CMS Primary Cares Initiatives
CMS Primary Cares Initiative:
New Alternative Payment Models for Primary Care Physicians
Is this right for my practice?
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.
Applications(innovation.cms.gov) for the Jan. 2021 start date of the Primary Care First payment model are being accepted through Jan. 22, 2020. 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.
Is the PCF model right for your practice?
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.
PCF offers three ways to participate:
Participate only in the PCF general model
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:
- The total primary care payment, which is 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 (~$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 fee-for-service (FFS) for services provided outside those covered by the flat visit fee, such as procedures and vaccines.
Participate only in the PCF high-need-populations model
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:
- multiple co-morbid conditions,
- patterns of emergency-department and/or hospital utilization,
- the presence of proxies for frailty (i.e., orders for durable medical equipment such as a hospital bed), or
- no primary care practitioner.
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.
Participate in both the PCF general model and high-need-population model
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.
Webcast: CMS Primary Cares First Models
Watch this AAFP webcast to understand the components of the Primary Care First models, evaluate impact on your practice, and learn about next steps for participation.
Webcast: Primary Care First Model: Interactive Office Hours With CMS
Watch this webcast co-hosted by the AAFP, American College of Physicians (ACP), American Medical Association (AMA) to learn more about the PCF model and get your questions answered before the PCF application deadline of January 22, 2020.
PCF Frequently Asked Questions
Review these frequently asked questions developed by the AAFP, ACP, and AMA to get your questions answered before you apply for PCF.
The deadline to apply for PCF is January 22, 2020.
Should you apply?
This model isn’t for everyone.
The program’s basic design reflects what the AAFP has been pushing toward with its Advanced Primary Care Alternative Payment Model.
The AAFP’s analysis suggests that the PCF program, which uses prospective, risk-adjusted, population-based payments for primary care services, is structurally sound and directionally appropriate. Our 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.
However, there are important items to consider before you decide whether to apply:
Are you eligible?
In order to participate in the PCF models, your practice must meet some fairly specific eligibility criteria.
- be primary care physicians (MD and DO) or non-physicians (CNS, NP, PA) practicing in a primary care specialty (internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine);
- have a minimum of 125 attributed Medicare beneficiaries (excluding Medicare Advantage); and
- have 70% of practice revenue coming 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 (CEHRT);
- support data exchange with other providers and health systems via Application Programming Interface (API);
- connect to their regional health information exchange (HIE), if available; and
- attest on practice application to advanced primary care functions (24/7 access, empanelment, etc.)
Are PCF options available in your state?
Family physicians practicing in 26 states and regions may be eligible to apply.
In 2021, PCF will be offered in: Alaska, Arkansas, California, Colorado, Delaware, Florida, Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma, Oregon, Rhode Island, Tennessee, and Virginia.
Is this model right for your practice?
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.
- with more than 600 Medicare fee-for-service beneficiaries (but no fewer than 300);
- already engaged in a value-based payment program with one or more commercial insurers, Medicare Advantage or Medicaid managed care organization;
- fluent with hierarchical condition category risk scores (ideally with up-to-date HCC scores on their Medicare patients); and
- that have a firm understanding of their Medicare population's makeup: severity of illness, social factors, etc.
Population Based Payment (PBP)
The use of prospective, risk-adjusted population-based payments for primary care services is structurally sound as research shows that capitation at or above approximately 60%(www.healthaffairs.org) allows practices to gain revenue through shifting to team- and non-visit-based care.
Things to Consider
The PBP is based on the average hierarchical condition category (HCC) risk score of your attributed Medicare FFS patients. Gauge the accuracy of the HCC scores of your patients. If you plan to apply, ensure all traditional Medicare patients in your practice receive an Annual Wellness Visit before the start of the program (January 2021).
Flat visit fee for primary care services
The flat visit fee, in combination with the PBP, allows for flexibility of care delivery to meet the specific needs of a practice’s patient population.
Things to Consider
The flat visit fee is billed for primary care services, including evaluation and management services, the Annual Wellness Visit, Advance Care Planning, and Transitional Care Management. Evaluate the impact of shifting to alternative revenue streams in PCF will have on your practice.
Performance-based Adjustment (PBA)
Down side risk capped at -10% with and upside potential of up to 50%.
Things to Consider
Reaching the 50% bonus will be challenging and only the top performing practices will achieve this bonus. Use the PCF Dashboard to assess the impact of a range of likely PBA scenarios (-10%, 0%, 10%, and 20%).
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)(innovation.cms.gov) on the Geographic PBP model. More details on this model will be available in the coming months.
Are you eligible?
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.