Primary Care First
Primary Care FirstFoster Independence. Reward Outcomes.Model BriefingCenter for Medicare & Medicaid InnovationCMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation1
Primary Care First Builds on the UnderlyingPrinciples of Prior CMS Innovation ModelsCMS primary care models offer a variety of opportunities to advancecare delivery, increase revenue, and reduce burden.21PCFComprehensive PrimaryCare Plus (CPC ) Track 1 isa pathway for practices readyto build the capabilities todeliver comprehensive primarycare.CPC Track 2 is a pathwayfor practices poised toincrease thecomprehensiveness ofprimary care.CMS Primary Cares InitiativesPrimary Care First rewardsoutcomes, increasestransparency, enhances care forhigh need populations, andreduces administrative burden.Center for Medicare & Medicaid Innovation2
Primary Care First Rewards Value and QualityThrough an Innovative Payment StructurePrimary Care First Goals1To reduce Medicare spending bypreventing avoidable inpatient hospitaladmissions2To improve quality of care and access tocare for all beneficiaries, particularly thosewith complex chronic conditions and seriousillnessPrimary Care First Overview5-year alternative payment modelOffers greater flexibility, increasedtransparency, and performance-basedpayments to participantsPayment options for practices that specializein patients with complex chronicconditions and high need, seriously illpopulationsFosters multi-payer alignment to providepractices with resources and incentives toenhance care for all patients, regardless ofinsurerCMSCMS PrimaryPrimary CaresCares InitiativesInitiativesCenter for Medicare & Medicaid Innovation3
Primary Care First Will Be Offered in 26States and Regions Beginning in 2020In 2020, Primary Care First will include 26 diverse regions:Current CPC Track 1 and 2 regionsCMSCMS PrimaryPrimary CaresCares InitiativesInitiativesNew regions added in Primary Care FirstCenter for Medicare & Medicaid Innovation4
Primary Care Practices Can Participate inOne of Three Payment Model OptionsThe three Primary Care First (PCF) payment models accommodate acontinuum of providers that specialize in care for different patient populations.Option 1Option 2Option 3PCF PaymentModelPCF High Need PopulationsPayment ModelParticipation in bothoptions 1 and 2Focuses on advancedprimary care practicesready to assume financialrisk in exchange for reducedadministrative burdens andperformance-basedpayments. Introduces new,higher payments for practicescaring for complex,chronically ill patients.Promotes care for high need,seriously ill population(SIP) beneficiaries who lacka primary care practitionerand/or effective carecoordination.CMS Primary Cares InitiativesAllows practices to participatein both the PCF PaymentModel and the PCF High NeedPopulations Payment Model.Center for Medicare & Medicaid Innovation5
Participants Achieve Model Aims ThroughInnovations in Their Care DeliveryPCF participants are incentivized to deliver evidence-basedinterventions across 5 comprehensive primary care functions:Access and ContinuityPlanned Care andPopulation HealthCare ManagementComprehensivePrimary CareFunctionsPatient and CaregiverEngagementCMS Primary Cares InitiativesComprehensivenessand CoordinationCenter for Medicare & Medicaid Innovation6
Practices Have the Freedom to Innovate WhileImplementing Core Functions ofComprehensive Primary CareComprehensive Primary CareFunctionPCF InterventionAccess and Continuity Provide 24/7 access to a care team practitionerwith real-time access to the EHRCare Management Provide risk-stratified care managementComprehensiveness andCoordination Integrate behavioral health care Assess and support patients’ psychosocial needsPatient and CaregiverEngagement Implement a regular process for patients andcaregivers to advise practice improvementPlanned Care and PopulationHealth Set goals and continuously improve upon keyoutcome measuresCMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation7
The PCF Payment Model Option EmphasizesFlexibility and AccountabilityPCF Payment Model Option GoalsPromote patient accessto advanced primary careboth in and outside of theoffice, especially for complexchronic populationsTransition primary carefrom fee-for-service payments tovalue-driven, population-basedpaymentsReward high-quality,patient-focused carethat reduces preventablehospitalizationsPCF PaymentsProfessional population-based paymentsand flat primary care visit fees to helppractices improve access to care and transitionfrom FFS to population-based paymentsCMSCMS PrimaryPrimary CaresCares InitiativesInitiativesPerformance-based adjustments ofup to 50% of revenue and a 10%downside, based on a single outcomemeasure, with focused qualitymeasuresCenter for Medicare & Medicaid Innovation8
