches
  • April 2020 – Payment changes begin
  • Mid-2020 – Second round applications
  • January 2021 – Second round begins

For more information, see the CMS PCF web page(innovation.cms.gov) and fact sheet(links.govdelivery.com).


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 fee-for-service. The three DC models are:

Professional Population-based Payment  

What it includes:

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

Global Population-based Payment  

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.
  • 100% savings/losses.
     

Geographic Population-based Payment  

CMS has issued a Request for Information (RFI)(links.govdelivery.com) on the Geographic PBP model. More details on this model will be available in the coming months.
 

Eligibility

Organizations will be eligible to apply if they meet the following criteria:

  • There are no geographic limitations on the DC model.
  • Professional PBP and Global PBP: minimum of 5,000 attributed Medicare lives.
  • Geographic PBP: proposed minimum of 75,000 beneficiaries in target region.
  • All participants must submit a non-binding letter of intent (LOI) before applying.
  • Organizations operating in the Medicare Advantage program and Medicaid Managed Care Organizations that provide Medicaid benefits for full-benefit dually eligible beneficiaries will be eligible to apply.
  • Subject to RFI responses, the Geographic PBP model would encourage participation from innovative organizations (e.g., health plans, health care technology companies, and others) that want to contract with physicians and suppliers and take risk for a Medicare FFS beneficiary population in a defined geographic region.
  • Medicare ACOs will be eligible to participate in all three DC payment model options.

Timeline

Professional and Global Population-based Payment:

  • Summer-Fall 2019  – Organizations submit LOI
  • Fall 2019 – Organizations with completed LOI submit applications
  • Fall-Winter 2019 – Organizations selected
  • January 2020 – Model launch (Year 0 – onboarding year, performance will not be measured and payment structure does not change until 2021)
  • January 2021 – Performance period begins

Geographic Population-based Payment:

  • Pending RFI – Organizations submit LOIs, applications, and are selected to participate
  • January 2020 – Model launch (Year 0)
  • January 2021 – Performance period begins

For more information, see the CMS DC web page(innovation.cms.gov) and fact sheet(www.cms.gov).