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CMS Announces New Medicare Voluntary Primary Care-Focused Models

April 26, 2019

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PRESS CONTACTS
Erin Hahn, Health Policy Analyst, Value Based Care
Phoebe Ramsey, Sr. Regulatory Analyst, Quality & Payment Policy

The Centers for Medicare and Medicaid Services (CMS) April 23 announced the introduction of two new primary care-focused  voluntary Alternative Payment Models (APMs), under a new Primary Cares Initiative: The Primary Care First model and the Direct Contracting model.

These models are designed to incentivize primary care practitioners to increase the quality of care and decrease costs while also encouraging the greater engagement and empowerment of Medicare fee-for-service (FFS) patients. These models are both set to begin in January 2020 and will last five years. CMS plans to open the Request for Application (RFA) process for the Primary Care First model in May and the Direct Contracting model in June (for two of the three available model options). CMS predicts that these two models will cover 25% of Medicare Beneficiaries, as well as 25% of primary care practitioners.

The Primary Care First model seeks to follow on the Comprehensive Primary Care Plus model set to end in 2021 and features two options based on prospective monthly capitation payments. The first option, Primary Care First, will open in 26 different regions nationwide. An additional option, Primary Care First — High Needs Population Payment, follows a similar structure, while focusing on patients with complex medical needs, chronic health care issues, and seriously ill populations (SIP).

Under this option, the capitation payments are then increased for those providers assuming patients with higher risk. Both options offer up to 50% shared savings and a 10% shared losses risk. In addition, quality measures will be applied to the payment methodology, including Advance Care Plans, patient experience of care surveys, controlling high blood pressure, colorectal cancer screenings, and diabetes hemoglobin A1c poor control.

There are three options that fall under the label of the Direct Contracting model and offer variations in risk arrangements, reductions in costs, and increases in quality for Medicare FFS patients. These models seek to involve providers and organizations on a broader scale, including Next Generation Accountable Care Organizations (model ends December 2020), Medicare Advantage, as well as others.

The first option is the Professional Population-Based Payment (PBP) model, which offers a symmetric 50% savings and losses arrangement with CMS and monthly partial capitated payments for enhanced primary care services. The second, Global PBP, allows for either partial or total capitation and maintains high risk at 100% of shared savings and losses for enhanced primary care services. Lastly, the Geographic PBP option would authorize a provider to assume responsibility for all health care costs associated with all Medicare FFS patients in a given area at 100% risk for savings and losses.

CMS has issued a Request for Information (RFI) with regards to the Geographic model, due May 23. The Direct Contracting models will allow a year for organizations to prepare, with the first performance period starting January 2021, following a year of operation under the PBP payment model options in 2020.

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