Primary Care First: A Low-Risk Payment Model Aimed at Primary Care Redesign

Editor’s Note: Sg2 Associate Principal Kristin Oberfeld contributed to this post.

When it comes to new payment models, CMS has been busy this year. Some models have received much fanfare, others have slid under the radar (you can read about the new models in my previous post). There is one model in particular that we think is a good fit for many organizations in the early stages of value-based care (VBC)—and the request for application (RFA) period will open soon. We’re talking about Primary Care First (PCF).

Primary Care First is a 5-year, voluntary payment model that’s like Comprehensive Primary Care Plus’s (CPC+) older sibling who moved out of the house. If you’re not familiar with CPC+, it’s a medical home model that started with the original CPC and is successful because it provides reasonable incentives to drive change with limited risk. PCF builds on this success and expands the model into new states. Let’s take a look at the program.

Who is PCF designed for?

The model was developed for primary care practices/providers with advanced primary care capabilities, meaning MDs, DOs, CNSs, NPs, and PAs certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine.

What are the other participation requirements?

This model is driven by practice, with practitioners identified by NPI. Each practice must have a minimum of 125 attributed beneficiaries, and primary care must be a minimum of 70% of the practice’s services (based on revenue). Practices should also have some experience with VBC or alternative payment models.

On the clinical side, there are certified EHR requirements, and practices must provide evidence of the following:

  • 24/7 access to a practitioner or nurse call line
  • Empanelment of patients to a primary care provider or care team

Is PCF available everywhere?

The model is only available to practices in 26 states or regions, but it’s expanding beyond those states where CPC+ was offered. The new states include Alaska, California, Delaware, Florida, Maine, Massachusetts, New Hampshire and Virginia. Don’t forget: this is a multipayer model, which means it will include other payers beyond Medicare.

How much risk do practices take on?

A relatively low amount. In fact, practices could be eligible for a performance-based adjustment that includes upside of up to 50% of revenue with potential downside of 10% of revenue. This performance-based adjustment is assessed and paid quarterly, which is a benefit over other CMS alternative payment models. In the first year, this adjustment is entirely based on reducing acute hospital utilization; quality components are added in the second year.

Do PCF practices continue to be paid fee-for-service (FFS)?

Ultimately the payment structure is meant to transition practices away from FFS. Practices will receive a flat visit fee for services ($50.52, geographically adjusted). In addition, practices will be paid a population-based payment in a tiered structure based on the overall HCC level of their assigned patients (ranging from $24–$175 per beneficiary per month).

There is also a track for the seriously ill population (SIP). Payment for SIP will be set to reflect the high-need, high-risk nature of the population and payment will increase or decrease based on quality.

Does the model qualify as an advanced alternative payment model (aAPM)?

Like CPC+, we expect that PCF will qualify as an aAPM when it starts in 2020 (performance year), impacting payments in 2022. If all criteria are met, participants would be exempt from MIPS and receive the 5% lump sum bonus payment.

So…what do we do now?

Sg2 highly recommends that eligible practices review this model, as many of our members have had great experiences in CPC+. Also keep in mind that there are interaction questions to consider, such as “Can you be in the Medicare Shared Savings Program and PCF? And if so, what will the financial implications be?”’

While you wait for the RFA to open, email us with your questions and thoughts on Primary Care First. Sg2 has extensive experience with medical home models, including CPC+ and aligning primary care physicians around the transition to value. We’re here to help you understand the Primary Care First model, plan your strategy for participation and set up the infrastructure you need to succeed.

Fill out the form below to download exclusive resources on Primary Care First and other aAPMs.

CNS = clinical nurse specialist; DO = doctor of osteopathy; HCC = Hierarchical Condition Categories; MIPS = Merit-based Incentive System; NP = nurse practitioner; NPI = National Provider Identifier; PA = physician assistant.

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