CMS Primary Care First Model to Launch Early 2020

Primary Care First is a set of voluntary five-year payment model options that reward value and quality by offering payment model structures to support delivery of advanced primary care. According to CMMI, Primary Care First is based on the underlying principles of the existing CPC+ model design. Recently, CMS held a webinar about the model, and this article helps explain more information about Primary Care First, along with some feedback from industry.

Primary Care First

According to CMS, the model reflects a regionally-based, multi-payer approach to care delivery and payment. The agency argues that Primary Care First fosters practitioner independence by increasing flexibility for primary care, providing participating practitioners with the freedom to innovate their care delivery approach based on their unique patient population and resources. Primary Care First rewards participants with additional revenue for taking on limited risk based.

In Primary Care First, CMS will use a focused set of clinical quality and patient experience measures to assess quality of care delivered at the practice. A Primary Care First practice must meet standards that reflect quality care in order to be eligible for a positive performance-based adjustment to their primary care revenue. These measures were selected to be actionable, clinically meaningful, and aligned with CMS’s broader quality measurement strategy. Measures include a patient experience of care survey, controlling high blood pressure, diabetes hemoglobin A1c poor control, colorectal cancer screening, and advance care planning. CMS will assess quality of care based on a focused set of measures that are clinically meaningful for patients with complex, chronic needs and the serious illness population.

Primary Care First aims to improve quality, improve patient experience of care, and reduce expenditures. CMS believes 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. The specific approaches to care delivery will be determined by practice priorities. Practices will be incentivized to deliver patient-centered care that reduces acute hospital utilization. Primary Care First is oriented around comprehensive primary care functions: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement; and (5) planned care and population health.

Webinar Slides

The webinar was a comprehensive look at Primary Care First. Below are a few slides that help flesh out CMS’s thinking on this model.

Explanation of CPC + Model vs Primary Care First

States Primary Care First is available.

Payment Model

Risk Stratification

Responses

MedPage Today has an interesting article on this model describing stakeholder feedback. In particular, MedPage explains that Primary Care First’s early reviews “reveal that longstanding conflicts remain between, on the other hand, budgetary savings and administrative feasibility goals and, on the other hand, more ambitious desires in parts of the medical community redesign care to elevate the role of effective primary care (regardless of the short-term costs),” Tom Miller, JD, resident fellow at the American Enterprise Institute, a right-leaning think tank, said in an email to the outlet. “Perhaps more medical outcomes per se could be improved by simply paying primary care doctors more, but that assumes away the political food fight it would require to get there.”

A more straightforward approach to “subsidize patients more directly to find and receive the care that they could choose to receive would upset providers either benefiting from the current system or imagining that they could be winners in the next round of political reimbursement roulette, labeled ‘value-based,'” he added.

Gail Wilensky, PhD, senior fellow at Project HOPE in Bethesda, Maryland, and a former CMS administrator, said in an email to MedPage Today that the difficulty with the model “seems to be the amount paid is too small and too unreliable … That is certainly consistent with the ongoing CMS attempts. It is certainly reason to be skeptical although the results will only become clear after it is tried, assuming [the] CMS goes forward with it … It has been discouraging how difficult it has proven to be to affect change in this area.”

Commentary

There are some critics of the program, in that it is largely limited to large practices and there is no clear delineation on what the bonus or penalties are eventually going to look like.  HHS has made this clear that this is a next step for the innovation center but only a step and not a final solution.  Hopefully we will have a final solution for primary billing of which we as country are at the bottom compared to other countries.  Eventually, this model could save billions of funds.