Primary Care First and Alternative Payment Models

1. Medical Billers and Coders Primary Care First (PCF) And Alternative Payment Models

2. Primary Care First Model Options is a set of voluntary five-year payment options that reward value and quality by offering an innovative payment structure to support the delivery of advanced primary care. It will help in prioritizing the doctor-patient relationship; enhancing care for patients with complex chronic needs and high need, seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes. Primary Care First Model Options will be offered in 26 regions for a 2020 start date.

3. Background Primary care is central to a high-functioning healthcare system and thus, there is an urgent need to preserve and strengthen primary care as well as a need for support of serious illness care services for Medicare beneficiaries. PCF will focus on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments. PCF also encourages advanced primary care practices, including providers whose clinicians are enrolled in Medicare who typically provide hospice or palliative care services, to take responsibility for high need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination – population groups referred to under the model as the Seriously Ill Population or SIP.

4. Model Design Primary Care First reflects a regionally-based, multi-payer approach to care delivery and payment. 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. CMS will assess the 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. PCF is aimed at smaller primary care practices, who will be paid a fixed amount for each patient. Practices will get a bonus for keeping patients out of the hospital and will bear the cost for extra spending incurred by admissions, up to a certain share of their practices’ revenue.

5. Alternative Payment Models The models were developed by the Center for Medicare and Medicaid Innovation (CMMI). Administered through CMMI, the CMS Primary Cares Initiative will provide primary care practices and other providers with 5 payment model options under 2 paths: Primary Care First (PCF), focused on individual providers, and Direct Contracting (DC). DC, which is similar to accountable care organizations, Medicare Advantage plans, and Medicaid managed care organizations, would give organizations full responsibility for the cost and care for their patients. In some models, doctors would get paid a flat stream of revenue for keeping patients healthy and get a bonus for when they do well; in other models, there would be more risk, but they could also potentially receive more rewards.

6. The 5 payment model options are • PCF • PCF – High-Need Populations • DC – Global • DC – Professional • DC – Geographic PCF could create new coordinated care opportunities for beneficiaries who are dually eligible for Medicare and Medicaid, specifically, those in Medicaid managed care and Medicare FFS. Through the PCF payment model options, high-need patients with serious illness who do not have a primary care practitioner or care coordination and indicate an interest in receiving care from a practice participating in the model will be assigned to a provider.

7. Providing adequate financial support for high-quality primary care must be an essential element of any strategy to improve the quality and affordability of the healthcare system. Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The new primary care payment models announced will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.

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