The United States Centers for Medicare and Medicaid Services (CMS) recently announced a new primary care model to be tested under the Center for Medicare and Medicaid Innovation (CMMI). The model, termed Making Care Primary, will start next summer in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington. It aims to focus on primary care organizations with limited experience in alternative payment models to help set up the infrastructure, especially for safety net and smaller or independent primary care organizations.
The Making Care Primary model is a 10.5-year multi-payer model with three participation tracks that build upon prior primary care models and the Maryland Primary Care Program. The Making Care Primary model will provide a pathway for primary care clinicians with varying levels of experience in value-based care to gradually adopt prospective, population-based payments while building infrastructure to improve behavioral health and specialty integration and drive equitable access to care.
As CMS notes in the announcement of the new model, primary care providers “are the first line of defense for prevention, screening, management of chronic conditions, and overall wellness” and that care coordination is becoming “increasingly challenging” because patients see more specialists on a more frequent basis.
The Making Care Primary model will “attempt to strengthen coordination between patients’ primary care clinicians, specialists, social service providers, and behavioral health clinicians, ultimately leading to chronic disease prevention, fewer emergency room visits, and better health outcomes.”
The model will provide resources and data to her primary care providers to better coordinate care with specialists and will support better care integration, which should help providers better address physical and behavioral health needs and connect to community networks to reduce health disparities.
The Making Care Primary model communicates its vision for care delivery via three domains: care management, care integration, and community connection. Under care management, participants will build their care management and chronic condition self-management support services, with an emphasis on managing chronic diseases like diabetes and hypertension, and reducing unnecessary emergency department visits (and overall total cost of care). When it comes to care integration, participants will strengthen their connections with specialty providers while using evidence-based behavioral health screening and evaluation to help improve patient care and coordination. Finally, under community connection, participants will identify and address health-related social needs (HRSNs) and connect patients to relevant community supports and services.
The model has three progressive tracks designed to recognize participants’ varied experience in value-based care, from those who are under-resourced to those with existing advanced primary care experience in alternative payment models. The first track is focused on building infrastructure, the second track on implementing advanced primary care (including partnering with social services providers and specialists, implementing care management services, and screening for behavioral health conditions), and the third track is optimizing care and partnerships. Payment calculations vary based on the track.
CMS is working with state Medicaid agencies in the participating states to “engage in full care transformation across payers, with plans to engage private payers in the coming months.” To be eligible to participate in the model, an organization must be Medicare-enrolled, bill for health care services furnished to at least 125 attributed Medicare beneficiaries, and have the majority of their primary care sites located in an eligible state. Additionally, the organization must be a legal entity formed under applicable state, federal, or Tribal law authorized to conduct business in each state in which it operates.
For a brief video on the model, click here.
For a detailed webinar on the model that outlines not only the model expectations but also care delivery requirements, quality performance measures, next steps, and a brief question and answer session, click here, here, and here (transcript here).
For frequently asked questions, click here.
For an overview factsheet, click here. For a payer partner factsheet, click here.
CMS plans to accept applications for the model in late summer of 2023. Interested participants can submit a non-binding Letter of Intent here. Applications must be submitted by November 2023, and the first cohort model launch will be in July 2024.