Primary Care First Model
On November 20, 2020, Centers for Medicare & Medicaid Services (CMS) announced details of the Primary Care First Payment Model, a five-year endeavor by the CMS Innovation Center. While the Primary Care First Payment Model will not exactly mirror the Direct Primary Care model, it represents an important step by CMS in support of delivering primary care outside of the fee-for-service structure. The incoming Biden Administration will inherit the operational aspects of this and we expect ongoing dialogue on future iterations of the model. The model will be adopted by 916 primary care practices and 37 regional partnerships with commercial, State, and Medicare Advantage plans across 26 regions as of January 1, 2021. The model includes a flat, primary care visit fee based on population outside of traditional administrative requirements and seeks to provide participants with performance transparency. A selection of participating practices will elect to care for the “Seriously Ill Population” (SIP) patients at a higher payment level to reflect the high need, high risk nature of the population. We expect periodic reporting by CMS in the future concerning the progress of the Primary Care First Payment Model and anticipate the knowledge and data gained will only contribute to supporting Direct Primary Care.
CMS Primary Care Demonstrations
Press Conference: New Value-Based Approach to Primary Care
On April 22, 2019, members of the DPC Coalition attended a meeting with HHS Secretary Alex Azar, CMS Administrator Seema Verma, and CMS Innovation Center Director Adam Boehler announcing the roll out of several new CMS Center for Innovation demonstrations designed to improve primary care and continue the drive toward value based payment arrangements for Medicare and Medicaid. The Coalition has worked closely with the Innovation Center to inform CMS of some of the best practices within DPC practices. While the demonstration is not what we would consider a DPC arrangement, it’s a step in the right direction, signaling CMS’ commitment to moving on from fee-for-service or the ACO models of the past. These programs are strictly voluntary; while some practices in the DPC community might not choose to participate in them, there are those practices that might consider the model, particularly for complex patient populations with seriously ill seniors. We will continue to work with CMS and the Administration to help with the transformation towards value based care.
The CMS Primary Cares Initiative, will feature a direct contracting model and an updated version of the Comprehensive Primary Care demonstration that will allow CMS to test how direct payments to physicians can improve care and potentially reduce costs. According to Secretary Azar, these are “models that will transform primary care to deliver better value for patients throughout the healthcare system." CMS Administrator Seema Verma said, “Building on the lessons learned from and experiences of the previous models, the CMS Primary Cares Initiative will reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing overall health care costs."
The primary payment method for these programs will be a flat fee paid by Medicare for primary care services. There are still fee for service elements, such as per-visit fees, and bonus payments for performance based on quality measures, but we are pleased that CMS is moving in the right direction.
There are several different potential payment tracks. Additionally, each of the models outlined below will contain separate tracks for seriously ill patients (SIP)— aimed at patients with multiple complex chronic conditions or those in fee for service with acute illnesses who are not receiving well-coordinated care. The two models presented are called Primary Care First, and Direct Contracting. Details below:
Primary Care First is a set of voluntary five-year payment model options that reward value and quality by offering innovative payment model structures to support delivery of advanced primary care. Primary Care First is based on the underlying principles of the existing CPC+ model design and will be offered to smaller providers in prioritizing the doctor-patient relationship; enhancing care for patients with complex chronic needs and high need, seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes. Requests for applications to the model will come in the next few months for participation starting in January 2020. This program will feature a flat monthly fee per beneficiary, with an opportunity for 50% upside increase based on performance measures, and a potential of 10% downside risk. There will also be a mix of per-visit fees. Performance measures will be based on risk adjusted hospitalization rates. Practices with complex patients in the SIP tracks might be paid a flat fee as much as $300 per beneficiary per month (PBPM). Providers must be Medicare participating providers, but will be allowed to opt in to participate. The program will be available in 26 regions around the country, including the existing regions for the Medicare Shared Savings Program ACOs (which are no longer being awarded). Practices currently participating in CPC+ Track 1 or 2 may choose to end their participation in CPC+ early after the first year of Primary Care First (2021) to participate in this model. In addition, new regions may be identified at this time for an additional round of practice applications and payer solicitations as well.
New Regions Added in Primary Care First:
Current CPC Track 1 and 2 Regions:
Kansas City Area
New York Metro Area
Direct Contracting will be a fully–at-risk program aimed at larger practices with patient populations containing at least 5,000 beneficiaries. The DC payment model options are designed to test and evaluate the next evolution of risk-sharing arrangements to produce value and high quality health care. Building on lessons learned from initiatives involving Medicare Accountable Care Organizations (ACOs), such as the Medicare Shared Savings Program (MSSP) and the Next Generation ACO (NGACO) Model, the payment model options available under DC also leverage innovative approaches from Medicare Advantage (MA) and private sector risk-sharing arrangements. It was made clear that this model is indented as a transition from and ultimately a replacement for CMS’ existing ACO models. There will be two voluntary risk-sharing population based payment (PBP) model options as well as a third payment model option for which CMS is seeking public input:
Professional PBP offers the lower risk-sharing arrangement—50% savings/losses—and provides Primary Care Capitation, a capitated, risk-adjusted monthly payment for enhanced primary care services.
Global PBP offers the highest risk sharing arrangement—100% savings/losses—and provides two payment options: Primary Care Capitation (described above) or Total Care Capitation, capitated, risk-adjusted monthly payment for all services provided by DC Participants and preferred providers with whom the Direct Contracting Entity has an agreement.
Geographic PBP, for which we are seeking public input through an RFI, would offer a similar risk-arrangement as the Global PBP option as potential participants would assume responsibility for the total cost of care for all Medicare FFS beneficiaries in a defined target region. We are seeking public input to further refine the design parameters. Responses to the RFI will be accepted through 11:59 p.m., EDT, May 23, 2019 and can be submitted electronically to DPC@cms.hhs.gov.
While It’s hard to call these programs “simple” we believe they do represent a fairly dramatic evolution of CMS’ thinking about putting primary care up front, with what appears to be a commitment towards much more appropriate payments for primary care in Medicare. There are still many questions around these new CMS models. We do not yet have a full understanding of the actual risk-adjusted payment rates, a full accounting of the administrative requirements, and any reporting burden left to primary care providers. They do plan to offer fairly open access to downstream patient claims data for purposes of measurement, and at least monthly updates to the current CPC dashboard for smaller practices to evaluate progress. We also have very few details on specific means of patient enrollment. These plans are billed as “multi-payer,” in nature, but outside of the Geographic PBP track, for which CMS seeks comment, there is little indication of what Health Plan or hospital system participation would be expected.
We will continue to work with HHS with a goal of getting to a model that would allow beneficiaries in CMS programs to choose a direct primary care provider independently, or as a part of a Medicare Advantage plan or health system or plan. There will be public webinars and educational sessions in the coming weeks.
Program Details can be found here: https://www.cms.gov/newsroom/press-releases/hhs-news-hhs-deliver-value-based-transformation-primary-care
Seriously Ill Population Presentation
Primary Care First