The Centers for Medicare & Medicaid Services (CMS) introduced five value-based transformation models for primary care services. The Department of Health and Human Services and CMS believe this new Primary Cares Initiative “will transform primary care to deliver better value for patients throughout the healthcare system.” CMS Administrator Seema Verma said, “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost while allowing clinicians to focus on what they do best: treating patients.” Read the CMS press release.
The models are separated into two categories: Primary Care First (PCF) and Direct Contracting (DC):
The PCF model is a set of two voluntary programs: PCF General and PCF High Needs Population. The model seeks to improve 1) access and continuity, 2) care management, 3) comprehensiveness and coordination, 4) patient and caregiver engagement, and 5) planned care and population health for individual primary care practice sites. The PCF model is a voluntary, five-year model that is scheduled to begin in January 2020. Eligible Primary Care practitioners include MDs, DOs, CNSs, NPs, and PAs certified in internal medicine, general medicine, geriatric medicine, family medicine and palliative medicine.
This payment model option tests whether delivery of advanced primary care can reduce the total cost of care and focus on advanced primary care practices that are willing to assume:
- financial risk in exchange for reduced administrative burden and performance-based payments;
- a population-based payment to provide more flexibility in the provision of patient care along with a flat primary care visit fee; and
- a performance-based adjustment providing an upside of up to 50% of revenue as well as a 10% downside of revenue incentive to reduce costs and improve quality, assessed, and paid quarterly. CMS will use a focused set of clinical quality and patient experience measures to assess the quality of care.
High Need Population Payments Model
This payment model option encourages advanced primary care practices, including clinicians enrolled in Medicare that typically provide hospice and palliative care services, to take responsibility for high-need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination. The payments in this model will be higher than the PCF General payment model option to reflect the complex, chronic needs of this seriously ill population.
The DC model is a set of three voluntary programs, DC Professional, DC Global and DC Geographic. The model seeks to reduce expenditures and enhance the quality of care for Medicare fee-for-service beneficiaries. The payment model options are expected to reduce burden, support a focus on beneficiaries with complex, chronic conditions, and encourage participation from organizations that have not typically participated in Medicare fee-for-service or CMS Innovation Center models.
Direct Contracting – Professional
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.
Direct Contracting – Global
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 DC entity has an agreement.
Direct Contacting – Geographic
CMS is still seeking public input through an RFI, but intends to offer a similar risk-arrangement as the Global population-based payment option as potential participants would assume responsibility for the total cost of care for all Medicare FFS beneficiaries in a defined target region.