CMS’ New Primary Care Payment Models: What You Need To Know

CMS’ New Primary Care Payment ModelsCMS has announced a new set of primary care payment models. The Primary Cares Initiative is intended to deliver better value for patients, reduce administrative burden for physicians, and empower them to spend more time caring for patients.

The initiative will provide primary care practices and other providers with five new primary care payment models under two paths: Primary Care First and Direct Contracting. Here’s what you need to know.

Primary Care First
  • Provides payment to practices through a simplified monthly reimbursement that allows physicians to spend more time with patients.
  • Incentivizes providers to reduce hospital utilization and total cost of care through performance-based payment awards.
  • Focuses on key outcome-based clinical quality measures, such as controlling high blood pressure, managing diabetes mellitus, and screening for colorectal cancer.
Primary Care First – High-Need Populations
  • Has the same features as Primary Care First, but offers higher payments to practices that specialize in care for high-need patients, including those with complex, chronic conditions and seriously ill populations.

Both Primary Care First models will be tested for five years, beginning in January 2020.

Direct Contracting

The Direct Contracting models aim to engage organizations that have experience taking on financial risk and serving larger patient populations, such as Accountable Care Organizations, Medicare Advantage plans, and Medicaid managed care organizations.

Direct Contracting – Global
  • Allows healthcare providers to take greater control of managing costs of care for Medicare fee-for-service beneficiaries.
  • Focuses on care for patients with complex, chronic needs and seriously-ill populations.
  • Allows beneficiaries to use the healthcare provider of their choice.
  • Reimburses providers with a fixed monthly payment that can range from a portion of anticipated primary care costs to the total cost of care, but the provider assumes all financial risk.
Direct Contracting – Professional
  • Has the same features as Direct Contracting – Global except that the financial risk is shared with CMS.
  • Participants can choose from varying levels of financial risk, providing more predictable revenue streams and reducing provider burden commensurate with the level of financial risk they assume
Direct Contracting – Geographic
  • This model is still under development and CMS is seeking public comment on how it should be structured when it launches in 2021.
  •  The geographic, population-based option is designed to offer innovative organizations the opportunity to assume responsibility for the total cost of care and healthcare needs of a population in a defined target region.

CMS says driving accountability to a local level empowers communities to devise strategies best designed to meet their healthcare needs.

CMS expects these five new primary care payment models to:
  • Have more than 25 percent of all Medicare beneficiaries participate, with nearly 11 million included in the new programs.
  • Offer new primary care payment models options for an estimated 25 percent of primary care physicians.
  • Create new coordinated care opportunities for many of the 11 to 12 million beneficiaries dully eligible for Medicare and Medicaid, specifically those in both Medicaid managed care and Medicare fee-for-service.

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