CMS announced five new voluntary payment models known as the Primary Cares Initiative (PCI) aimed at transforming primary care. The PCI models share elements commonly found in the CMS advance alternative payment models (APM), but go a step further in their risk-sharing offering to promote better patient outcomes and care coordination through primary care to drive down Medicare fee-for-service (FFS) costs. CMS has stated the five models, which are divided between two paths, may cover more than 25 percent of all Medicare FFS beneficiaries. Each model will have a five-year participation period.
BKD’s Health Care Performance Advisory Services team is committed to evaluating the program models when CMS releases more detailed information and working with clients to leverage data analytics and experience with CPC+, Accountable Care Organizations (ACO), the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Bundled Payments for Care Improvement and other value-based models to evaluate participation and prepare applications.
So what exactly are the five new voluntary PCI models?
Primary Care First (PCF) Path
PCF is a regionally based, multipayor approach to improving quality, patient experience and cost reduction. PCF is based on many of the elements from the CPC+ program but with some key differences. There are two model options under the PCF path in which practices may participate:
- PCF Payment Model: Offers risk-adjusted population-based payments with flat primary care visit fees versus standard FFS to fund practices’ care delivery redesign efforts. Practices also are offered a performance-based adjustment incentive to reduce total costs of care for Medicare beneficiaries while meeting quality and patient experience goals.
- PCF High-Need Population Model: A specialized track similar to the PCF Payment Model above, but geared toward practices providing care to high-need, seriously ill beneficiaries who lack primary care provider (PCP)-coordinated services. CMS has stated payments will reflect the high-risk nature of this population.
The model options will begin January 2020 for practices not currently participating in the CPC+ model but are located in the 18 existing CPC+ regions plus eight new regions. The application period is expected to open this spring. CMS also plans to offer a second round of applications for a 2021 start date, including allowing CPC+ practices to end their current agreements to participate in PCF.
Direct Contracting (DC) Path
CMS touts this path as an opportunity to engage a variety of organizations such as health systems, Medicare Advantage plans, Medicaid managed care organizations and other private sector organizations to leverage competition. The DC Path contains three models and draws on experience with Medicare Shared Savings Program and Next Generation ACO Models and Medicare Advantage. The three models include:
- DC Professional: The model convenes participants into Direct Contracting Entities (DCE), provides monthly risk-adjusted, primary care-capitated payments for “enhanced primary care services” only, and shares 50 percent of the financial savings/losses with providers.
- DC Global: Similar to the DC Professional model but offers DCEs the option to choose primary care-capitated payments or Total Care Capitation for all services in the DCEs’ patient population instead. DCEs under this model would bear 100 percent of the savings/losses for patient total cost of care.
- DC Geographic: Similar to the DC Global model but goes even further, allowing DCEs to assume 100 percent financial risk for Total Cost of Care of Medicare beneficiaries for an entire geographic region. This option is still “under construction” and CMS is seeking public input to refine parameters.
The payment model options available under DC will start in January 2020, with an initial alignment year for organizations that want to align beneficiaries to meet the minimum beneficiary requirements. Performance periods will begin January 2021 and will be five years.
How will PCI interact with other Advance Payment Models?
It’s not yet known how PCI will intersect with current CMS Advance Payment Models or MACRA. Practices can expect additional information this spring as the recent announcement was scant on participation requirements and the financial models. What we do know is U.S. Department of Health & Human Services Secretary Alex Azar has stated these models are the “biggest step ever taken toward” implementing value-based payments in primary care.
Take Steps Early to Prepare & Leverage Best Practices
- Begin by reviewing your organization’s current risk-based strategy, including:
- Best practices for care pathways
- Clinical risk management of provider engagement and alignment
- Provider patient panel sizes
- Data analytics capabilities
- Review your historical performance in current APMs or Medicare value-based purchasing programs
- Begin discussions with your PCPs to identify potential strategies and care coordination gaps
- Save the date for BKD’s PCI webinar on June 19 from 2:00 p.m. Central time. Click here to register. Can’t attend live? Register and we’ll send you the archived version.
Ready to outline your value-based payment model strategy or explore PCI participation? Use the Contact Us form on our Value-Based Payment Models page and let us connect you with a BKD trusted advisor.