On April 22, the Centers for Medicare and Medicaid Services (CMS) announced the launch of five new alternative payment models in two unique pathways: Primary Care First (PCF) and Direct Contracting (DC). The application for both five-year demonstration programs will be available within the month. Which value-based payment model is the right fit for your practice?
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.
- 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 created a presentation that explains the details of PCF including eligibility, payment options, quality measures, and a crosswalk of how the PCF program compares to CMS’s Comprehensive Primary Care Plus (CPC+) program.
Countdown to Launch
Timeline
The timeline below 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 the coming weeks. The RFA will contain all application and eligibility requirements, as well as other useful information. Watch for future editions of the Weekly Family Medicine Update for more information as it becomes available.
Direct Contracting
CMS’s second pathway and alternative payment model, 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 a 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 presentation.
Please direct any questions to AAFP’s Care Delivery and Payment Strategist Kate Freeman, MPH, or call 913.906.6000 ext. 6168.