Primary Care First: New Model for Financial Rewards

CMS Primary cares patient in wheelchair

Just when it seems like everything is running amok in the way primary care providers treat patients and get fairly reimbursed for their efforts, a new development is on the horizon that might actually make a difference in the way patients are treated. Doctors often express frustration with increasingly complex repayment methods, and frequently feel like they are being prevented from providing the highest levels of care.

Many long for a return to the “good old days,” where they could focus on primary care, get paid for providing value of care instead of quantity, and return the patient to the center of their focus. That day might finally be here!

On April 22, 2019, the U.S. Department of Health and Human Services and Centers for Medicare & Medicaid Services (CMS) announced the CMS Primary Cares Initiative. This is a new set of payment models that is designed to transform primary care in order to deliver better value for patients throughout the entire healthcare system.

The stated goals of the CMS Primary Cares Initiative are to foster independence and reward outcomes. These will be achieved by reducing administrative burdens and encouraging primary care providers to spend more time caring for their patients. The hope is that it will also reduce overall health care costs by promoting greater patient involvement and focusing on preventative care as opposed to more expensive forms of care management once a disease has progressed to a high-maintenance state.

The CMS Primary Cares Initiative creates five payment models under two paths: Primary Care First and Direct Contracting. All five models focus on care for chronically and seriously ill patients. Under the Primary Care First path, primary care practices and other providers will have two payment model options:

  1. Primary Care First (PCF) – General
  2. Primary Care First (PCF) – High Need Populations

According to CMS, the first performance period is scheduled to begin on January 1, 2020 in 26 regions (regions are statewide unless otherwise noted):

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

This Knowledge Drop will take an advance look at what is anticipated for this program and explore some ways that medical practices in the designated areas can adapt to this new model in order to improve patient care and reap increased financial rewards.

What Are The Value Based Programs?

As most doctors realize, primary care is vital to the efficient functioning of our healthcare system. Doctors have the first opportunity to interact with patients, observe symptoms, discuss preventative care, and manage high-risk cases. With this development, the federal government is finally acknowledging an acute need to strengthen the role of primary care, as well as provide critical support for Medicare beneficiaries with serious illnesses.

The general payment option available through Primary Care First will test whether the delivery of advanced primary care can reduce the overall costs of medicine. It will focus on advanced primary care practices that are prepared to assume some financial risk in exchange for a reduced administrative burden and payments based on improved performance.

The second payment model option will concentrate on practices consisting of high-need and seriously ill patient populations. These are practices which typically provide palliative or hospice care services and those that care for seriously ill beneficiaries who function without primary care practitioners or effective care coordination.

Primary Care First places patients at the center by emphasizing strong doctor-patient relationships. By reducing administrative requirements, practitioners will free up more time to spend with patients during in-person appointments or manage care through an online portal. CMS plans to prioritize patient choice in assigning Medicare beneficiaries to Primary Care First practices.

How Was the Primary Care First Model Designed?

Primary Care First is a regionally-based, multi-payer approach to improving care delivery and payment. It gives primary care practitioners wider independence because they will have increased freedom to innovate a care delivery approach based on their specific patient population and resources. Participants will be financially rewarded for taking on limited risk based on easily understood, actionable outcomes.

CMS plans to use a designated set of patient experience and clinical quality measures to assess the quality of care delivered at each practice. The practice must meet specified standards that reflect quality healthcare measures, and will then be eligible for a positive performance-based adjustment to their primary care revenue. For the general population, these measures include:

  • Patient surveys regarding their care experience
  • Evidence of improved high blood pressure control
  • Better diabetes management
  • Regular screenings for colorectal cancer
  • Advance care planning

CMS will also assess the quality of care for high-risk patient populations using a focused set of clinically-meaningful measures.

What are the Goals of Primary Care First?

