The Centers for Medicare & Medicaid Services (CMS) announced the Primary Cares Initiative, consisting of five new voluntary payment model options under two paths: primary care first (PCF) and direct contracting (DC).
Administered through CMS’ Innovation Center, the new models build on the experience of the Medicare Shared Savings Program and Next Generation Accountable Care Organization (ACO) model and include:
- PCF — general;
- PCF — high-need populations;
- DC — global;
- DC — professional; and
- DC — geographic.
Primary Care First
The PCF path offers two voluntary five-year payment model options — general and high-need populations — based on the underlying principles of the existing Comprehensive Primary Care Plus (CPC+) model design. Participants will receive a population-based payment along with a flat primary care per-visit fee, and will be subject to two-sided risk based on cost and quality performance.
The PCF general option is designed for advanced primary care practices that care for complex, chronically ill patients and are ready to assume increased financial risk in exchange for potential rewards based on practice performance.
The PCF high-need populations option encourages primary care practices, including those that provide hospice and palliative care services, to take responsibility for high need, seriously ill beneficiaries who lack a primary care practitioner or effective care coordination.
Participating practices are expected to meet standards that reflect quality care to be eligible for a positive performance-based adjustment to their primary care revenue. Measures include a patient experience of care survey, controlling high blood pressure, diabetes hemoglobin A1c poor control, colorectal cancer screening, and advance care planning.
The PCF model options are available to practices not currently participating in the CPC+ model, but located in the 18 existing CPC+ regions. Additionally, practices in these regions also may submit an application: Alabama, California, Delaware, Florida, Maine, Massachusetts, New Hampshire, and Virginia.
The PCF model will run from Jan. 1, 2020, to Dec. 31, 2025.
Direct Contracting
The three DC payment model options focus on care for patients with complex, chronic needs and seriously ill populations, as well as a voluntary option that allows beneficiaries to align with the health care provider of their choosing.
While the PCF model options focus on individual primary care practice sites, the DC five-year payment model options aim to engage a wider variety of organizations serving larger patient populations, such as ACOs, Medicare Advantage plans, and Medicaid managed care organizations.
Depending on the chosen model option, participants will receive a fixed monthly payment that can range from a portion of anticipated primary care costs to the total cost of care. Participants in the global option will bear full financial risk (100 percent) of shared savings and losses on the total cost of care (i.e., all Part A and Part B services) for aligned beneficiaries, while those in the professional payment model option will bear risk for 50 percent of shared savings and losses. As with the PCF model, quality performance will impact final shared savings and losses, with a set of quality measures that focuses more on outcomes and beneficiary experience than on process.
To further refine the geographic DC payment model option, CMS seeks additional input from the public through a request for information. The geographic option is expected to begin January 2021. Submit comments to DPC@cms.hhs.gov by May 23.
This spring, CMS will request a letter of intent from organizations interested in the DC global and professional model options, set to begin Jan. 1, 2020. Subsequently, the agency will release a request for applications, which will provide additional details, including eligibility requirements, payment methodology, and selection criteria.
Additional Information
CMS will host four webinars on the PCF model on:
- Tuesday, April 30, at noon ET;
- Tuesday, April 30, at 3 p.m. ET;
- Thursday, May 16, at noon ET; and
- Thursday, May 16, at 3 p.m. ET.
Webinars on the DC model will be held:
Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.
