CMS Releases Details of 'Primary Care First' Program

Ken Terry

October 25, 2019

The Centers for Medicare and Medicaid Services (CMS) on Thursday unveiled the details of its new Primary Care First demonstration, which it announced last April.

The purpose of this program is to financially reward advanced primary care practices for providing comprehensive care that reduces Medicare costs and improves outcomes, especially for complex and seriously ill patients.

While the basics of Primary Care First remain the same, the 6-year demonstration will not begin until January 2021. Originally, it was supposed to launch in January 2020. The application period for practices applying to begin participation in 2021 opened on October 24 and will close on January 22, 2020.

While participation in Primary Care First is voluntary, participants will be expected to remain in the program for 5 years. Two staggered cohorts of practices will participate, one from 2021 to 2025 and the other from 2022 to 2026.

A request for application from the Center for Medicare and Medicaid Innovation (CMMI), which is running the program, explains that Primary Care First uses a two-tiered payment structure designed to shift the focus of providers to patient outcomes.

Participating practices will be paid risk-adjusted primary care capitation and a flat visit fee, the sum of which CMMI calls the total primary care payment (TPCP). The practices will also have the opportunity to earn a bonus of up to 50% of TPCP and may also lose up to 10% of TPCP, based on a performance-based payment adjustment (PBA) that is calculated and applied on a quarterly basis.

The cost component of the PBA is a measure of acute hospital utilization, which CMMI says is highly correlated with the total cost of care. Thus the participants are not taking risk for the total cost of care as accountable care organizations (ACOs) do in the Medicare Shared Savings Program (MSSP). Instead, they are taking risk for the hospital admission rate of their fee-for-service Medicare patients.

To get a positive PBA, a practice must exceed a national acute hospitalization utilization (AHU) benchmark, which is the 50th percentile of national performance. In the first year, the PBA will be based solely on this measure and there will be no negative adjustment. After that, practices must also pass through a Quality Gateway, based on a small set of quality and patient experience measures.

At the end of the first year, CMS will evaluate practices' quality performance. If it does not exceed the threshold score, they cannot get a positive PBA in year 2.

Whether or not the practices see a negative adjustment in each quarter depends on their AHU performance relative to both a regional benchmark and their own historical experience. In performance year 3 and beyond, failing to exceed the Quality Gateway in the previous year will result in an automatic downward adjustment of 10% of the TPCP.

A positive PBA has two components: performance in comparison with other practices in a region, which generates up to 34% of the TPCP, and continuous improvement, which contributes up to 16% of the TPCP.

Patients Without a Medical Home

Applicants to Primary Care First can elect to participate in the program's Seriously Ill Population (SIP) segment. These Medicare beneficiaries — many of whom are in nursing homes or hospices — are not only very sick but also have a fragmented pattern of care, often because they lack a regular primary care doctor.

Practices that take on these patients will receive a higher capitation rate than other practices in Primary Care First. Participants can decide whether to care only for SIP patients, only for non-SIP patients, or both.

The base capitation rate for practices will be a mix of four rates ranging from $28 to $175 per beneficiary per month, depending on how sick they are. Including a flat fee of $40.82 per visit, the practices will receive an estimated monthly payment of between $49 and $212 per beneficiary, after their health risks and the number of expected visits are calculated.

There are two methods of attributing Primary Care First patients to doctors. First, a Medicare beneficiary may pick a doctor in a participating group on MyMedicare.gov. For other patients, CMS will use claims data to determine attribution prospectively.

Practices aren't guaranteed the ability to participate in Primary Care First. They must be located in one of 26 regions for the initial launch and must meet other requirements.

If 3000 or more applicants meet the program's requirements, CMS will conduct a lottery and use practices that don't make the cut as study controls. Control groups will get $5000 per year plus access to Medicare data and will qualify as advanced payment models under CMS's Quality Payment Program.

In their initial announcement, CMS officials expressed the hope that state Medicaid programs and private payers would join the Primary Care First demonstration. CMS did not respond to Medscape Medical News' request for information on whether any other payers have shown interest.

In a statement about the new information on Primary Care First, Clif Gaus, ScD, president and chief executive officer of the National Association of ACOs, said the organization was grateful that CMS will allow practices in ACOs that contract with the MSSP to also participate in Primary Care First.

"This allows ACOs to further engage primary care providers, which is a bedrock of successful population health management," he said. "The Innovation Center's work will help us move to a health system that emphasizes value-based care."

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