In order to improve the patient’s experience of care and reduce expenditures, Primary Care First seeks to increase patient access to advanced primary care services, and support practices that care for patients with complex chronic needs. Practices will be financially incentivized to deliver patient-centered care that reduces the need for acute hospital care. The five primary care functions on which PCF will focus are:

  1. Access and continuity
  2. Care management
  3. Comprehensiveness and coordination
  4. Patient engagement with the caregiver
  5. Planned care and population health improvement

The Primary Care First payment structure will include:

  • A payment mechanism that allows care to be driven by clinicians rather than administrative requirements.
  • A population-based payment that provides more flexibility in providing patient care, along with a flat primary care visit fee
  • A performance-based adjustment providing an upside of up to 50% of revenue. There is also a small downside incentive to reduce costs and improve quality, consisting of 10% of revenue, which will be assessed and paid quarterly.

Performance transparency will be achieved by providing practices with practitioner-identifiable performance information to motivate continuous improvement. CMS believes that Primary Care First will provide the tools and incentives that medical practices need to provide comprehensive and continuous care, while reducing the need for higher-cost care. It is seen as a win-win-win situation for practices, patients and CMS.

How Can Your Medical Practice Participate in Primary Care First?

The general Primary Care First payment model is designed for primary care practices that are prepared to accept increased financial risk in exchange for flexibility and potential rewards based on their practice performance. Eligible applicants include primary care practices that:

  • Are located in one of the selected test regions listed above.
  • Include primary care practitioners who are certified in general medicine, family medicine, internal medicine, geriatric medicine, and hospice and palliative medicine.
  • Provide primary care health services to a minimum of 125 Medicare beneficiaries at a specific location.
  • Have primary care services that account for at least 70% of the practice’s collective billing based on revenue.
  • Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance.
  • 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.
  • Can meet the requirements of the Primary Care First Participation Agreement.

To be eligible to begin participating in the model program in January 2020, interested practices must complete a Request for Application in spring 2019. CMS reserves the right to reject an application based on the results of a program integrity screening. CMS will also encourage other payers such as Medicare Advantage plans, Medicaid managed care plans, State Medicaid agencies, and health insurance companies to align their payment, quality measurement, and data sharing measures with CMS in support of PCF practices.

Practices with a Seriously Ill Population (SIP) of patients who lack a primary care practitioner or care coordination can also opt to participate in the second payment model option. Payment for SIP patients differs from the general payment option, and will be set to reflect the high need, high risk nature of the population as well as include an increase or decrease in payment based on quality.

How to Get Your Practice Technology Ready for Primary Care First

As can be seen in the CMS directives, a great deal of emphasis will be placed on technology and efficiency that can enable the practitioner to reduce administrative loads and free up time to interact with patients. Some actions your practice can take during 2019 to prepare for this revenue-enhancement opportunity include:

Electronic Health Records
Electronic Health Records are a Primary Care First requirement. They will be used to reduce charting time and help you keep track of patient care needs.

Practices will be required to support data exchange with other providers and health systems. Make sure your system is ready to link up and improve communication capabilities.

Patient Portal
You’ll need to have a way of communicating with patients on a more regular and effective basis. Use the patient portal to follow-up on blood pressure management or diabetes readings, and schedule regular screenings.
Improve scheduling efficiency to make maximum use of office hours while allowing for improved provider-patient communication time.
Seriously III Population Management
If your practice will be participating in the SIP model, you will also need to have technology capabilities that allow practitioners to easily address the special needs of this unique population.
Care Gaps

Drill down on individual patient data to look for care gaps that need to be addressed, prior to the patient coming in for an appointment.

Population Health
An EMR may be able to analyze data on a single patient but Population Health can provide analytics on the practice as a whole. Use a data tool that helps you to aggregate, analyze, and achieve results such as better patient care, reduced patient costs, and increased practice productivity.
Clinical Quality Measures

Use an EHR that helps to aggregate and submit CQM data in order to earn available incentives based on healthcare results.

If you are tired of waiting for the solution to reducing administrative needs and increasing care quality, while still reaping financial rewards, the Primary Care First model might be right for your practice. Success with the PCF model will depend upon, but not limited to, a few critical factors:

  1. The average risk score of the patients under the provider’s care as this impacts the payment level for the advance payment.
  2. Completion of Annual Wellness exams because this impacts which patients get attributed.
  3. Identifying and addressing care-gaps proactively since this contributes to the overall quality score, cost reduction and patient satisfaction.

Resources and Support

Primary Care First will have a five year performance period. Additional information, such as application deadlines and information as well as other model details will be available in the RFA.


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