Payments Under the PCF Payment ModelOption Are Made Up of Two Major ComponentsTotal Medicare paymentsTotal primary care nce-based adjustmentOpportunity for practices to increase revenueby up to 50% of their total primary carepayment based on key performance measures,including acute hospital utilization (AHU).Flat Primary CareVisit FeeCMS Primary Cares Initiatives1National adjustment2Cohort adjustment3Continuous improvementadjustmentCenter for Medicare & Medicaid Innovation9
Total Primary Care Payment Includes TwoPayment Types: a Population-Based Paymentand a Flat Visit FeeHybrid Total Primary Care Payments replace Medicare fee-for-servicepayments to support delivery of advanced primary care.Professional Population-Based PaymentFlat Primary Care Visit FeePayment for service in or outside of the office, adjusted forpractices caring for higher risk populations. This paymentis the same for all patients within a practice.Flat payment for face-to-face treatment thatreduces billing and revenue cycle burdenPaymentPractice Risk GroupPer beneficiary per monthGroup 1 (lowest average HCC) 24Group 2 28Group 3 45Group 4 100Group 5 (highest average HCC) 175 50.52per face-to-face patient encounterAdjusted for geographyThese payments allow practices to: Easily predict payments for face-to-facecare Spend less time on claims processingand more time with patientsPayment adjusted to account for beneficiariesseeking services outside the practice.CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation10
Performance-Based Payment Adjustments AreDetermined Based on a Multi-Step ProcessIn Year 1, adjustments are determined based on acute hospital utilization (AHU) alone.In Years 2-5, adjustments are based on performance as described below.Did the practice exceedthe Quality Gateway?No-10%Adjustmentto Total Primary CarePayment for nextapplicable yearCMS Primary Cares InitiativesYesAdjustment of up to 50% of total primarycare payment determined by comparingperformance to three different benchmarks:1National adjustment2Cohort adjustment3Continuous improvementadjustmentCenter for Medicare & Medicaid Innovation11
In the National Adjustment, ApplicablePractices Are Compared to a NationalBenchmark of Similar Practices1National adjustmentThe national minimum benchmark is based on the lowest quartile of AcuteHospital Utilization (AHU) performers in a national reference group.PCF practiceperformanceAbove nationalminimum benchmarkAt or below nationalminimum benchmarkEligible for cohortadjustment-10%Adjustment(still eligible for continuousimprovement bonus)CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation12
In the Cohort Adjustment, an Eligible Practiceis Compared to Other Practices Enrolled inthe Model2Cohort adjustmentPractice performance is next compared against other PCF participants todetermine the performance-based adjustment.Bottom 50% of PCF practicesbased on performanceTop 50% of PCF practices basedon performance0%AdjustmentPerformance LevelAdjustment to TotalPrimary Care PaymentTop 20% of eligible practices34%Top 21–40% of eligible practices27%Top 41–60% of eligible practices20%Top 61%–80% of eligible practices13%Top 81–100% of eligible practices6.5%CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation13
A Continuous Improvement Bonus is Based onWhether a Practice Improved Relative to thePrior Year’s Performance3Continuous improvement adjustmentPractices are also eligible for a continuous improvement bonus of up to 1/3rd of total PerformanceBased Adjustment amount if they achieve their improvement target. CMS may use statisticalapproaches to account for random variations over time and promote reliability of improvement data.Performance LevelPotential Improvement BonusTop 20% of PBA-eligible practices16% of Total Primary Care PaymentTop 21–40% of PBA-eligible practices13% of Total Primary Care PaymentTop 41–60% of PBA-eligible practices10% of Total Primary Care PaymentTop 61%–80% of PBA-eligible practices7% of Total Primary Care PaymentTop 81–100% of PBA-eligible practices3.5% of Total Primary Care PaymentPractices performing above nationwide benchmark,but below top 50% of practices3.5% of Total Primary Care PaymentPractices performing at or below nationwideminimum benchmark3.5% of Total Primary Care PaymentCMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation14
