Part 1 of Our Breakdown of the CMS Primary Cares Initiatives: Primary Care First

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Announced in April of 2019, the Centers for Medicare & Medicaid Services (CMS) revealed two new paths of payment options for primary care and other providers pursuing risk-based agreements: Primary Care First (PCF) and Direct Contracting (DC).

As with any new CMS guideline, there is much to unpack. This week, we are discussing Primary Care First and the options primary care providers (PCPs) have based on their patients.

Primary Care First

“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. Primary Care First rewards participants with additional revenue for taking on limited risk based on easily understood, actionable outcomes.” — CMS

Primary Care First is based on the existing Comprehensive Primary Care Plus (CPC+) program. The objectives behind these newer initiatives are to offer new, voluntary payment models that improve beneficiaries’ access to primary care services, strengthen care, and reward primary care providers for their efforts to raise quality measures and reduce hospital admissions. There is always an underlying goal from CMS as well: incentivize the adoption of value-based care models. Depending on the patient population, a primary care provider will be considered General or High Needs based on their hierarchical condition category (HCC) risk score.

PCF: General

The PCF General track is for typical primary care patient populations with an under-control risk score. In simplest terms, according to CMS, the primary care provider who opts for the General track wants to advance their primary care offerings for patients and enter into a risk arrangement. As a result, they hope to earn performance-based payments and reduce administrative burden within their practices.

PCF: High Need Populations

Providers qualify for the PCF High Need Populations track based on their HCC risk score. The High Need Populations track aims to promote care for the seriously ill population (SIP) beneficiaries who lack a primary care provider equipped for their needs. It could also be that a general PCP does not have the care coordination facilities in place for these high-risk patients.

Primary Care First Requirements

There are two separate sets of requirements that applicants must be aware of for participation:

PCF General payment model applicants:

  • Includes primary care providers (MD, DO, CNS, NP, or PA) that are certified in internal medicine, general medicine, geriatric medicine, family medicine, palliative medicine, and hospice care.
  • A practice must have at least 125 Medicare patients at their location.
  • Primary care services must account for at least 70% of the practices’ total billing based on revenue. For multi-specialty practices, 70% of the practice’s eligible primary care practitioners’ combined revenue must come from primary care.
  • Applicants must have experience with these forms of payment arrangements, either value-based or payments based on cost, quality, and/or utilization performance.
  • PCF General applicants must have 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE).

PCF High Need payment model applicants need to be aware that:

  • If a practice demonstrates relevant capabilities, they can opt to be assigned SIP patients or beneficiaries who lack a primary care practitioner or proper care coordination.
  • Medicare-enrolled clinicians who provide hospice or palliative care have the opportunity to partner with other participating practitioners.

Why Partner with Lightbeam for Primary Care First?

To actively participate and succeed in the PCF model, providers will need up-to-date patient data on current HCC coding gaps. They also need the ability to stratify their patient population into different buckets of risk for care management. With our cohort builder technology, identifying high-risk patients is simple, and primary care providers, administrators, and care managers have access to unique analytics that syncs to their appointment calendar. Physicians are notified when their high-needs patients are coming in, so they can allocate the appropriate amount of time and familiarize themselves with their records. Lastly, every Lightbeam client has access to a Lightbeam advisor who is a value-based care expert already knowledgeable about Primary Care First. 

On October 3, 2019, I will be hosting an Innovation Center briefing webinar on both of these new initiatives as part of Lightbeam’s Thought Leadership Series. Register today to learn more.

Kent Locklear, MD

Read more from Dr. Kent Locklear, Lightbeam’s Chief Medical Officer.

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