Primary Care First & Direct Contracting

On April 22, 2019, the Centers for Medicare and Medicaid Services (CMS) announced the Primary Cares Initiative, a new set of payment models that will transform primary care to deliver better value for patients throughout the healthcare system.

Building on the lessons learned from experiences of previous models, (such as the Comprehensive Primary Care Plus (CPC+) program), the goal of the Primary Cares Initiative is to reduce administrative burdens and empower primary care physicians and other providers to spend more time caring for patients while reducing overall health care costs. Administered through the CMS Innovation Center, the Primary Cares Initiative will provide primary care practices and other providers with five new payment model options under two paths: Direct Contracting and Primary Care First.

To explain these two alternative payment models in greater detail and to help physicians grasp CMS’ eligibility requirements in order to assess whether these payment models align with individual practice goals, the Ohio Academy of Family Physicians enlisted the help of two of our trusted partners at The Health Collaborative to create a 45-minute video.

The video details how payments, incentives, and quality strategies align in the pathway options.

The application for both five-year demonstration programs should be available in the summer of 2019.

Following are additional details, information, and resources on both demonstration programs:

Primary Care First

PCF 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. PCF aims to improve quality, improve patient experience of care, and reduce expenditures. The model will achieve these aims by increasing patient access to advanced primary care services, and has elements specifically designed to support practices caring for patients with complex chronic needs or serious illness.

There are three ways that primary care practices may participate in PCF:
  • Option 1: PCF General Practices will increase patient access to advanced primary care services. This option is designed for practices with advanced primary care capabilities that are prepared to accept financial risk in exchange for flexibility and potential rewards based on practice performance.
  • Option 2: Seriously Ill Population (SIP) CMS will attribute SIP patients lacking a primary care practitioner or care coordination to PCF practices that opt to participate in this model option. This option is designed for practices that have a network of relationships with other care organizations in the community to ensure beneficiaries can access the care best suited to their longer-term needs.
  • Option 3: PCF General & PCF SIP Available to practices that demonstrate the capabilities to participate in both PCF options and meet eligibility criteria for both payment models.

The American Academy of Family Physicians (AAFP) has a webpage and a presentation that explains the details of PCF including eligibility, payment options, quality measures, a crosswalk of how the PCF program compares to CMS’s CPC+ program, and a timeline.

This timeline shows important events related to the launch of PCF. CMS anticipates releasing a Request for Applications (RFA) and posting a payer Statement of Interest in the coming weeks for the first cohort of practices. Practice applications and interested payers will be solicited during summer/fall 2019. The model will launch in January 2020.

Next Steps
Look out for a RFA on the PCF website in July 2019. The RFA will contain all application and eligibility requirements, as well as other useful information.

Direct Contracting

Direct Contracting (DC) is aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS). The payment model options available under DC create opportunities for a broad range of organizations to participate with CMS in testing the next evolution of risk-sharing arrangements to produce value and high quality health care.

DC creates three payment model options for participants to take on risk and earn rewards, and provides them with choices related to cash flow, beneficiary alignment, and benefit enhancements. The payment model options are anticipated to appeal to a broad range of physician practices and other organizations because they 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 FFS or CMS Innovation Center models before.

Extra-large practices and health systems would have additional choices which could be very lucrative, but pose steeper risks (qualifying practices must have 5,000 aligned Medicare FFS beneficiaries). Under the first “professional option,” providers would assume 50% of the risk, including savings and losses. Under the “global option,” providers would take on full risk.

There is also a “geographic option,” in which health systems or insurance plans could assume the risk for the total cost of care for all Medicare FFS beneficiaries in defined communities or geographic region.

Medicare accountable care organizations will be eligible to participate in all three DC options.

For more information on the DC pathway, view the AAFP’s webpage and presentation.

Still have qeustions? Please contact AAFP’s Care Delivery and Payment Strategist Kate Freeman, MPH, or call 913.906.6000 ext. 6168.