Primary Care First Explained: Everything independent physicians need to know about Medicare’s new quality program for primary care

This post is the first in a series of posts that aim to educate independent primary care practices about CMS’ recently announced Primary Cares Initiative.

As policy programs continue to center around value-based care, Elation is here to ensure that independent practices and innovative organizations like ACOs and IPAs are at the forefront of this new healthcare landscape. By keeping you informed, we’re committed to supporting small practices’ participating in programs that focus on prioritizing high-quality, patient-centered care.

Summary of everything independent physicians need to know about Primary Care First:

• Geared towards smaller practices who provide primary care services, and centered around comprehensive care management and coordination for Medicare patients and those that are seriously ill and high risk.
• Need a minimum of 125 Medicare beneficiaries to qualify for participation. Providers are incentivized for keeping patients out of hospitals (i.e. measured performance against hospital utilization).
• Due to 50% upside, doctors who earn $200,000 today could earn up to $300,000, depending on their ability to keep patients healthier.
• Must be using a 2015 CEHRT platform with API data exchange capabilities and a connection to their regional Health Information Exchange (HIE), to facilitate care coordination, which Elation can support.

Building on the underlying principles of its current Comprehensive Primary Care Plus (CPC+) model, the Centers for Medicare & Medicaid Services (CMS) Innovation Center has announced the Primary Care First initiative, designed to increase rewards and reduce administrative burden for independent physicians. Primary Care First (PCF) is one of two tracks that will be launched as part of the CMS Primary Cares Initiative, set to launch in 2020. The new initiative involves 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 intended for smaller practices, and will offer providers a simple “flat stream of revenue” for each patient. When a patient stays healthy and out of the hospital, these practices will get paid a bonus, but if a patient ends up sicker than expected, these practices will bear responsibility for the extra spending up to a certain share of their practice’s revenue.

Direct Contracting is also being introduced as a track within the Primary Cares Initiative. Direct Contracting is “a set of three voluntary payment model options aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS).” Through the multiple tracks and payment options included in the Primary Cares Initiative, CMS is “testing the next evolution of risk-sharing arrangements to produce value and high quality health care.”

The PCF initiative was developed based on input from primary care clinician stakeholders. Reporting requirements that have kept physicians from providing quality care for their patients have been a concern, especially for independent practices. CMS states that the PCF initiative will prioritize the doctor-patient relationship, enhance care for patients with complex needs, reduce administrative burden, and focus financial rewards on improved health outcomes.

In fact, according to CMS, PCF “fosters practitioner independence by increasing flexibility for primary care, providing participating practitioners with the freedom to innovate their care delivery approach based on their unique patient population and resources.  Primary Care First rewards participants with additional revenue for taking on limited risk based on easily understood, actionable outcomes.”

PCF aims to hold independent physicians accountable for healthcare quality outcomes with a simple payment structure. The new structure includes:

• a payment mechanism that allows care to be driven by clinicians rather than administrative requirements and revenue cycle management;
• 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 small downside (10% of revenue) incentive to reduce costs and improve quality, assessed and paid quarterly.

Independent physicians interested in participating in the new CMS Primary Care First payment initiative must meet a set of eligibility requirements that include providing healthcare services in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine in one of the selected Primary Care First regions. Additionally, the independent physician must “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).”

2020 Regions

Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

CMS anticipates releasing a Request for Application in the spring of 2019 for the first group of Primary Cares Initiative participants. Practices and payers will begin participation in the model in January 2020.