The High Need Population Payment ModelOption Increases Seriously Ill Populations’Access to Primary CarePCF incorporates the following unique aspects for practices electing to serve seriouslyill populations to increase access to high-quality, advanced primary care.Eligibility and Beneficiary AttributionPractices demonstrating relevantcapabilities can opt in to be assignedSIP patients or beneficiaries who lack aprimary care practitioner or carecoordination.Medicare-enrolled clinicians who providehospice or palliative care can partnerwith participating practitioners.PaymentsPayments for practices serving seriously illpopulations:First 12 Months One-time payment for first visit with SIPpatient: 325 PBPM Monthly SIP payments for up to 12 months: 275 PBPM Flat visit fees: 50 Quality payment: up to 50CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation15
The Model’s Quality Strategy Includes aFocused Set of Clinically Meaningful MeasuresThe following measures will inform performance-basedadjustments and assessment of model impact.Measure TypeMeasure TitleUtilization Measure forAcute Hospital Utilization (AHU) (HEDISPerformance-Based Adjustmentmeasure)Calculation (Year 1-5)Quality Gateway(starts in Year 2)BenchmarkPCF and Non-PCFreference populationCPC Patient Experience of Care Survey(modernized version of CAHPS)Diabetes: Hemoglobin A1c (HbA1c) Poor Control( 9%) (eCQM)1Controlling High Blood Pressure (eCQM)MIPSCare Plan (registry measure)MIPSColorectal Cancer Screening (eCQM)1MIPSPCF and Non-PCFreference populationMIPSQuality Gateway for practicesTo be developed during model; domains couldserving high-risk and seriously illinclude 24/7 patient access and days at homepopulations11. The following measures will not apply to practices in Practice Risk Groups 4 or 5 and for practices receiving SIPidentified patients: (a) Diabetes: Hemoglobin A1c (HbA1c) Poor Control ( 9%) (eCQM) and (b) Colorectal CancerScreening (eCQM)CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation16
Primary Care First Innovates Data Sharing toInform Care DeliveryParticipants get access to timely, actionable data to assessperformance relative to peers and drive care improvement.Participants submit claims withreduced documentation requirements.ParticipantsPCF DataSharingCMS provides data to feed into participants’analytic tools and offer a view of theirperformance compared to peers.CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation17
Practices Participating in the PCF PaymentModel Option Must Meet the FollowingEligibility RequirementsPractices participating in the PCF Payment Model Option must: Include primary care practitioners (MD, DO, CNS, NP, PA) in good standing with CMS Provide health services to a minimum of 125 attributed Medicare beneficiaries* Have primary care services account for the predominant share (e.g., 70) of the practices’ collectivebilling based on revenue* Demonstrate experience with value-based payment arrangements, such as shared savings,performance-based incentive payments, and alternative to fee-for-service payments Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support dataexchange with other providers and health systems via Application Programming Interface (API),and, if available, connect to their regional health information exchange (HIE) Attest via questions in the Practice Application to a limited set of advanced primary care deliverycapabilities, including 24/7 access to a practitioner or nurse call line, and empanelment of patients toa primary care practitioner or care team*Note: Practices participating only in the SIP option are not subject to these specific requirements.CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation18
Practices Participating in the High NeedPopulation Model Option Must Meet theFollowing Eligibility RequirementsPractices receiving SIP-identified patients (identified basedon risk score) must: Include practitioners serving seriously ill populations (MD, DO, CNS, NP, PA) in goodstanding with CMS Meet basic competencies to successfully manage complex patients and demonstraterelevant clinical capabilities (e.g., interdisciplinary teams, comprehensive care, person-centeredcare, family and caregiver engagement, 24/7 access to a practitioner or nurse call line) Have a network of providers in the community to meet patients’ long-term care needs forthose only participating in the SIP option Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support dataexchange with other providers and health systems via Application Programming Interface (API),and, if available, connect to their regional health information exchange (HIE)CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation19
