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CMS Primary Cares Initiative-Is Your Practice Ready to Accept the Challenge?

Friday, May 24, 2019
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Overview

The U.S. Department of Health and Human Services and Centers for Medicare and Medicaid Services (CMS) recently announced five new primary care payment models under the Primary Care First (PCF) and Direct Contracting (DC) tracts.  Titled “CMS Primary Cares Initiative,” the overall objective of this program is to reduce administrative burdens and empower primary care providers to spend more time with patients while reducing overall healthcare costs.

Background

Primary Care First

Primary Care First payment options are risk based payment models with a small downside risk that will reward practices for the delivery of advanced primary careactivities and be accountable for patient outcomes. The ultimate goal of these payment models is to reduce the overall cost of care and the administrative burdens associated with caring for these patients. Primary Care First is based on the underlying principles of the Comprehensive Primary Care (CPC+) model design.

Primary Care First-High Need Populations model is designed for practices who are willing to take responsibility for high need, seriously ill patients who currently lack access to primary care and/or effective care coordination.

Primary Care First includes the following comprehensive primary care functions:

  • Access and continuity
  • Care management
  • Comprehensiveness and coordination
  • Patient and caregiver coordination
  • Planned care and population health

The specific approaches to delivering advanced primary care will be determined by each practice. The performance period is five years commencing in January 2020.  Participation in either model is voluntary.

In order to assess the quality of the care being delivered by the practice and earn a positive performance based adjustment to their primary care revenue, quality measures including a  patient experience of care survey, controlling high blood pressure, diabetes hemoglobin A1c testing, colorectal cancer screening, and advance care planning will be measured.

The application process will commence in late spring of this year. In order to be eligible to participate, primary care practices must have advanced primary care capabilities and be prepared to accept increased financial risk in exchange for flexibility and potential rewards based on practice performance. Eligible applicants are primary care practices that:

  • Are located in one of the selected Primary Care First regions
    • Greater Buffalo and North-Hudson-Capital are the two New York State Primary Care First regions
  • Include primary care practitioners (MD, DO, CNS, NP, and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine.
  • Provide primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location
  • Have primary care services account for at least 70% of the practices’ collective billing based on revenue. In the case of a multi-specialty practice, 70% of the practice’s eligible primary care practitioners’ combined revenue must come from primary care services.
  • Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.
  • 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).
  • Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team.
  • Can meet the requirements of the Primary Care First Participation Agreement

Direct Contracting

Direct Contracting includes three payment model options that are aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS). All three models are risk sharing arrangements with varying levels of risk depending on which model is selected and provide choices related to cash flow through Population-Based Payment (PBP), beneficiary alignment, and benefit enhancements.

Direct Contracting-Professional will bear risk for 50% of shared savings/shared losses on the total cost of care for Medicare Part A and B services for aligned beneficiaries. Direct Contracting Entities (DCEs) will receive monthly capitation payments equal to seven percent of the total cost of care for enhanced primary care services (primary care capitation).

Direct Contracting-Global will bear risk at 100% of shared savings/shared losses on the total cost of care for Medicare Part A and B services for aligned beneficiaries. DCEs will be able to choose between primary care capitation explained above and Total Care Capitation. Total Care Capitation is a capitated, risk-adjusted monthly payment for all services provided by DC Participants and Preferred Providers with whom the DCE has an agreement with.

Direct Contracting-Geographic will bear risk at 100% of shared savings/shared losses on the total cost of care for Medicare Part A and B services for aligned beneficiaries in a target region. DCEs will be selected as part of a competitive application process and must commit to providing CMS a specified discount amount off total costs of care for the defined target region. DCEs will be able to choose between Total Care Capitation or assume full financial risk while having CMS continue to make FFS payments to all providers in the target region.

Direct Contracting entities should have at least 5,000 aligned Medicare FFS beneficiaries in order to be considered for participation. The CMS Innovation Center will request a non-binding Letter of Intent (LOI) from organizations interested in the Professional or Global options. Interested parties must provide an LOI in order to participate in the Request for Applications (RFA) for these two programs. As indicated above, the Geographic option will involve a competitive bidding process with CMS.

The DC payment options will start in January 2020 with an initial alignment year for organizations that want to align beneficiaries to meet the minimum beneficiary requirements. Performance periods will begin in January 2021 and will be for five years.

What You Can Do

Review the requirements to determine if your practice is eligible to participate in either of the tracks. For example, if you are leaning towards the Primary Care Tract, is your practice located in one of the Primary Care First Regions? In addition, does your practice have recent experience managing under a risk-based environment for the care of patients? And, even if your practice is not located in one of the Primary Care First regions, what would be the impact from the Primary Cares First initiative on your practice?

CMS has created a web page labeled “Primary Care Model Options” at the following link:

https://innovation.cms.gov/initiatives/primary-care-first-model-options/

This webpage provides up to date information on the application process and webinar dates for interested stakeholders.

For further information contact Richard T. (Terry) Lang, FHFMA, CPA