In late April, the U.S. Department of Health and Human Services (HHS) announced the Centers for Medicare and Medicaid Services (CMS) Primary Cares Initiative, a new set of voluntary, value-based payment models for primary care providers (PCPs).
The initiative builds on other value-based programs and helps to advance CMS’s “patients over paperwork” mission. Providers that participate in the new payment models will be incentivized to deliver high-quality, cost-efficient care. This framework encourages PCPs to spend more time focusing on patient care and less on billing.
Set to launch in January 2020, PCPs who wish to opt-in to the new payment models may need to consider upgrades to practice operations in order to ensure success within this new value-based structure.
Specifically, developing better processes to support care management and coordination, including the ability to track and trend quality metrics, will be essential to mitigating risk and driving high performance; this is especially important with respect to successfully managing patients with chronic conditions. The Initiative has a heightened focus on Seriously Ill Populations (SIP) and recognizes the additional resources and efforts needed to manage this complex and costly patient group.
In addition to traditional care management and coordination activities, providers will work to identify Social Determinants of Health (SDH) and resolve barriers preventing patients from thriving in the community.
Two New Paths to Value-Based Primary Care
The initiative offers two paths for PCPs that care for Medicare fee-for-service (FFS) beneficiaries – Primary Care First (PCF) and Direct Contracting (DC). The paths encompass five payment models that have varied degrees of risk sharing and will be tested over a five-year period.
- Primary Care First (PCF): PCF is geared toward individual practices that are already delivering advanced primary care and builds on the Comprehensive Primary Care Plus (CPC+) program. This track will test the extent that financial risk sharing and performance payments reduce Medicare spending, enhance care quality, and improve patient outcomes. The two models in this path will compensate PCPs with a monthly population-based payment, and clinicians eligible to participate in the SIP model will receive payments set to reflect the high-need, high-risk nature of this population. In addition, performance-based adjustments that provide an upside of up to 50% of revenue (downside of 10%) will be assessed and paid out on a quarterly basis retrospectively.
- Direct Contracting (DC): While DC will advance progress toward the same overarching goals of PCF, it is designed to engage a wider variety of organizations that care for large patient populations and have experience taking on risk, such as accountable care organizations (ACOs), Medicare Advantage (MA) plans, and Medicaid managed care organizations (MCOs). It can also be thought of as the successor to the Next Generation ACO Model, which ends in 2020. Like PCF, PCPs that participate in one of the DC models will receive fixed monthly payments, which will be based on either a portion of primary care costs or percentage of total cost of care, along with flat visit fees. This financial approach allows providers to participate in a value-based care model, without complete disruption of their current fee-for-service revenue cycle. The models offered through this path include Professional, Global, and Geographic:
- Professional: This model offers the lowest risk-sharing arrangement (50% of savings/losses) and Primary Care Capitation, which are capitated monthly payments adjusted for patient population risk.
- Global: This model offers the highest risk-sharing arrangement (100% of savings/losses) and two payment options: Primary Care Capitation or Total Care Capitation, the latter of which provides risk-adjusted monthly payments for all services rendered by DC entities as well as preferred providers with which they have downstream arrangements.
- Geographic: This would offer a similar risk arrangement as the Global model, but participants would assume responsibility for the care of Medicare FFS beneficiaries in a specific target region. CMS has released an RFI soliciting public comment for this model and the anticipated launch date is January 2021.
Positioning Physician Practices for Success with Targeted, Automated Outreach
While CMS has yet to release full details regarding how performance will be measured, it’s clear that incentive payments will be influenced by the degree to which participating PCPs reduce unnecessary utilization and total cost of care for FFS beneficiaries. To achieve these goals, it will be essential for providers to take proactive steps in keeping patients engaged with their care, and technology can help drive and scale these efforts.
For example, automated patient outreach can enable PCPs to scale targeted communications to close specific gaps in care by encouraging activities around better health management, such as coming in for colonoscopies or mammograms, or reminding patients to consistently schedule and keep appointments, which is especially important for high- and rising-risk patients. This can help providers meet key quality benchmarks as well as improve quality and efficiency of care provided.
The PCF fact sheet cites several measures that will be used to evaluate performance, including colorectal cancer screening and controlling high blood pressure, and incentive payments will be dependent on meeting benchmarks tied to these metrics and managing the overall cost of care for each beneficiary. Similarly, the DC fact sheet makes broad reference to a focused set of outcome- and experience-based measures that participating providers will be required to report on, which will impact shared savings and losses.
Another significant opportunity area for providers participating in the Primary Cares Initiative is to use technology to support chronic care management programs, as beneficiaries with multiple comorbidities account for a majority of Medicare FFS spending.
Chronically ill patients have complex needs that require ongoing engagement with their care team such as education, guidance, and coaching. These activities are necessary to keeping these patients healthy and functioning optimally within their communities. Care managers will need to leverage technology to scale their efforts and effectively manage a larger volume of patients. Codified care plans and processes will allow care managers to intervene and resolve issues prior to an adverse event or hospitalization, helping PCPs meet the financial goals of these value-based payment options.
A Win-Win for PCPs and Patients
While primary care only accounts for a small portion of total healthcare spending, the new payment models attest to the important role PCPs play in keeping patients healthy and out of the hospital. PCPs are on the front lines of healthcare and are increasingly expected to be master care coordinators, in terms of helping patients navigate the system and collaborating with other care team members. Compensation for these activities, however, has historically not been commensurate with the required level of effort. The Primary Cares Initiative helps to put PCPs back in the driver's seat and gives them the tools and financial incentives needed to succeed.
The new payment models have generally been met with support from industry groups and are praised as a key step toward reducing overall healthcare costs. Given the timeline CMS put forth to roll out the program, healthcare organizations will need to act quickly to ensure that they have the necessary processes and technology infrastructure in place to mitigate downside risk and ensure value-based success.
About CipherHealth
Ranked as the top-performing vendor for patient outreach and digital rounding by KLAS Research in 2019, CipherHealth is a proven healthcare technology partner committed to enhancing communication and care team coordination throughout the patient journey. CipherHealth’s enterprise platform empowers physician groups to improve patient engagement before, during, and after visits, and drive higher practice performance.
About the Author
As the Vice President of Clinical Services, Lyndsey Lord, MBA, BSN, RN brings over 15 years of experience in clinical practice, healthcare operations, case management, patient throughput, and healthcare IT strategy to her current role at CipherHealth. Prior to joining CipherHealth, Lyndsey worked with healthcare providers to implement alternative payment models, such as BPCI, and supported clinical care redesign efforts to promote success within value-based healthcare programs.