CMS is Committed to Partnering with AlignedPayers in Selected RegionsIn PCF, CMS will encourage other payers to engage practices on similaroutcomes. CMS is soliciting interested payers starting in summer 2019.Medicare sCommercial HealthInsurersState MedicaidAgenciesMedicaidManaged CarePlansMulti-payer alignment promotes:An alternative to fee-for-service paymentsPerformance-based incentive opportunityPractice- and participant-level data on cost,utilization, and qualityCMS Primary Cares InitiativesAlignment on practice quality and performancemeasuresBroadened support for seriously ill populationsCenter for Medicare & Medicaid Innovation20
Your Practice Can Experience Many BenefitsBy Participating in Primary Care FirstLess administrative burden and more flexibility so providers can spendmore time with patients and deliver care based on patient needsAbility to increase revenue with performance-based payments thatreward participants for easily understood primary care outcomesEnhanced access to actionable, timely data to inform your caretransformation and assess your performance relative to peersFocus on single outcome measure that matters most to patients:acute hospital utilizationOpportunities for practices that specialize in complex, chronicpatients and high need, seriously ill populationsPotential to become a Qualifying APM Participant by practicing in anAdvanced Alternative Payment ModelCMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation21
Primary Care First Will Launch in Early 2020Spring 2019Summer 2019Fall-Winter 2019 January 2020April 2020Practiceapplications openPracticeapplications due;Payer solicitationPractices andpayers selectedPayment changesbeginPractice applicationperiodPractice and payerselection periodModel launchPrepare for model application release by confirming your organization’s eligibility and willingnessto participate today. Email our mailbox to join our listserv for updates on application release.CMSCMS PrimaryPrimary CaresCares InitiativesInitiativesCenter for Medicare & Medicaid Innovation22
Use the Following Resources to Learn MoreAbout Primary Care tesLook out for additional PCF events in the coming months!CMS Primary Cares InitiativesCenter for Medicare & Medicaid Innovation23
Comprehensive Primary Care Plus (CPC ) Track 1 . is a pathway for practices ready to . build the capabilities. to deliver comprehensive primary care. CPC Track 2 . is a pathway for practices poised to . increase the comprehensiveness . of primary care. CMS Primary Cares Initiatives Center for Medicare & Medicaid Innovation 3
3,070 primary care practices Multi-payer Payment model: Track 1 FFS, Care management fee, performance based payment Track 2 -Comprehensive Primary Care Payment, reduced FFS, performance based payment Care delivery requirements and milestones Comprehensive Primary Care Plus Primary Care First 5 year demonstration
2.4 Overall structure of primary care 61 2.5 Good practices and challenges for structuring primary care 63 2.6 Conclusion 65 References Chapter 3 The delivery of primary care services 67 Andrew Wilson, Adam Windak, Marek Oleszczyk, Stefan Wilm, Toralf Hasvold, Dionne Kringos 3.1 Access to primary care 67 3.2 Continuity of primary care 77
Principles of Primary Health Care Although the name of the program team reflects key service elements, it functions based on the principles of Primary Health Care. Primary health care is integrated and inter-sectoral. Primary health care emphasizes health promotion. Primary health care views the individual as a whole being.
4 Figure 1. The Ecology of Medical Care, 2001 2.2. What Are the Benefits of Primary Care There is strong evidence of the benefits of primary care for both populations and personal health.6-17 Studies show that robust systems of primary care can improve health.6 Access to primary care can lower overall health care utilizat
Primary Health Care Providers Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and
Mental health in primary care A briefing for Clinical Commissioning Groups 5 One in four of us will experience a mental health problem in any given year, but most of us don’t get professional help. Of those of us who do get treatment, the majority are treated within primary care.10 This is why good mental health support in primary care is so important. Local GPs and other primary care staff .
Primary Care Physicians HEALTH CARE SYSTEMS 217 PRIMARY CARE PHYSICIANS KEY FINDINGS Supply of Primary Care Physicians The supply of primary care physicians per 100,000 population in the Appalachian Region is 12 percent lower than the national average. Central Appalachia (33 percent lower) and Southern Appalachia (21 percent lower) both .
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